Arteriovenous Fistula Surveillance Using Tomographic 3D Ultrasound

OBJECTIVE

A well functioning arteriovenous fistula (AVF) is essential for haemodialysis. Despite regular duplex ultrasound (DUS) a significant number of AVFs fail. Tomographic 3D ultrasound (tUS) creates a 3D image of the AVF that can be interpreted by the clinician. DUS, tUS, and fistulograms were compared for the identification and measurement of flow limiting stenosis.

METHODS

Patients with AVF dysfunction on routine Transonic surveillance, defined as (1) > 15% reduction in flow on two consecutive occasions, (2) > 30% reduction in flow on one occasion, (3) flow of < 600 mL/sec, (4) presence of recirculation, underwent DUS. AVF tUS imaging was performed prior to fistulography. All fistulograms were reported by the same consultant radiologist and tUS images by the same vascular scientist blinded to the fistulogram results. Maximum diameter reduction in all stenoses were measured using all three imaging techniques.

RESULTS

In 97 patients with 101 stenoses, the mean (± standard deviation [SD]) severity of stenosis was 63.0 ± 13.9%, 65.0 ± 11.6%, and 64.8 ± 11.7% for the fistulograms, DUS, and tUS respectively. The mean (± SD) time between ultrasound and fistulography imaging was 15.0 ± 14.5 days. Assuming the fistulogram as the "gold standard", Bland-Altman agreement for DUS was -1.9 ± 15.5% (limit of agreement [LOA] -32.2 - 28.4) compared with -1.7 ± 15.4% (LOA -31.9 - 28.4) for tUS. Median (± interquartile range) time to complete the investigation was 09:00 ± 03:19 minutes for DUS and 03:13 ± 01:56 minutes for tUS (p < .001).

CONCLUSION

DUS and tUS were equally accurate at detecting AVF complications but tUS investigation requires less skill and was significantly quicker than DUS.

Significance of fistulography findings to the healing time of postoperative pancreatic fistula after pancreaticoduodenectomy

PURPOSE

Pancreatic fistula (PF) is a common and serious complications after pancreaticoduodenectomy (PD). However, few studies have discussed the time required for PF healing in patients with this complication. This study investigates the PF healing time (PF-HT) and its association with findings of postoperative fistulography performed via the drainage tubes.

METHODS

The subjects of this study were 35 patients with PF among a total of 144 patients who underwent PD for periampullary diseases in our hospital. PF-HT, which was defined as the duration from the first postoperative fistulography to removal of the drainage tubes, was assessed in the enrolled patients. Fistulography findings were classified into four types based on fluid collection and communication with the jejunal loop. We investigated the factors affecting the PF-HT, including the fistulography findings.

RESULTS

The average PF-HT was 22 ± 20 days. Multivariate analysis revealed that the fistulography type was the only independent factor that affected PF-HT significantly. The PF-HT was significantly shorter in patients without fluid collection than in those with fluid collection. Moreover, those patients with fluid collection and a communication had a significantly shorter PF-HT than those without a communication.

CONCLUSIONS

We found that fistulography findings were significantly associated with the PF-HT. This suggests that fistulography findings could help to predict the time needed for PF healing.

Congenital bronchobiliary fistula: A case report and review of the literature

BACKGROUND

Congenital bronchobiliary fistula is a rare developmental abnormality with an abnormal fistula between the respiratory system and biliary tract. The aim of this report is to analyze and summarize the clinical features and experience of diagnosing and treating congenital bronchobiliary fistula (CBBF) occurring in the neonatal period.

CASE SUMMARY

The onset of symptoms was 3 d after birth in our patient with progressive cyanosis and respiratory distress, and a large amount of green fluid was noticed in her respiratory secretion. We performed computed tomography (CT), fiberoptic bronchoscopy, and cholangiography to make a diagnosis, as well as fistulography with a bronchoscope for the first time. These examinations provided us with valuable images to make a correct diagnosis. The fistula was dissected and removed with excellent results. Surgical removal of the fistula was successful, and the baby recovered well and was discharged. She has been followed for 4 mo without any signs of discomfort.

CONCLUSION

The main symptom of CBBF is bile-like sputum. CT, bronchoscopy, fistulography, and intraoperative cholangiography can provide important evidence for diagnosis. Surgical resection of the fistula is the first choice of treatment.

Transfemoral Venous Access Facilitates Upper Extremity Dialysis Interventions: Procedural Success and Clinical Outcomes

PURPOSE

To report technical success and clinical outcomes of transfemoral venous access for upper extremity dialysis interventions.

MATERIALS AND METHODS

A total of 15 patients underwent a transfemoral venous approach for fistulography (n = 4; 27%) or thrombectomy (n = 11; 73%) over a 14-month period. Access characteristics, sheath size, thrombectomy method, angioplasty site, fluoroscopy time, radiation dose, technical and clinical success, complications, and post-intervention primary and secondary patency rates were recorded.

RESULTS

Access type included arteriovenous fistulas (n = 10; 67%) and grafts (n = 5; 33%). The most common configuration was brachio-brachial (n = 6; 38%). Mean age of access was 37 months. Mean prior interventions were 4. Right CFV access was used in all patients using 6-8-French (most common: 7-French [n = 10; 67%]) sheaths. Most thrombectomies (n = 11; 73%) required both pharmacologic and mechanical maceration (n = 9; 82%). All accesses required angioplasty to treat underlying stenosis at the outflow vein (n = 12; 80%) or arteriovenous anastomosis (n = 9; 90%). Mean fluoroscopy time was 26.43 min. Air kerma and dose area product were 178.06 ± 225.77 mGy and 57,768.83 ± 87,553.29 μGym², respectively. Procedural and clinical success rates were 93% and 80%, respectively. Technical failure was due to persistent stenosis in one patient. Clinical failure was due to unsuccessful dialysis immediately following intervention in three patients. Mean post-intervention primary patency and secondary patency durations were 2.8 and 4.8 months, respectively. Primary patency rates at 1 and 3 months were 50% and 35%, respectively. Secondary patency rates at 1 and 3 months were 58% and 30%, respectively.

CONCLUSION

A transfemoral venous approach for intervention of upper extremity dialysis accesses may be a valuable adjunct to traditional approaches.

Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT).

MATERIAL AND METHOD

Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement.

RESULTS

Ten patients (mean age 47.1 years, range 64-29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m(2) ± 6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4-31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29-293 days) after GCF diagnosis.

CONCLUSIONS

Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.

A case report on interprofessional collaboration between radiologist and surgeon

INTRODUCTION

Trans sternal fistula can occur after sternotomy/heart surgery. Diagnosing this can be difficult.

PRESENTATION OF CASE

In this report, we present a unique case of a patient with infection of an ascending aortic prosthetic graft. This patient was oozing from the wound despite several revisions. Many fistulographies were performed before fistulography with surgeon and radiologist revealed a trans sternal fistula.

DISCUSSION

Infection with Propionibacterium acnes is often difficult to diagnose. This is in line with the present case, where a surgeon guided fistulography had to be performed followed by appropriate redo surgery with succesful subsequent sternal wound healing.

CONCLUSION

Our case demonstrates the importance of performing a fistulography with the presence of a surgeon, to obtain the best possible result.

A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review

BACKGROUND

Richter's hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter's hernia is extremely rare.

CASE PRESENTATION

A 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter's hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient's small defect and infection risk.

CONCLUSION

Richter's hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter's hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.

High resolution MRI for preoperative work-up of neonates with an anorectal malformation: a direct comparison with distal pressure colostography/fistulography

Objective

To compare MRI and colostography/fistulography in neonates with anorectal malformations (ARM), using surgery as reference standard.

Methods

Thirty-three neonates (22 boys) with ARM were included. All patients underwent both preoperative high-resolution MRI (without sedation or contrast instillation) and colostography/fistulography. The Krickenbeck classification was used to classify anorectal malformations, and the level of the rectal ending in relation to the levator muscle was evaluated.

Results

Subjects included nine patients with a bulbar recto-urethral fistula, six with a prostatic recto-urethral fistula, five with a vestibular fistula, five with a cloacal malformation, four without fistula, one with a H-type fistula, one with anal stenosis, one with a rectoperineal fistula and one with a bladderneck fistula. MRI and colostography/fistulography predicted anatomy in 88 % (29/33) and 61 % (20/33) of cases, respectively (p = 0.012). The distal end of the rectal pouch was correctly predicted in 88 % (29/33) and 67 % (22/33) of cases, respectively (p = 0.065). The length of the common channel in cloacal malformation was predicted with MRI in all (100 %, 5/5) and in 80 % of cases (4/5) with colostography/fistulography. Two bowel perforations occurred during colostography/fistulography.

Conclusions

MRI provides the most accurate evaluation of ARM and should be considered a serious alternative to colostography/fistulography during preoperative work-up.

Key Points

• High-resolution MRI is feasible without the use of sedation or anaesthesia.

• MRI is more accurate than colostography/fistulography in visualising the type of ARM.

• MRI is as reliable as colostography/fistulography in predicting the level of the rectal pouch.

• Colostography/fistulography can be complicated by bowel perforation.

Fistulectomy of the parotid fistula secondary to suppurative parotitis: a case report

A parotid fistula is a communication between the skin and a parotid duct or gland through which saliva is discharged. The most common cause of the parotid fistula is trauma. The major causes of parotid trauma in a civilian practice are penetrating injury to the parotid gland from an assault weapon or injury due to shattered glass after a motor vehicle accident. Acute suppurative parotitis can rarely produce a parotid fistula, and it will be difficult to manage successfully. In this article we have described diagnosis by fistulography, meticulous dissection, and complete excision of the fistulous tract with layered closure of the parotid fascia followed by application of a post-operative pressure bandage, use of anticholinergic agents and antibiotics contribute significantly to the successful management of this difficult clinical condition.

Imaging of anal fistulas: comparison of computed tomographic fistulography and magnetic resonance imaging

The primary importance of magnetic resonance (MR) imaging in evaluating anal fistulas lies in its ability to demonstrate hidden areas of sepsis and secondary extensions in patients with fistula in ano. MR imaging is relatively expensive, so there are many healthcare systems worldwide where access to MR imaging remains restricted. Until recently, computed tomography (CT) has played a limited role in imaging fistula in ano, largely owing to its poor resolution of soft tissue. In this article, the different imaging features of the CT and MRI are compared to demonstrate the relative accuracy of CT fistulography for the preoperative assessment of fistula in ano. CT fistulography and MR imaging have their own advantages for preoperative evaluation of perianal fistula, and can be applied to complement one another when necessary.

CT imaging with fistulography for perianal fistula: does it really help the surgeon?

OBJECTIVE

To prospectively evaluate the relative accuracy of computed tomography (CT) fistulography for preoperative assessment of fistula in ano.

MATERIALS AND METHODS

Ethical committee approval and informed consent were obtained. A total of 22 patients (15 male and 7 female, age 21-58 years) who were suspected of having fistula in ano underwent preoperative CT fistulography (CTF). The CT images of 0.6 mm were obtained respectively before and after fistulography; contrast-enhanced CT scan was also performed in 22 patients. CTF images were evaluated by two expert radiologists to assess the fistulas in the following respects: (a) the volume-rendered imaging; (b) the extensions of active inflammatory tissue; (c) the internal opening and external opening; (d) the hidden areas of tract or abscess; and (e) the deep abscess adjacent to fistula. CT findings in 18 patients were compared with surgical findings or exam under anesthesia.

RESULTS

The CTF findings in 18 cases were basically in accordance with the surgical findings and/or examination findings under anesthesia. Both coronal and transverse planes were useful in assessing the location and direction of tracts or abscesses. Complicated spatial information within the perianal soft tissue about the fistula with secondary ramifications or abscesses can be easily demonstrated to the surgeons. Contrast-enhanced images were useful in assessing the inflammatory lesion activity and infiltrated area.

CONCLUSION

CTF exquisitely depicts the perianal anatomy and shows the fistulous tracks with their associated ramifications, enables selection of the most appropriate surgical treatment, and therefore minimizes all chances of recurrence.

Prevention of Biliary Leakage after Removal of T-tube in Immunocompromised Patients

Biliary leakage after T-tube removal is an important complication which can be lethal especially in patients who received immunosuppressant agents. The purpose of the study is to determine a method which can evaluate the completion of tract formation in high-risk patients. Participants include 46 patients who were candidates for open cholecystectomy and common bile duct (CBD) exploration and T-tube insertion. Twelve of patients received corticosteroids and were divided into two groups. In the first group, T-tube was removed conventionally, but in the other group, we performed a "fistulography" 1 month postoperative to evaluate maturity of tract between CBD and the skin. Biliary peritonitis was seen in half of patients who are managed conventionally, but no complication was detected in patients who underwent fistulography. Fistulography is suggested to be done before T-Tube removal in immunocompromised patients in order to detect tract formation, which is effective in reduction of postremoval complications.