Fistula In Patients Research Articles

Biofilm Detection on Catheter Associated Uropathogenic Bacteriuria among Fistula Patients Attending National Obstetric Fistula Centre Ningi, Bauchi State, Nigeria

Background: Biofilm production caused by bacteria plays a vital role in catheter associated urinary tract infection (UTI) or bacteriuria being responsible for persistence and recurrent infection. Biofilms forming bacteria are difficult to eradicate due to antimicrobial resistance to the commonly used antibiotic. Biofilms are currently estimated to be responsible for over 65% of nosocomial infections and 80% of microbial infections. This study aimed to perform biofilm detection on uropathogenic bacterial isolates among fistula patients attending National Obstetric Fistula centre Ningi and investigate the antimicrobial susceptibility pattern.
 Methods: A total of 217 strains of significant bacteriuria were isolated from vesico vaginal fistula (VVF) patients. A cross sectional study was conducted at the hospital. The urine samples were collected and cultured on CLED and blood agar media while confirmation was done using their biochemical reaction. The detection of biofilms formation on the isolates was performed using tube adherence and Congo red agar method. Antimicrobial susceptibility testing was carried out by disc diffusion method on Muller Hinton agar.
 Results: Out of 217 significant bacteriuria isolated, 38 strains produced biofilms;28 strains tested positive on tube adherence method while 15 strains were positive on Congo red agar method. Bacteria that produced biofim showed multiple drug resistance compared to the platonic bacterial cells. All the biofilm producers showed 100% resistant to septrin, ampiclox, gentamycin and amoxicillin. There was no significant value between tube adherence and Congo red agar method with P value > 0.05.
 Conclusion: Biofilm detection should form part of routine testing while antimicrobial susceptibility testing is paramount on better choice of antibiotic therapy for proper management to reduce economic lost, treatment failure and drug resistance.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BackgroundManagement of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.MethodsDutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.ResultsIn total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).ConclusionsDutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Perforator-Based Intercostal Artery Muscle Flap: A Novel Approach for the Treatment of Tracheoesophageal or Bronchoesophageal Fistulas.

Postoperative tracheoesophageal or bronchoesophageal fistulas represent a major surgical challenge. The authors report the description of an original perforator-based intercostal artery muscle flap, aiming to cover all types of intrathoracic fistulas, from any location, in difficult cases such as postoperative fistulas after esophagectomy in an irradiated field. Between June of 2016 and January of 2019, eight male patients were treated with a perforator-based intercostal artery muscle flap. All had previous surgery for esophageal cancer and developed a tracheoesophageal or bronchoesophageal fistula during the perioperative course. The mean patient age was 55.9 ± 8.8 years. All patients received neoadjuvant chemotherapy and seven received neoadjuvant radiation therapy. A perforator-based intercostal artery muscle flap, with a mean skin paddle size of 9.86 × 5 cm, was harvested. The median operative time was 426.50 minutes. The tracheoesophageal or bronchoesophageal fistula was successfully and definitively occluded in three patients; two patients experienced recurrence; and one patient underwent re operation. At 1 year, five patients were alive (62.5 percent), and among them, three (37.5 percent) were free from any intrathoracic complications. Three patients died, because of massive digestive bleeding, mesenteric ischemia, and multiorgan failure, respectively. The perforator-based intercostal artery muscle flap, like the Taylor flap in abdominoperineal reconstruction, could become a workhorse flap for all intrathoracic reconstructions, as it can always be harvested, even if a previous thoracotomy has ruined most of the options. This surgical technique, easily feasible, reliable, and reproducible, became our first option for all postoperative tracheoesophageal or bronchoesophageal fistula patients during the postoperative course following esophagectomy. Therapeutic, IV.

Perianal Fistula-Associated Carcinoma in Crohn's Disease: A Multicentre Retrospective Case Control Study.

Carcinoma associated with perianal fistula in Crohn's disease is a pending threat for patients. This study aimed to improve understanding and facilitate development of diagnostic and therapeutic strategies. A retrospective case-control study was conducted at four German hospitals. The analysis included 40 patients with proven malignancy associated with perianal Crohn's fistulas and 40 randomly selected controls with fistulizing perianal Crohn's disease. Differences between groups were analysed and multivariate calculations were performed to describe risk factors for oncological outcomes. Histology revealed adenocarcinoma in 33/40 patients and squamous cell carcinoma in 7/40 patients. Compared to fistula patients without carcinoma, patients with malignancies associated with fistula had a diagnosis of Crohn's disease at younger age. Crohn's disease lasted longer in patients with malignancy [25.8 ± 9.0 vs 19.6 ± 10.4; p = 0.006]. Fistula-related findings differed significantly between the two groups. Signs of complicated and severe fistulation including complex anatomy and chronic activity occurred significantly more often in patients with malignancy associated with fistula. Significant multivariate hazard ratios for overall mortality and progression-free survival were shown for histological type of cancer, metastatic disease and R1 resection. Overall survival was 45.1 ± 28.6 months and the 5-year survival rate was 65%. In patients with adenocarcinoma or squamous cell carcinoma associated with perianal fistula in Crohn's disease, fistula characteristics determine the risk of malignancy. Early diagnosis influences outcomes, while treatment of chronic fistula activity may be key to preventing malignancy. Expert multimodal therapy is paramount for successful treatment of perianal fistula-associated malignancies.

Application of mediastinal drainage tube in intrathoracic esophageal anastomotic leakage for early diagnosis and effective treatment: a retrospective study

BackgroundIntrathoracic esophageal anastomotic leakage (AL) is one of the most fatal complications after esophagectomy. In this study, we placed an additional drainage tube in the esophagus bed and evaluated its effect in early diagnosis and treatment of AL.MethodsFrom January 2010 to August 2020, 312 patients with esophageal or cardia carcinoma underwent esophageal resection with intrathoracic esophagogastric anastomosis. A total of 138 patients with only one pleural drainage tube were divided into the “Control Group” and 174 patients with a pleural drainage tube and an additional mediastinal drainage tube (MDT) were divided into the “Tube Group”. For all patients, the incidence of postoperative AL, the time to diagnosis, time to recovery, and patient outcome were analyzed.ResultsNo significant differences were observed in the AL rate (P = 0.837) and postoperative pain between two groups. However, in the Tube Group, almost all the patients were diagnosed prior to the appearance of hyperpyrexia, which was considered as the earliest and most common symptom after AL. In the Tube Group, a significant decrease was observed in the incidence of incurable fistula, which required re-operation or variable treatments under gastroscopy when compared to the Control Group (P = 0.032). Finally, patients in the Tube Group showed reduced post AL hospital day (P = 0.015) and a lower mortality, however, when compared to the Control Group, no significant differences were observed (P = 0.188).ConclusionsPlacement of an MDT does not prevent AL, but it is an effective approach for earlier diagnosis of AL and facilitates fistula healing and patient recovery.

Midterm results of salvage surgery for autogenous dialysis access in aneurysmal arteriovenous fistulas.

Autologous arteriovenous fistulas are commonly constructed in patients undergoing hemodialysis for end-stage renal disease. However, they are associated with a high rate of aneurysm formation, and aneurysmal arteriovenous fistulas that have become symptomatic require surgical intervention. This study was performed to evaluate the midterm results of salvage surgery for autogenous dialysis access in patients with aneurysmal arteriovenous fistulas. Of 1326 arteriovenous fistula operations, 81 involving surgery for aneurysmal arteriovenous fistulas between January 2008 and January 2012 were included in this study. The database was searched to identify all complicated arteriovenous fistula patients undergoing surgery for vascular access. The number of complicated arteriovenous fistula surgeries, for example for aneurysms, was greater than the number of patients undergoing surgery to create a new arteriovenous fistula. We performed three different surgical procedures to treat arteriovenous-related aneurysms in our clinic: primary repair, resection and saphenous vein interposition, and resection and polytetrafluoroethylene (PTFE) interposition. We compared the patency rates at the 12- and 24-month follow-ups among these three techniques. The study population consisted of 24 cases of primary repair, 29 cases of resection and saphenous vein interposition, and 30 cases of resection and PTFE graft interposition. True aneurysms occurring in patients undergoing hemodialysis did not require treatment unless they were symptomatic. Arteriovenous access salvage therapy is recommended after the aneurysm has become symptomatic. Symptomatic arteriovenous fistula aneurysms can be treated by maintaining arteriovenous fistula continuity. Moreover, patient safety is ensured by long-term patency.

Diagnostic Value of CT Angiography (CTA) in Carotid Cavernous Fistula (CCF) Patients Using the Digital Subtraction Angiography (DSA) as The Gold Standard: Observation in Dr. Soetomo General Hospital Surabaya from January 2016 to July 2020

Background: CT angiography (CTA) is the initial modality for diagnosing the Carotid Cavernous Fistula (CCF), identifying the type of CCF, measuring the diameter of the fistula and the diameter of the internal carotid artery (ICA) pre and post fistula, and then confirmed by Digital Subtraction Angiography (DSA) as the gold standard. CTA is expected to provide more information to improve the accuracy of CCF diagnosis to benefit therapy and prevent complications. This study aimed to determine the diagnostic value of CTA in CCF patients in Dr. Soetomo General Hospital Surabaya, using the DSA as a gold standard.
 Methods: An observational retrospective study of CCF patients met the inclusion and exclusion criteria and underwent CTA and DSA examinations at the Radiology Installation of Dr. Soetomo General Hospital, Surabaya, from January 2016 to July 2020.
 Results: In the comparison of types of CCF CTA to DSA, the direct group was 53.8% and 57.7%, respectively, while the indirect group was 46.1% and 42.3% with a very strong correlation (κ = 0.922; p = 0.000), sensitivity was 93.3%, specificity was 100 %, PPV of 100%, NPV of 91.7% and accuracy of 96.15%. Direct type evaluation on the DSA showed a large picture of the fistula diameter; the ICA pre fistula's size was enlarged; therefore, the ICA post fistula diameter was reduced or absent. There was a strong correlation of fistula diameter measurement results between CTA and DSA (r = 0.695, p = 0.006).
 Conclusion: CTA has a similarity rate of 92.2% with DSA in identifying the type of CCF. The accuracy value of CTA is close to DSA in fistula diameter measurements.

Diagnostic Value of CT Angiography (CTA) in Carotid Cavernous Fistula (CCF) Patients Using the Digital Subtraction Angiography (DSA) as The Gold Standard: Observation in Dr. Soetomo General Hospital Surabaya from January 2016 to July 2020

Introduction: CT angiography (CTA) is the initial modality for diagnosing theCarotid Cavernous Fistula (CCF), identifying the type of CCF, measuring thediameter of the fistula and the diameter of the internal carotid artery (ICA) pre andpost fistula, and then confirmed by Digital Subtraction Angiography (DSA) as thegold standard. CTA is expected to provide more information to improve theaccuracy of CCF diagnosis to benefit therapy and prevent complications. Thisstudy aimed to determine the diagnostic value of CTA in CCF patients in Dr.Soetomo General Hospital Surabaya, using the DSA as a gold standard. Methods:An observational retrospective study of CCF patients met the inclusion andexclusion criteria and underwent CTA and DSA examinations at the RadiologyInstallation of Dr. Soetomo General Hospital, Surabaya, from January 2016 toJuly 2020. Results: In the comparison of types of CCF CTA to DSA, the directgroup was 53.8% and 57.7%, respectively, while the indirect group was 46.1% and42.3% with a very strong correlation (κ = 0.922; p = 0.000), sensitivity was 93.3%,specificity was 100 %, PPV of 100%, NPV of 91.7% and accuracy of 96.15%. Directtype evaluation on the DSA showed a large picture of the fistula diameter; the ICApre fistula's size was enlarged; therefore, the ICA post fistula diameter wasreduced or absent. There was a strong correlation of fistula diametermeasurement results between CTA and DSA (r = 0.695, p = 0.006).Conclusion: CTA has a similarity rate of 92.2% with DSA in identifying the typeof CCF. The accuracy value of CTA is close to DSA in fistula diametermeasurements.

Observation of fundus and optical coherence tomography angiography manifestations in carotid cavernous fistula patients.

This study aimed to investigate fundus and optical coherence tomography angiography (angio-OCT) manifestations in carotid cavernous fistula (CCF) patients. Nine eyes of 7 CCF patients diagnosed with digital subtraction angiography (DSA) were included in this study. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), slit lamp, fundus, spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (angio-OCT) examination in the CCF patients and 10 normal controls were conducted. Subfoveal choroidal thickness (SFCT) and macular vascular density (VD) were measured and compared with the control group. SFCT and VD were also compared before and after embolization therapy. Two male and 5 female CCF patients were included. The average age was 59.7 ±10.0 (years). Embolization therapy was conducted in 3 patients. Fundus manifestations included disc oedema and exudation, retinal venular dilation, and retinal haemorrhage. B-scan OCT examination revealed retinal and choroidal undulations, retinal-choroidal thickness, retinal cystoid oedema, and subretinal fluid. The SFCT of the affected eyes was thicker than that of the control group (412.3 ± 123.7 μmvs. 272.9 ± 62.9μm; P = 0.006). Macular superficial capillary plexus (SCP) VD in affected eyes was lower than that in the control eyes (50.1 ±2.3 % vs. 52.7 ± 1.7 % ; P = 0.014). The SFCT was reduced, and the vessel density in the SCP was increased after embolization therapy. We demonstrated decreased VD in CCF patients with specific fundus and OCT manifestations. The pathological changes were immediately reduced after embolization therapy. This preliminary observation provides a supplemental method for the diagnosis and pathophysiological examination of CCF patients.

Outcome of urethral reconstruction among vesico-vaginal fistula patients: a cross-sectional study

BackgroundObstetric fistula (OF) complicated by urethral loss (UL) poses a challenge to both the fistula surgeon and obstetric fistula patient. The involvement of the urethra and urethral closure mechanism in OF is an important determinant of successful closure of fistula and restoration of urinary continence. OF with UL is often associated with unsuccessful repair outcome. We describe urethral reconstruction in genital tract fistula patients with UL and the outcomes of the repair.MethodsAim To review the clinical characteristics and outcome of vesico-vaginal fistula associated urethral loss following urethral reconstruction.This was a descriptive cross-sectional study conducted at the University College Hospital, Ibadan, Nigeria. A 5-year prospective data of all vesico-vaginal fistula patients with urethral loss (2011–2016) were reviewed and analysed. Data collected include socio-demographic and obstetric characteristics; cause of the fistula; and fistula characteristics—type of fistula, number of previous repairs, urethral loss, outcome of repair and follow-up. Data were entered and analysed using IBM SPSS version 20.ResultsUrethral loss occurred in 23 (15.3%) out of 150 women with OF; these women had urethral reconstruction surgery. The commonest type of urethral loss encountered in this cohort was proximal urethral loss which was seen in 12 (52.2%) patients. The most common types of fistula seen with urethral loss were large vesico-vaginal fistula (34.8%) and mid-vaginal fistula (26.1%). More than half of the women (56.6%) had previous unsuccessful repair at other facilities before presentation. The fistula closure rate was high (82.6%) regardless of type of urethral loss. Among the women with successful closure of OF with UL, about 36.8% had urinary stress incontinence post-fistula repair.ConclusionUrethral loss appears to be a rare complication of obstetric fistula. Successful closure with stress incontinence was seen in a sizeable number of women with OF with UL. Preoperative assessment for determinant of post-repair incontinence and surgical repair by experienced surgeons will improve successful outcome of repair in women with obstetric fistula with UL.

A Simple Protocol to Effectively Manage Anal Fistulas with No Obvious Internal Opening.

PurposeIn some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested.Patients and MethodsAll anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores).ResultsA total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the “internal-opening found” group, the fistula healed completely in 486/546 (89%) and in the ‘internal-opening not found group’, the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups.ConclusionThis new protocol seems effective as a high cure rate could be achieved in ‘internal-opening not found’ fistulas which was comparable to fistula healing in the ‘internal-opening found’ group.

Lack of anti-TNF drugs levels in fistula tissue - a reason for nonresponse in Crohn's perianal fistulating disease?

Anti-TNF therapy is recommended as treatment for patients with Crohn´s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn's disease. Currently, it is unknown whether anti-TNF agent levels can be detected in tissue from fistula tracts themselves and whether this is associated with response. We undertook a pilot study to measure fistula tissue levels of anti-TNF medication (infliximab and adalimumab). We used a previously validated targeted proteomic technique, employing ultraperformance liquid chromatography-mass spectrometry, to detect/quantify anti-TNF drugs. Biopsies were obtained from fistula tracts of patients with Crohn's disease on maintenance treatment; with idiopathic (cryptoglandular) fistula tissues used as negative controls as well as positive controls (by spiking the latter tissues with anti-TNF drugs). Tissue was sampled from the fistula tracts of seven patients with Crohn's perianal disease (five patients were on adalimumab and two patients were on infliximab). The anti-TNF drugs, infliximab and adalimumab, were not detected in fistula samples from any of the Crohn's patients despite detection in 'spiked' positive control samples. Absence of detection of the anti-TNF drugs in fistula tissue raises the question on the role of tissue penetrance of anti-TNF drugs in response to therapy. Further work is required in a larger number of patients to validate the findings observed and investigate if any correlation exists between tissue and serum levels of anti-TNF and clinical outcome. Predicting response in Crohn's fistula patients on biologic therapy is difficult with no reliable biomarkers. This pilot study uses targeted proteomics to investigate the potential role of tissue drug levels in acting as a biomarker of treatment response.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: a clinical observation of 17 cases

BackgroundBronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula.MethodsBetween March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed.ResultsStent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5–431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure).ConclusionsThe modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

A comparative study of ligation of intersphincteric fistula tract (LIFT) and conventional fistulotomy in treatment of fistula-in-ano

Background: A hospital randomized control study was conducted at a tertiary care Hospital, to compare outcomes between the Ligation of Intersphincteric Fistula Tract (LIFT) technique and conventional fistulotomy for the treatment of low trans-sphincteric fistula in ano, including 50 patients of low trans-sphincteric fistula in ano randomly divided into two groups. LIFT technique was used in first group while Conventional Fistulotomy was performed in another. Mean duration of operation was significantly less and mean hospital stay, post-operative pain and analgesics need was significantly less in cases operated with LIFT. Mean time for complete healing was significantly less in cases operated with LIFT technique and the difference in complication rate was statistically nonsignificant. Recurrence was reported in 3 (12%) and 1 (4%) cases operated by LIFT and fistulotomy respectively. Ligation of Intersphincteric Fistula Tract (LIFT) procedure is effective and preferred sphincter saving technique for fistula-in-ano. Despite slightly more recurrence, LIFT procedure has certain advantages over standard fistulotomy like shorter operative time, less postoperative pain, shorter hospital stay and faster wound healing and early resumption of normal duties.

Role of Diffusion-Weighted Imaging in the Evaluation of Perianal Fistulae.

Background Magnetic resonance imaging (MRI) is the imaging modality of choice for evaluating perianal fistulae, due to its ability to show the relationship of perianal fistulae with anal sphincters, fistula extensions, secondary ramifications and associated complications. Aim To evaluate the role of diffusion-weighted MRI in the evaluation of perianal fistulae. Settings and Design A hospital-based cross-sectional study. Materials and Methods The study group composed of 47 patients of perianal fistula. MRI with diffusion-weighted imaging (DWI) was performed with Philips 0.5 T Ingenia scanner. DWI with different b -values ( b = 50, b = 400, and b = 800 smm 2 ) were obtained. The MRI findings were correlated with local clinical examination and or surgical findings. Statistical Analysis Used Chi-square test, independent samples t -test, and receiver operating characteristic curve analysis. Result Fifty-nine perianal fistulas in 47 patients were included in the study sample. The visibility of perianal fistula on DWI was less than T2-weighted (T2W) and combined DWI-T2W images. Distinctly visualized (visibility score 2) perianal fistulas were observed in 47 fistulas (79.6%) on DWI, 54 (91.5%) on T2W, and 58 (98.3%) on DWI-T2W images. The mean of apparent diffusion coefficient (ADC) values of active fistula was 0.972 ± 0.127 [SD] 10 −3 mm 2 /s and inactive was 1.232 ± 0.185 [SD] 10 −3 mm 2 /s with a significant difference ( p -value < 0.0005). A cut-off mean ADC value of 1.105 × 10 −3 mm 2 /s was used to differentiate active from the inactive fistula with a sensitivity of 87.5% and specificity of 73.3%. Conclusion Combined DWI-T2W evaluation had a better performance in the detection of fistula than DWI or T2W alone. DWI with mean ADC calculation had a good performance in differentiating active from the inactive fistulas.

Research Progress of Traditional Chinese Medicine on Wound Healing After Anal Fistula Operation

Anal sputum disease, "Surgery Zhengzong" has said that "the husband is dirty with poison, the wine has a strong taste, the hard work, the poisonous and the anus forms a lump", which explains the etiology and pathogenesis of the perianal abscess. Chinese medicine believes that the anus the formation of sputum is caused by perianal abscess that does not heal for a long time. The anus is dominated by the bladder meridian of the full sun. The body's damp and heat residual toxin is injected into the bladder, which eventually causes heat to overcome meat rot. "Lectures on Evil Flesh Forty-two" pointed out: "Evil flesh is also carrion. After carbuncle ulceration, the carrion must be removed first, which means that the old and the new." The existence of the carrion affects the normality of the fresh granulation tissue of the wound. The growth and decaying granulation tissue affects the healing of the wound: Ren Donglin believes that [2], followed by the sequelae of the abscess rupture or incision drainage that occurred around the anorectum, is that the anal canal or rectum communicates with the perianal skin A kind of granulation canal, which often has the risk of sepsis and sepsis, and the conservative treatment effect is not good. AGGARWAL V[3] believes that due to the special anal anatomy position, postoperative open trauma, local pollution and Long-term repair is inevitable, so that some patients have slow wound healing and poor healing quality after anal fistula surgery. Synthesis slows down and decomposition speeds up, affecting wound healing. "After anal fistula, the tissue will release inflammatory factors due to trauma stimulation, causing local swelling, compressing blood vessels, and causing local blood to run poorly", which will cause local tissue ischemia and hypoxia , Blood viscosity increases, resulting in insufficient tissue perfusion. Studies such as Jonsson [34] found that insufficient tissue perfusion will cause a decrease in the oxygen content and collagen content of the wound, and the perfusion of wound tissue can promote wound healing. Therefore, the long time for wound healing after anal fistula, postoperative infection, postoperative pain and other aspects trouble patients and anorectal clinicians. External treatment of traditional Chinese medicine has a long history of promoting wound healing after anal fistula. There are many treatment methods, and the curative effect is remarkable, which reflects the unique advantages of the external treatment of TCM. The author consulted the relevant literatures in recent years about the external treatment of TCM to promote the healing of wounds after anal fistula. Conduct an overview.

Association Between Attempted Arteriovenous Fistula Creation and Mortality in People Starting Hemodialysis via a Catheter: A Multicenter, Retrospective Cohort Study

Background:In North America, most people start hemodialysis via a central venous catheter (“catheter”). These patients are counseled to undergo arteriovenous fistula (“fistula”) creation within weeks of starting hemodialysis because fistulas are associated with improved survival.Objectives:To determine whether attempting to create a fistula in patients who start hemodialysis via a catheter is associated with improved mortality. We also sought to determine whether differences in baseline patient characteristics, vascular procedures for access-related complications, or days in hospital may confound or mediate the relationship between attempted fistula creation and mortality.Design:Multicenter, retrospective cohort study.Setting:Six dialysis programs located in Ontario, Alberta, and Manitoba.Patients:Patients aged ≥18 years who initiated hemodialysis via a catheter between January 1, 2004, and May 31, 2012, who had not had a previous attempt at fistula creation. We excluded those who had a life expectancy less than 1 year, who transitioned to peritoneal dialysis within 6 months of starting dialysis, and people who started hemodialysis via a graft.Measurements:Attempted fistula creation, all-cause mortality, patient characteristics and comorbidities, vascular procedures for access-related complications, and days spent in hospital.Methods:We used survival methods, including marginal structural models, to account for immortal time bias and time-varying confounding.Results:In total, 1832 patients initiated hemodialysis via a catheter during the study period and met inclusion criteria. Of these patients, 565 (31%) underwent an attempt at fistula creation following hemodialysis start. As compared to those who did not receive a fistula attempt, these people were younger, had fewer comorbidities, and were more likely to have started dialysis as an outpatient and to have received pre-dialysis care. In a marginal structural model controlling for baseline characteristics and comorbidities, attempted fistula creation was associated with a significantly lower mortality (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.43-0.66). This effect did not appear to be confounded or mediated by differences in the number of days spent in hospital or vascular procedures for access-related complications. It also remained similar in analyses restricted to patients who survived at least 6 months (HR = 0.60; 95% CI = 0.47-0.77) and to patients who started hemodialysis as an outpatient (HR = 0.48; 95% CI = 0.33-0.68).Limitations:There is likely residual confounding and treatment selection bias.Conclusions:In this multicenter cohort study, attempting fistula creation in people who started hemodialysis via a catheter was associated with significantly reduced mortality. This reduction in mortality could not be explained by differences in patient characteristics or comorbidities, days spent in hospital, or vascular procedures for access-related complications. Residual confounding or selection bias may explain the observed benefits of fistulas for hemodialysis access.Trial Registration:Not applicable (cohort study).

Extreme horseshoe and circumanal anal fistulas-challenges in diagnosis and management.

Objectives:Extreme horseshoe anal fistulas are rare, and there are little data on the diagnosis and management of these fistulas.Materials and Methods:Patients with horseshoe anal fistula, in which the fistula tract encircled more than 75% of the anal circumference were included in the study. All patients were assessed by a preoperative magnetic resonance imaging (MRI). The patients were managed by a sphincter-sparing procedure. The continence was evaluated by an objective continence scoring system (Vaizey's scores).Results:1059 anal fistula patients were operated on over 7-years with a median follow-up of 36 months (range: 5–79 months). There were 47/1059 (4.4%) patients with extreme horseshoe anal fistulas. In 4/47 patients, the fistulas were complete circumanal (encircling anal canal completely). The mean age was 39.5 ± 10.9 years, M/F-41/6. The fistula was supralevator in 12/47 (25.5%), had an associated abscess in 28/47 (59.6%), and was recurrent in 33/47 (70.2%) patients. The tracts were intersphincteric in 27/47, transsphincteric in 2/47, and both (intersphincteric and transsphincteric) in 18/47 patients. All patients (n = 47) were managed by a sphincter-sparing procedure. Four patients were lost to follow-up. The fistula healed completely in 34/43 (79%) patients. There was no significant difference between preoperative and postoperative Vaizey's continence scores 0.031 ± 0.17 and 0.033 ± 0.18 respectively (P=0.90, Mann–Whitney U-test).Conclusion:Extreme horseshoe fistulas are rare, with an incidence of about 4% (in a referral practice). The missed diagnosis of circumferential tracts could lead to a recurrence. MRI was pivotal to confirm the diagnosis. Proper identification and management of internal opening and adequate drainage of all tracts were crucial for successfully treating extreme horseshoe fistulas.

Assessment of health-related quality of life of vesicovaginal fistula patients attending a repair center in Northwest Nigeria.

Introduction:Vesicovaginal fistula (VVF) has devastating effects on a woman's hygiene, self-esteem, interpersonal relationships, and environment disrupting all elements of her health. Despite VVF being a persistent condition, very few researches have been conducted in Nigeria to determine the quality of life (QoL) of these patients. This study was carried out with the aim of assessing the QoL of VVF patients receiving care in a repair center in Sokoto, Northwest Nigeria.Materials and Methods:This was cross-sectional study conducted at a VVF repair center in Sokoto. Study population comprised of patients who had undergone VVF repair at the health facility. The total number of study participants present at the facility was 81, and all were recruited into the study. The study assessed socio-demographics and QoL of the respondents. Data obtained were entered into IBM software package and subsequently analyzed. Level of significance was set at 5%.Results:The environmental domain had the highest mean score of 51.7 ± 11.8 while psychological domain had the least score of 41.3 ± 14.3. The mean overall QoL and general health were 49.5 ± 10.2. There was a moderate positive correlation between physical domain score and Age, (r = 0.258, P < 0.005). There was also a positive correlation between psychological domain score and Husband's educational status (rpb = 0.241, P < 0.05). Social relationship domain score positively correlated with being married (rpb = 0.414, P < 0.01).Conclusion:Older study participants had higher mean scores for physical and psychological domains, while younger study participants had higher overall QoL and general health scores compared with older study participants. Future research should compare the pre and postoperative QoL of women who undergo repair of obstetric fistula.

Survival of Vascular Accesses in Chronic Hemodialysis Patients

Background/Aims: Vascular access (VA) is the highest risk factor for blood infections, hospitalization, and mortality of patients undergoing hemodialysis (HD). The risk of mortality while using a catheter is greater than that while using grafts. The objective of this article is to know the survival rate in relation to the type of VA. Methods: A retrospective cohort of HD patients was studied. The data gathered included age, gender, first VA at the surrogate site, days between the first and second access, number of accesses, and anatomical site of VA placement. Mean differences were estimated using χ2 or Student’s t test. Survival was calculated using the Kaplan-Meier curves and included in tables. Statistical significance was established as p < 0.05. The statistical computer software package SPSSw v25 was used for the analysis. Results: A total of 896 patients were included with a mean age of 47.88 years (SD ± 16.52), the duration of the first VA was 398.81 days (±565.79), the mean number of VAs used was 2.26 (±1.15), and the median time undergoing HD was 728.73 days. The duration of catheter placement was 330.42 days, and 728.60 days for fistula use (p = 0.001). The mean number of days of renal replacement was 611.59 days for catheter and 1,495.25 days for internal arteriovenous fistula (IAVF) patients (p = 0.001). Conclusions: The survival of the initial VA is greater for the IAVF, followed by the tunneled catheters and the lowest by the non-tunneled catheters, which continue to be frequently used in our setting.