Technical report: percutaneous treatment of a pancreatic duct fistula facilitated by an hydrophilic guide wire

A case in which a pancreatico-cutaneous fistula was successfully treated percutaneously is presented. The use of an hydrophilic guide wire enabled a catheter to be negotiated across an irregular abscess cavity and into the occluded main pancreatic duct. The low friction and good flexibility of hydrophilic guide wires can greatly facilitate difficult procedures.

Surgical treatment of primary aortoduodenal fistula

Primary aortoduodenal fistula is a rare and potentially fatal condition. Awareness of its existence, precise diagnostic evaluation, and early surgical intervention are essential for the survival of the patient. Although early experience indicated that interruption of the fistula, repair of the enteric defect, oversewing of the aorta and extraanatomic bypass was the procedure of choice, in situ aortic replacement with a prosthetic graft seems to be a viable option. This article includes a case report of a primary aortoduodenal fistula and review of the literature.

Arterial-ureteral fistula: case study with review of published reports

Arterial-ureteral fistula, a rare cause of gross hematuria, may be associated with life-threatening hemorrhage if not rapidly diagnosed and treated. Recently, a patient at the Hunter H. McGuire Veterans Administration Medical Center developed an arterial-ureteral fistula at the site of the confluence of the external iliac artery and a superior mesenteric artery bypass graft. Review of the world's literature revealed 31 additional reported cases of arterial-ureteral fistulas. This current case is only the second one reported in which the diagnosis was made with arteriography. Several common features of arterial-ureteral fistulas were present in this case: a history of ureteral obstruction and urinary tract infections, upper urinary tract disease, and previous vascular surgery. The condition is usually associated with either prior upper urinary tract instrumentation or vascular surgery, and an antecedent period of intermittent hematuria, followed by life-threatening hematuria, is common. A high index of suspicion and early surgical intervention are required for successful management. The major surgical challenges are to establish unobstructed urinary drainage and restore vascular continuity. Exclusion of prosthetic material from potentially infected areas is mandatory.

Surgical management of post-traumatic parotid sialoceles and fistulae

A simple operation has been used in 12 patients with persistent post-traumatic parotid sialoceles and fistulae with a success rate of 92 per cent. The operation is easy and safe, and can be performed under local anaesthesia.

Perilymph fistula--a diagnostic dilemma

A retrospective series is presented of 51 cases operated on for suspected perilymph fistula. In 26 ears a fistula was identified at surgery. A positive fistula test was found to strongly indicate a perilymph fistula but was more often negative than positive in surgically demonstrated fistula ears. Other vestibular tests were found to be of little value in the pre-operative diagnosis. Ears with a surgically demonstrated fistula and sensorineural hearing loss had either flat or downward-sloping audiograms. Difficulties in diagnosing a perilymph fistula at tympanotomy are discussed. At follow-up, vestibular symptoms were found to be eliminated or improved in 96 per cent of cases with surgically demonstrated fistulae and in 68 per cent of cases in which no fistula was detected at tympanotomy but hearing improved significantly in only one ear (4 per cent) of the former group and in five ears (20 per cent) of the latter group.

Management of sub-areolar abscess and mammary fistula

Sub-areolar abscess is a form of chronic non-lactational mastitis often presenting in young women at the areolar margin as a recurring discharge or painful infection. Incision and drainage is inadequate and will be followed by recurrence unless the major duct leading from the abscess to the nipple is identified and laid open. Three cases are presented to illustrate this problem and its management.

[Vesicovaginal fistulas: correction using lyophilized dura mater]

Thirty three cases of surgically corrected vesicovaginal fistulae, from a total of 73 patients with iatrogenic or pathological urinary tract conditions examined and treated in our service, are presented in this paper. Both the etiology and different surgical techniques that can be used are reviewed, contributing the novelty use of freeze dried dura mater as the material to interpose for the correction of the fistulae by means of abdominal surgical techniques. The material was used in 6 patients, with recovery being obtained in all cases and achieving the fistulae closure with a single surgical procedure.

[Anesthetic management of a hydatid cyst adhering to the inferior vena cava]

A patient with a hepatic hydatid cyst with fistula formation to inferior vena cava is reported. To carry out the resection, the cyst was isolated from systemic circulation by means of cardiopulmonary bypass. Inferior vena cava was cannulated through the right atrium until the implantation area of the cyst (above the hepatic veins) was surpassed. Bypass was carried out in 25 minutes by means of cannulation of the ascending aorta, without clamping the aorta, myocardial protection or hypothermia. Postoperative analgesia was achieved with a lumbar epidural catheter. Measures to prevent anaphylactic shock are recommended, an anesthetic technique based on the prevention of hypersensitivity reactions and a careful surgical technique to prevent hydatid dissemination.

A herald bleed: a case of aortoesophageal fistula and a review of the literature

Survival in AEF is rare because the diagnosis of this uncommon entity is not always suspected, and few patients survive despite aggressive but often late intervention. We present this case to increase awareness of AEF, which although rare, does occur and should be suspected in any patient who presents with midthoracic pain or dysphagia and herald bleeding.

Split palatal U-flap: a new technique for repair of caudal hard palate defects

Oronasal fistulas located in the central portion of the hard palate can be surgically repaired using a transposition flap of hard palate mucoperiosteum from tissue adjacent to the defect. The purpose of this report is to describe a new technique, the split palatal U-flap, for the surgical repair of large caudal hard palate defects in the dog and cat. A description of this new technique and case reports of a dog and a cat in which this technique was utilized to repair caudal hard palate defects are included.

Reoperations for late complications following abdominal aortic operation

Fifty patients were identified who, following abdominal aortic operation, developed late complications affecting the vascular graft or endarterectomy and who underwent their first reoperation between 1979 and 1989. Thrombosis was the commonest complication affecting 28 (56 per cent) patients, followed by false aneurysm in 11 (22 per cent), enteric fistula in nine (18 per cent) and graft infection in two (4 per cent). The 30-day mortality rate for reoperation was 8 per cent; longer follow-up revealed mortality rates of 22, 50 and 63 per cent at 1, 3 and 5 years respectively. Thirty-four complications required reoperation within 5 years of the original surgery. Reoperation was needed for 35 patients whose original pathology was occlusive disease and for 15 whose original pathology was aneurysm. The nature of the complication was related to initial pathology; thrombosis was far commoner in those with occlusive disease, and enteric fistula and false aneurysm were commoner in those with aneurysmal disease.

A new approach for repair of oro-antral-nasal fistulae. The anteriorly based buccinator myomucosal island flap

Oral-antral-nasal fistula (OAN) is a commonly encountered clinical problem. The literature is filled with a plethora of methods described for closing a persistent OAN. Local flaps are available to close minor to moderate defects, however, large fistulae can be a very challenging reconstructive problem. Various areas of the oral cavity have been used for closure of OAN. We describe a technique to reconstruct the oral cavity, in this case an OAN. The anteriorly based buccinator myomuosal island pedicle flap (BMIP) provides an alternative method for reconstructing the oral cavity. An extensive review of the literature as well as the anatomy of the buccinator, its reconstructive capabilities, and two case reports are included.

The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula

Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n = 7), rectus abdominis muscle flap (n = 2), and omental graft (n = 1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6-54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage.

Perilymph fistulas: the House Ear Clinic experience

The diagnosis, evaluation, and surgical treatment of perilymph fistulas has recently been the focus of a great deal of attention in otology. Authors have focused on perilymph fistulas as the cause of hearing loss and vertigo in many diverse situations. Additionally, surgical repair has been suggested when there is little objective support for intervention. To address some of the problems inherent in the diagnosis and treatment of perilymph fistulas, records of patients operated on at the House Ear Clinic during the past 12 years were reviewed retrospectively. Eighty-six patients were surgically explored for fistulas during this period. Thirty-five (40.7%) fistulas were found, and 51 ears were patched whether fistulas were found or not. Of the 80 patients who were seen for follow-up, 35 (43.8%) were subjectively better, and 45 (56.2%) were the same. Although the number of fistulas found and the number of patients improved were similar, the composition of the two groups was different. On the basis of audiometric results, improvement in hearing occurred in only 18.7% of the patients. None of the demographic factors or diagnostic tests were predictive of either the presence of a fistula or the therapeutic outcome. Further work is required to facilitate the preoperative diagnosis of fistulas and to design appropriate surgical intervention.

[Rumen fistula operation in a sitatunga antelope (Tragelaphus spekei gratus)]

It is reported on a fistula of the rumen in a Sitatunga caused by the butt of a horn. Surgical removal was successful.

Ventriculo-pulmonary fistula. Case report, literature review and possible surgical approach to the infected LV suture line

We describe a patient who developed a ventriculo-pulmonary fistula 2 years after resection of a left ventricular aneurysm, and mention the management of two further patients, one with a sinus, the other with a pseudo-aneurysm, both after left ventricular aneurysmectomy, to illustrate a possible surgical approach to a patient with a ventriculo-pulmonary fistula.

Management of labyrinthine fistulas caused by cholesteatoma

The surgical management of labyrinthine fistulas caused by cholesteatoma remains controversial. Forty cases (41 ears) of labyrinthine fistulas were reviewed. This represented 10% of our total series of cholesteatomas in adults and children (426 ears). Clinical presentation, extent of disease, results of fistula testing and audiometric studies, and radiographic findings were analyzed. A canal wall-down procedure was performed in all but one patient. Generally an attempt was made to completely remove the cholesteatoma, to graft the fistulous area, and to reconstruct the middle ear mechanism in one stage. The matrix was preserved in patients with large fistulas where the involved ear was the only hearing one, when the matrix was adherent to the underlying optic duct, and in selected elderly persons. Long-term followup did not reveal a significant difference in hearing, degree of vertigo, or incidence of recidivism when those patients in whom the matrix was removed were compared with those in whom the matrix was preserved. The importance of recognizing the presence of a labyrinthine fistula preoperatively is stressed, along with the need to be prepared for an unexpected fistula. Operative management is described.

Persistent pleural effusion and post-traumatic subarachnoidal-pleural fistula

Post-traumatic subarachnoidal-pleural fistulae are rare. We have found 22 cases in the literature. A patient who was successfully treated by thoracotomy 1 1/2 years after blunt thoracic trauma is presented. Myelography is the diagnostic test of choice and surgical closure is necessary in most cases.

[Post pneumonectomy empyema with bronchopleural fistula--a successful management using pedicled intercostal muscle flap on an atypical mycobacteriosis following the irradiation]

A 48-year-old woman underwent a right pneumonectomy for advanced mycobacterial disease (M. avium Complex), which followed the postoperative radiotherapy against a malignant schwannoma of the right lower chest wall treated seven years ago. On the 13th postoperative day, re-suture of the bronchial stump was performed urgently because of early bronchopleural fistula development. On the heels of that, reclosure of the bronchial fistula with coverage of the stump by parietal pleural flap was performed on the forty-first post operative day. On the 110th day, however, open drainage with thoracoplasty was performed because development of insidious aspergillous empyema was detected. Since then, local instillation of amphotellisin B, with an oral administration of antifungus drug was started. After succeeding to control the mycotic infection, reclosure of the bronchofistula, covered with pedicled intercostal muscle flap were performed on the 280th postoperative day and extraperiostal air-plombage for reducing empyema cavity. Postoperative course was uneventful and the patient was discharged one year later. With respect to pathogenetic relationship between radiation pneumonitis and feasibility of infection to atypical mycobacteria, preoperative radiotherapy and concurrence of postoperative bronchofistula, and some problems on management of empyema bronchofistula were briefly discussed.

Non-traumatic CSF fistulae: clinical history and management

Non-traumatic 'spontaneous' CSF fistulae are uncommon. The clinical features of 23 patients treated for non-traumatic CSF fistulae are presented. Twenty of these patients had normal CSF pressure and six developed meningitis. Surgical repair of these fistulae is recommended in order to reduce the risk of meningitis. For this their localization is essential.

[Biological glue and obstruction of bronchial stumps. Experimental study. Sutureless bronchial closure of lobectomies in dogs]

From April, 1989 to January, 1990, we have been "inducing bronchial fistulae" in dogs by performing 10 lobectomies, 5 middle and 5 caudal, in both the right and the left lung. The bronchial stump was not sutured but closed by a "Tissucol-vicryl mesk" implant, which can be adapted to the size of the stump and is fully absorbed in the long term and replaced by a natural fibrous plug. The results seem to be fairly satisfactory: no dog died; all stumps--followed up a D10, D12... up to the 11th month--were obturated without complications, at least in these animals whose bronchi were normal and not infected. Bronchial fistulae still are a serious complication of lung resections, and while the smaller fistulae (2-3 mm) can be managed with biological glue delivered by simple endoscopy, severe fistulae--especially after pneumonectomy, above all in the right lung--often demand difficult, high-risk surgery. This points out to the interest of this small experimental series. Two conditions are essential to successfully implement this alternative procedure: 1) perfect sterilization of the excision pocket; a window is often required, which in addition has the advantage of facilitating the insertion and observation of the implant; 2) a high concentration of aprotinin (10,000 units) delaying the dissolution of the glue plug, thus allowing it to be integrated by the natural healing process.