Duct Fistula Research Articles

Cancer of the oral cavity.

Summary Treatment of SCCHN can have both acute and chronic sequelae and complications. Complications related to surgical treatment include injury to neurovascular structures and the thoracic duct, wound infection, and salivary fistulas. Radiotherapy injures the skin, mucosa, and parenchyma of the salivary glands of the oral cavity, which can lead to dental caries, tissue edema and erythema, xerostomia, and osteoradionecrosis of the mandible.

갑상설관 낭종 및 누공의 임상적 고찰

갑상설관 낭종 및 누공의 임상적 고찰

Branchio-oto-renal syndrome: A report on nine family groups

This study reviews nine new families with branchio-oto-renal (BOR) syndrome (Online Mendelian Inheritance in Man [OMIM] 113650). Diagnosis was made by studying 10 index cases, and then 22 other previously undetected patients were diagnosed within the nine families. The syndrome consists of conductive, sensorineural, or mixed hearing loss; preauricular pits; structural defects of the outer, middle, or inner ear; renal anomalies; lateral cervical fistulas, cysts, or sinuses; and/or nasolacrimal duct stenosis or fistulas. In our study, all patients first diagnosed in each familial group were recognized on the basis of severe renal anomalies associated with at least one of these symptoms. Our study showed that BOR syndrome is a misdiagnosed disorder, usually recognized in the presence of severe renal failure but often not diagnosed, especially in the adult in the presence of other isolated clinical signs, such as mild branchial or urological anomalies. We stress the meticulous search we performed for renal anomalies and/or hearing loss in all subjects showing minimal signs of branchial defects. BOR syndrome should be suspected in all cases of isolated urological anomalies, even if no other signs of the syndrome are present. After BOR syndrome has been diagnosed in a patient, all family members should be examined for the presence of the syndrome, even if there are only minimal stigmata of the disease.

Branchio-oto-renal syndrome: A report on nine family groups

This study reviews nine new families with branchio-oto-renal (BOR) syndrome (Online Mendelian Inheritance in Man [OMIM] 113650). Diagnosis was made by studying 10 index cases, and then 22 other previously undetected patients were diagnosed within the nine families. The syndrome consists of conductive, sensorineural, or mixed hearing loss; preauricular pits; structural defects of the outer, middle, or inner ear; renal anomalies; lateral cervical fistulas, cysts, or sinuses; and/or nasolacrimal duct stenosis or fistulas. In our study, all patients first diagnosed in each familial group were recognized on the basis of severe renal anomalies associated with at least one of these symptoms. Our study showed that BOR syndrome is a misdiagnosed disorder, usually recognized in the presence of severe renal failure but often not diagnosed, especially in the adult in the presence of other isolated clinical signs, such as mild branchial or urological anomalies. We stress the meticulous search we performed for renal anomalies and/or hearing loss in all subjects showing minimal signs of branchial defects. BOR syndrome should be suspected in all cases of isolated urological anomalies, even if no other signs of the syndrome are present. After BOR syndrome has been diagnosed in a patient, all family members should be examined for the presence of the syndrome, even if there are only minimal stigmata of the disease.

Choledochus revision in the age of endoscopic papillotomy. Indications and outcome

In the age of endoscopic papillotomy (EPT) the operative revision of the bile duct needs to be used stringently and interventional therapeutic options have to be considered primarily in the treatment of gallbladder and bile duct stone disease. 70 patients treated by choledochus revision for cholecysto- and choledocholithiasis in our department between 1988-1999 were analyzed retrospectively for indication and results. ERCPs were performed in only 24 patients. In 17 patients no endoscopic papillotomy could be accomplished due to a former operation (Billroth II or Whipple-OP). 70 patients underwent a surgical bile duct exploration with insertion of a T-drainage. The postoperative surgical complication rate amounted to 36%. The most frequent complications after revision of the common bile duct were edematous pancreatitis as well as bile duct fistula. 37 of 70 patients could be reexamined 4-48 months postoperatively. A pancreatitis or stenosis of papilla Vateri were not seen in these patients. In the sonography the common bile duct was inconspicuous. In the therapy of bile duct stones the therapeutic splitting has become generally accepted. The patients should be submitted to a ERCP with EPT and subsequent laparoscopic cholecystectomy. Surgical revision of the common bile duct nevertheless remains an important tool in the therapy of choledocholithiasis.

Cancer of the oral cavity

Treatment of SCCHN can have both acute and chronic sequelae and complications. Complications related to surgical treatment include injury to neurovascular structures and the thoracic duct, wound infection, and salivary fistulas. Radiotherapy injures the skin, mucosa, and parenchyma of the salivary glands of the oral cavity, which can lead to dental caries, tissue edema and erythema, xerostomia, and osteoradionecrosis of the mandible.

Neurotensin elevates hepatic bile acid secretion in chickens by a mechanism requiring an intact enterohepatic circulation.

Neurotensin (NT), given intravenously at 10-50 pmol/kg per min to anesthetized female chickens equipped with a bile duct fistula, dose-dependently elevated hepatic bile flow and bile acid output but only when the enterohepatic circulation was maintained by returning the bile to the intestinal lumen. Infusion of NT at 10 and 50 pmol/kg per min increased the average hepatic bile acid output over a 30-min period to 138 +/- 11 and 188 +/- 13% of control, respectively. During infusion of NT, plasma levels of immunoreactive NT (iNT) increased in time from the basal level (14 +/- 1.3 pM) to reach steady state at 30 min. There was a near linear relationship between the dose of NT infused and the increment in plasma iNT. In addition, infusion of NT at 40 pmol/kg min gave a plasma level of iNT (approximately/= 88 pM) which was within the range of those observed during duodenal perfusion with lipid (54-300 pM) and near to that measured in hepatic portal blood from fed animals (52 +/- 5 pM). Perfusion of duodenum with lipid released endogenous NT and increased the rate of hepatic bile flow. When NT antagonist SR48692 was given, bile flow rate decreased to the basal level. These results suggest that intestinal NT, released by lipid, may participate in the regulation of hepatic bile acid output by a mechanism requiring an intact enterohepatic circulation.

Central neck dissection for the treatment of recurrent thyroglossal duct cysts in childhood

Objective: The recurrence rate of thyroglossal duct cysts removed by the classic Sistrunk procedure exceeds 4%, even in skilled hands. Simple reexcision fails in 33% of these patients. Recent pathology literature suggests that the tracts of thyroglossal duct cysts may arborize, arguing for a wide-field approach to recurrent lesions. We describe the anatomic rationale and technique of an en bloc central neck dissection in children, on the basis of cadaver dissections and histopathologic review of recurrent thyroglossal duct cyst specimens. Methods: We reviewed the medical records of all the children undergoing surgery for thyroglossal duct cysts and fistulas during the years 1990 to 1998 by the senior author. En bloc central neck dissections were performed on several cadaver specimens to further delineate the anatomic rationale for this procedure. Results: We have performed an en bloc central neck dissection in 7 children, 5 with recurrent or multiply recurrent thyroglossal duct cysts. None has had a recurrence after follow-up of 9 months to 6 years. All have acceptable functional and cosmetic results. Conclusion: An en bloc central neck dissection is a logical and effective surgical technique for the removal of recurrent or multiply recurrent thyroglossal duct cysts. (Otolaryngol Head Neck Surg 1999;121:543-7.)

Treatment of chronic thoracic duct fistula with the sternocleidomastoid muscle flap

Thoracic duct fistula is a rare but potentially serious complication of head and neck surgery. The fistulae can be difficult to treat, and several techniques, both operative and nonoperative, are advocated. We present a simple technique for the treatment of chronic thoracic duct fistula where other procedures have failed. After identification and ligation of the duct, the area is covered with the clavicular head of the sternocleidomastoid muscle.

A fistula from the portal vein to the bile duct: an unusual complication of transjugular intrahepatic portosystemic shunt

We describe a case of a portal vein bile duct fistula as a complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The patient’s course was complicated by endocarditis, hemobilia, recurrent episodes of fever, and bacteremia, followed by liver transplant. The findings of fever, bacteremia (especially with Gram-negative organisms), and a decreased hematocrit after shunt placement should raise the suspicion of an infected shunt with a possible fistula.

Surgical management of periductal mastitis

Although the clinical manifestations of periductal mastitis are now well recognized, the role of cigarette smoking in disease aetiology, and its effect on outcome, are unclear.‘-3 Initial reports that heavy cigarette smoking led to the disease have been verified.2,3 Over 90% of women with mammary duct fistulae, non-lactating breast abscesses and periductal mastitis are heavy cigarette smokersm3 Smoking correlates with the amount of histological periductal inflammatory infiltrate and squamous neoplasia of the terminal lactiferous ducts (leading to duct obstruction) is reported almost exclusively in heavy smokers.’ Altered bacterial population, toxic metabolites (e.g. epoxides), increased tissue damage and microvascular injury have all been suggested as mechanisms by which smoking causes the disease.’ Yet petiductal mastitis is a relatively rare condition, representing only 7% of referrals to a benign breast clinical, even though 33% of women are reported to smoke cigarettes regularly. The recent finding that postmenopausal women with N-acetyl-transferase 2 (NAT2) genetic polymorphisms which leads to slow acetylation and detoxification of carcinogenic aromatic amines in cigarette smoke predisposes women to breast cancer may provide a further clue.” Aromatic amines formed by cigarette smoke are known to cause DNA damage in breast epithelium and induce mammary tumours in laboratory animals. Altered detoxification of aromatic amines caused by inherited genetic polymorphisms, may alter an individual woman’s risk of developing periductal mastitis.6 In this issue of

Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.

The objective of this paper was to assess the safety and efficacy of percutaneous catheter drainage for initial treatment of infected acute necrotizing pancreatitis. Thirty-four patients with acute necrotizing pancreatitis shown with contrast-enhanced CT were treated for sepsis with percutaneous catheter drainage. Extent of necrosis was less than 30% in 10 cases, 30-50% in 10 cases, and greater than 50% in 14 cases. Fourteen patients had central necrosis. Eighteen patients were critically ill with multiorgan failure. Sixteen (47%) of the 34 patients were cured with only percutaneous catheter drainage, including four (29%) of the 14 patients with central gland necrosis and 12 (60%) of the 20 with body-tail necrosis. Sepsis was controlled (defervescence of fever and return of WBC to normal) in an additional nine patients, allowing elective pancreatic surgery for control of pancreatic duct fistula. Eight patients failed to show clinical improvement after drainage and required necrosectomy. No patient experienced catheter-related complications. Mortality was 12% (all four deaths occurred after necrosectomy because of multiorgan failure). Percutaneous catheter drainage is a safe and effective technique for treating infected acute necrotizing pancreatitis. Overall, sepsis was controlled in 74% of patients, permitting elective surgery for treatment of pancreatic fistula, and 47% of patients were cured with no surgery required. No catheter-related complications occurred.

Operative Management of Papillary Cystic Neoplasms of the Pancreas

Background: Papillary cystic neoplasm (PCN) is a rare malignant tumor of the pancreas that typically occurs in young females and has an excellent prognosis. Study Design: We report a retrospective review of 12 patients treated during a 16-year period. Pre-, intra-, and postoperative data were evaluated in all patients to determine optimal management with specific reference to surgical strategy. Results: All 12 tumors occurred in young women (mean age 22 years, range 14–36 years). Six patients presented with an epigastric mass, and three with severe abdominal pain. The correct diagnosis was made preoperatively in only five patients. Incorrect diagnoses included hepatoma, pancreatic pseudocyst, and hydatid cyst. The PCNs had a mean diameter of 12.5 cm (range 8–20 cm), and occurred in the head (four), neck (three), body (three), and tail (two) of the pancreas. All were resected. Operations performed were pylorus-preserving pancreaticoduodenectomy (three), central pancreatectomy with pancreaticogastrostomy (three), distal pancreatectomy (three), and local resection (three). In one patient two liver metastases were resected in addition to the pancreatic primary. One patient presented with tumor rupture and a major bleed into the lesser sac and died of multiple organ failure after resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after temporary stenting, and a pancreatic duct fistula after local tumor resection, which required a distal pancreatectomy. Eleven patients are well at followup (mean 6.6 years; range 6 months to 15 years). Conclusions: PCN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Conservative resection, where technically feasible, is safe and effective and represents the therapy of choice.

Biliary fistulae and haemorrhage

Percutaneous biliary drainage is the most common aetiology of haemobilia. Bile duct fistulae can also arise from the hepatic or portal vein, most commonly as a result of trauma. Percutaneous methods for treating haemobilia from all these sources are discussed in detail.

Use of articulated catheters in the treatment of biliary strictures.

We have used a single articulated catheter to obviate the need for multiple catheters in patients with complex biliary strictures or strictures associated with small or immature tracts. Two- and three-arm articulated drains (8-14 Fr) made from segments of biliary catheters were placed in 16 patients. Nine were placed transhepatically, 6 transperitoneally through existing T-tube tracts, and 1 through a cystic duct fistula. Six malignant and 10 benign strictures were stented with various catheter configurations through a single tract. Fifteen patients had two catheter components with one articulation and 1 patient had three catheter components with two articulations. The average duration of catheter drainage was 7.0 +/- 4.2 months. Routine catheter exchanges were performed; two spontaneous occlusions occurred. In patients where internal stenting may be difficult or undesirable, articulated catheters allow satisfactory external and internal drainage of complex benign and malignant strictures through a single tract, avoiding the need for multiple transhepatic catheters.

Plastic surgical treatment of a chronic thoracic duct fistula using a sternocleidomastoid muscle flap ? a case report

Thoracic duct fistula is a rare but potentially serious complication of head and neck surgery. Such fistulae may be difficult to treat, and several techniques, both operative and non-operative, have been advocated. A case of successful surgical treatment of a chronic thoracic duct fistula is presented. The fistula occurred in a 51-year-old female following treatment of a solitary supraclavicular breast metastasis by local excision and radiotherapy. The divided duct was ligated and the area was covered with the clavicular head of the sternocleidomastoid muscle.

Life-threatening gastrointestinal bleeding after liver transplatation due to hepatic artery pseudoaneurysm perforating into the common bile duct. A case report

Abstract A 54-year-old male presented with acute rejection and life-threatening gastrointestinal bleeding 2 months following orthotopic liver transplantation. Since no bleeding was identified in the entire gastrointestinal (GI) tract, hematobilia was first suspected and an arteriocholedochal fistula angiogra-phically confirmed. Two days after resection of a pseudoaneurysm of the hepatic artery (HA) with primary repair and closure of the bile duct fistula, hepatic artery thrombosis (HAT) occurred. Various attempts to revascularize the HA eventually failed. Two weeks later, a CT scan showed necrotic areas within the two left lateral segments. At relaparotomy, major parts of the bile duct were found to be necrotic, and the biliary anastomosis was therefore abandoned and necrotic tissue removed. HAT was otherwise well tolerated by the graft and, at a further relaparotomy some weeks later, a hepaticojejunostomy was performed. Two years after transplantation the patient is well with a normally functioning graft.

Pathogenesis-based treatment of recurring subareolar breast abscesses

When a subareolar breast abscess (SBA) is incised and drained, an extraordinarily high frequency of recurrence is noted. To develop a pathogenesis-based treatment plan, 24 women with a total of 84 abscesses were monitored. In nine women SBA was under the left areola, under the right, in 7 and in eight the SBA occurred either simultaneously or sequentially under both areolae. In 11 of 24 patients a chronic lactiferous duct fistula also existed. In four of 24 patients four SBAs were treated with antibiotics; alone; all recurred. In 16 of 24 patients initial treatment was incision and drainage plus antibiotics; all recurred. When the abscess plus the plugged lactiferous duct was excised, there were no recurrences; however, in four patients a new abscess in a different duct occurred, which was treated by en bloc resection of all subareolar ampullae, without further recurrence. Patients with a fistulous tract had the fistula, its feeding abscess, and its plugged lactiferous duct excised, without recurrence. In first time SBA the organism was usually staphylococcus; in recurrences mixed flora was isolated. Pathologic findings ranged from squamous metaplasia with keratinization of lactiferous ducts to chronic abscess. The cause of SBA is plugging of lactiferous duct within the nipple by keratin. To prevent recurrence the abscessed ampulla with its plugged proximal duct needs excision.

Bile Secretion and Liver Regeneration in Partially Hepatectomized Rats

The purpose of this research was to study the correlation between bile secretion and the liver regeneration in the partially hepatectomized rat. Significant alteration in bile formation and secretion is expected in the liver after hepatectomy. There is scant literature, however, about the effects of liver regeneration in bile secretion. The work was done in rats with 50% hepatectomy, 75% hepatectomy, and sham operation as the control. A chronic common bile duct fistula and a duodenal cannula were established for bile collection and the sample analysis on days 1, 3, 5, 7, and 9. With size reduced in the liver after 50% and 75% hepatectomy, the total bile volume decreased 45.9% and 51.5%, bile salt independent flow decreased 59.3% and 64.9%, bile salt secretion rate decreased 36.1% and 43.4%, bile salt basal synthesis rate decreased 52.3% and 56.4%, phospholipid secretion rate decreased 52.6% and 68.0%, and cholesterol secretion rate decreased 54.3% and 72.4% from control on day 1, respectively. All changes returned to the control level in 3 to 9 days with accompanying increasing liver size during regeneration. Alterations of total bile flow, bile salt independent flow, bile salt secretion rate, bile salt basal synthesis rate, and biliary lipid secretion after partial hepatectomy correlate with the liver regeneration rate in rats. Partial hepatectomy reduces the bile salt independent fraction calculated as per 100 g body weight rather than the dependent fraction. The study of bile salt and biliary lipid secretion is a useful method for monitoring synthetic function in liver regeneration in vivo.

Physiologic study of bile salt and lipid secretion in rats after liver transplantation.

This experiment determined the effects of liver transplantation on bile salt kinetics and biliary lipid secretion. Depression of bile secretion in the three main components and bile cholesterol supersaturation with a high incidence of cholesterol stone formation have been documented in patients with end stage liver diseases after transplantation. However, physiologic changes of bile salt and lipid secretion in recipients remain unclear. The study was done using a rat liver transplant model with 1 and 6 hours of donor liver cold preservation in saline. A chronic common bile duct fistula and a duodenal cannula were established for bile collection and the sample biochemical study for 6 days. Altered bile salt kinetics in liver grafted rats included depressed bile flow for 1-3 hours after the revascularization, decreased bile salt concentration and outputs, reduced bile salt basal synthesis rate, and reduced bile salt pool size during the early postoperative period. Phospholipid concentration and secretion rate depressed for 1-3 days without altered cholesterol level. The uncoupling change of the cholesterol and the other bile components resulted in an increased lithogenic indices in bile on days 2 and 3. Alterations of bile composition and bile salt kinetics occur in liver transplanted rats. The changes may result from injuries of the liver microcirculation and parenchymal cells caused by cold preservation. The study of bile secretion is helpful for evaluation of the initial graft function. The changed ratio of three bile components may be important for cholesterol stone formation in the liver transplant recipient.