Fistula Length Research Articles

Insights into Atresia Ani Type IV in Felis catus: Preliminary Epidemiolocal Findings Associated with Surgery.

Atresia Ani (AA) is a rare congenital anomaly in companion animals affecting rectal and anal development. Its incidence in cats remains unreported. This retrospective study aimed to characterize age, body condition, fistula size, and perioperative outcomes in Type IV Atresia Ani (with recto-vaginal fistula) in female cats. Surgical intervention is the primary treatment. Conducted over 2 years, the study included nine female cats diagnosed with Type IV Atresia Ani and recto-vaginal fistula undergoing surgery. Statistical analysis used the R program (version 4.2.1) with Rstudio®® extension. Significant results were observed at a 95% confidence interval and p < 0.05. The condition had an incidence of 4.7% among the 192 cats evaluated over a 2-year period. The findings suggest that a body condition score of 3, an age of 3 to 4 weeks, and a fistula length of 1 to 2 mm correlated with better surgical outcomes, reducing the likelihood of fecal incontinence and anal stenosis development, and enhancing defecation awareness during the perioperative period. This study is the first to report the disease incidence in cats undergoing surgery, according to the authors' knowledge.

Development of an MRI-Based Prediction Model for Anti-TNF Treatment Failure in Perianal Crohn’s Disease: A Multicenter Study

Clinical and radiologic variables associated with perianal fistula (PAF) outcomes are poorly understood. We developed prediction models for anti-tumor necrosis factor (TNF) treatment failure in patients with Crohn's disease-related PAF. In a multicenter retrospective study between 2005 and 2022 we included biologic-naive adults (>17 years) who initiated their first anti-TNF therapy for PAF after pelvic magnetic resonance imaging (MRI). Pretreatment MRI studies were prospectively reread centrally by blinded radiologists. We developed and internally validated a prediction model based on clinical and radiologic parameters to predict the likelihood of anti-TNF treatment failure, clinically, at 6 months. We compared our model and a simplified version of MRI parameters alone with existing imaging-based PAF activity indices (MAGNIFI-CD and modified Van Assche MRI scores) by De Long statistical test. We included 221 patients: 32 ± 14 years, 60% males, 76% complex fistulas; 68% treated with infliximab and 32% treated with adalimumab. Treatment failure occurred in 102 (46%) patients. Our prediction model included age at PAF diagnosis, time to initiate anti-TNF treatment, and smoking and 8 MRI characteristics (supra/extrasphincteric anatomy, fistula length >4.3 cm, primary tracts >1, secondary tracts >1, external openings >1, tract hyperintensity on T1-weighted imaging, horseshoe anatomy, and collections >1.3 cm). Our full and simplified MRI models had fair discriminatory capacity for anti-TNF treatment failure (concordance statistic, 0.67 and 0.65, respectively) and outperformed MAGNIFI-CD (P= .002 and < .0005) and modified Van Assche MRI scores (P < .0001 and < .0001), respectively. Our risk prediction models consisting of clinical and/or radiologic variables accurately predict treatment failure in patients with PAF.

Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review.

Anal fistula (AF) with cryptoglandular origin tends to recur, and multiple risk factors are implicated. Recently, some magnetic resonance imaging (MRI) findings with predictive value for disease outcomes have been proposed. These intrinsic anatomic features include those of the AF and its surrounding structures. This study aims to clarify the prognostic role of MRI in AF. We performed a systematic search of PubMed, Embase, and EBSCO databases. Two independent reviewers conducted the search and screened the articles. We selected studies that used MRI to assess AF and reported its relationship to disease outcome. We extracted data regarding the study design, type of intervention, outcome, MRI-measured items, and their significance. Out of 1230 retrieved articles, 18 were eligible for final inclusion, and a total of 4026 patients were enrolled in the selected studies. For preoperative MRI, the significant items affecting the outcome were the length of the fistula, horseshoe type, presence of multiple tracts, supralevator extension, and apparent diffusion coefficient (ADC) value. Other studies investigated the healing process using postoperative MRI. This review found that MRI can be useful in the management of AF, both preoperatively and postoperatively. Factors, such as fistula length, horseshoe type, presence of multiple tracts, supralevator extension, and ADC value were found to be significantly associated with treatment outcomes. The presence of the fistula tract and the development of new abscesses on postoperative MRI was found to hinder the healing process. Further studies are needed to confirm these findings.

Clinical characteristics and MRI-based phenotypes of perianal abscess formation in children with fistulizing Crohn's Disease.

The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF). From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3). A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula (n = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts (n = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, p = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, p = 0.006) and presence of multiple external openings (n = 25 vs. 7, p = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, p = 0.1). Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.

Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series.

Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips. A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported. Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157±98days, the mean defect diameter was 4.5mm (range 2-10mm) and the mean fistula length was 15mm (range 2-25mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218days, range 25-673days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure. Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.

Efficacy and analysis of modified "three-tube method" in the treatment of intrathoracic anastomotic leakage after esophagectomy.

This study aimed to retrospectively evaluate the clinical efficacy of the modified "three-tube method" for the treatment of intrathoracic anastomotic leakage (IAL) after esophagectomy, and to analyze the independent risk factors for prolonging the treatment time of the modified "three-tube method". From January 2013 to December 2018, IAL was reported in 22 patients with esophageal cancer who underwent esophagectomy with intrathoracic anastomosis. By reviewing and analyzing the clinical data of the 22 patients, the efficacy of the modified "three-tube method" treatment and the independent risk factors associated with a longer treatment duration of the modified "three-tube method" were evaluated. Of the 22 patients, 19 were male (86.4%). The average age was 65.2 years old. A total of 4 patients (18.2%) underwent preoperative neoadjuvant chemotherapy; 6 patients (27.3%) had a Charlson comorbidity index (CCI) score of 1-3; the average diagnosis time of IAL was 9.5 days; the median intervention time was 4 days; and the average fistula length was 1.5 cm. The average albumin level after surgery was 30.5 g/L, and the average C-reactive protein (CRP) level was 139.4 mg/L. The modified "three-tube method" average treatment time was 19.5 days. One patient (4.5%) died of respiratory failure during treatment. Univariate analysis and multivariate analysis by establishing multiple linear regression model found that the date of intervention and the fistula size were significantly associated with a longer treatment duration of the modified "three-tube method". The modified "three-tube method" is a safe and effective means for non-surgical treatment of IAL after esophagectomy. The intervention time and the fistula size are independent risk factors for prolonging the treatment time of the modified "three-tube method".

Coronary artery changes in congenital coronary-cameral fistulas evaluated by computed tomographic angiography.

The study sought to determine coronary artery diameter in congenital coronary-cameral fistula (cCCF), factors associated with coronary artery aneurysm, coronary artery changes after fistula closure, and computed tomographic (CT) findings after treatment. We retrospectively reviewed CT findings of the cCCF for origins, terminations, fistula length, complexities, and Sakakibara classification. Coronary artery diameter was expressed as coronary artery Z score. Fistula features associated with coronary artery aneurysm were analyzed. Post-fistula closures were analyzed for coronary artery dilatation, coronary thrombosis, complete fistula closure, and fistula thrombosis. Twenty-five patients (median age 33months, interquartile range, IQR 25-48) were included. Coronary feeders and terminations were frequently right coronary artery (48%) and right ventricle (56%), respectively. Fistula aneurysm occurred in 52% of cases. Mean coronary artery Z score was 13.03 ± 6.36 with a high incidence of giant coronary artery aneurysm (68%). We found no statistically significant risk factors associated with coronary artery aneurysm (p value range 0.075-0.370). Median duration of the follow-up CT after closure of the fistulas was 6.4months (IQR 5.0-8.7). Coronary artery Z score significantly decreased by 0.82 (IQR 0.28-1.35), p = 0.006 and coronary thrombosis occurred in 23% of cases during follow-up. Large coronary aneurysm is common in cCCF. No characteristic feature of the fistula influencing coronary artery aneurysm is identified. There is a diminution in coronary artery Z score after fistula closure. Coronary thrombosis is a major complication after treatment.

Ability of Pelvic Magnetic Resonance Imaging to Predict Clinical Course of Perianal Fistula in Paediatric Crohn's Disease Patients.

Evidence is limited regarding clinical course and magnetic resonance imaging [MRI] features of perianal fistula [PAF] in Korean children with Crohn's disease [CD]. We investigated MRI features of PAF and associations with long-term outcomes. We retrospectively analysed 243 patients with pelvic MRI for diagnosis of CD. Incidence of clinically evident PAF at diagnosis was determined, as were the proportions of patients with clinical failure [failure to achieve fistula healing within 1 year] and recurrence [new/recurrent PAF after fistula healing within 1 year]. Associations between outcomes and MRI features, specified in modified Van Assche index and MAGNIFI-CD, were evaluated. Associations between later development of clinically evident PAF and subclinical PAF detected on MRI at diagnosis were evaluated. Among 243 included patients, 108 [44.4%] and 76 [31.3%] had clinically evident and subclinical PAF at diagnosis, respectively; 66.4% of the patients with clinically evident PAF achieved fistula healing within 1 year, and 32.7% of those patients developed recurrence. Fistula length and dominant features of the tracts were associated with clinical failure, and fistula length was associated with recurrence. Clinically evident PAF developed in 17.0% of the patients without clinically evident PAF at diagnosis. We did not find statistically significant association between subclinical PAF and later development of clinically evident PAF [adjusted hazard ratio, 2.438; p = 0.15]. A considerable proportion of Korean paediatric CD patients had clinically evident and subclinical PAF. Fistula length and dominant feature of the tract on MRI are useful predictors of outcomes.

High failure rates following ligation of the intersphincteric fistula tract for transsphincteric anal fistulas: are preoperative MRI measurements of the fistula tract predictive of outcome?

Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence. Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed. 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n=9), posterior (n=7) or lateral (n=6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%). The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

Photodynamic Therapy for the Treatment of Complex Anal Fistula.

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula. This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J). In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively. i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel.

Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing. A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months. Thirty patients (16 males, median age 52 years, range 26-72years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30months (range 6-24months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30mm were associated with a primary healing rate of 58.3% while tracts longer than 30mm were cured in only 16.6% of cases (p < 0.02). Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.

Resection of puncture site necrosis over an arteriovenous fistula: Endoclamp use for preservation of cannulation sites

Skin necrosis overlying an arteriovenous fistula at the cannulation site is a common and potentially life-threatening problem, often associated with underlying aneurysm formation. Arteriovenous fistula-skin necrosis generally requires resection of surrounding skin margins and the underlying aneurysmal vessel wall, allowing repair with healthy tissue of the arteriovenous fistula in addition to closure of soft tissue and skin. In patients with insufficient fistula length, salvage of these arteriovenous fistulas may result in difficult or insurmountable cannulation issues leading to attempts at one-needle cannulation dialysis or, most often, catheter placement. Pre-existing stents or extensive calcification may add to the technical challenge of gaining proximal and/or distal control. We describe our technique for dealing with such arteriovenous fistula-skin necrosis lesions utilizing endo-occlusion with an angioplasty balloon for vascular control, allowing a limited incision and tissue resection with preservation of arteriovenous fistula cannulation length.

Randomized clinical trial comparing a small intestinal submucosa anal fistula plug to advancement flap for the repair of complex anal fistulas

IntroductionCurrent treatments for complex anal fistulas are associated with substantial variability in healing, recurrence, and incontinence rates. This study compared the effectiveness and safety of the Biodesign anal fistula plug to the anorectal advancement flap in patients with transsphincteric anal fistulas. MethodsA total of 82 patients attending coloproctology clinics in Germany were enrolled in this prospective, non-blinded, multicenter trial and randomized to the advancement flap or the plug. Study endpoints included healing rates, health-related quality of life, continence-related quality of life, pain, and safety at the time of surgery and 2 weeks, 3, 6, and 12 months following surgery. ResultsFollow-up at 12 months (n = 82) revealed healing rates of 67% for the plug and 76% for the flap (p = 0.56), with the noninferiority analysis confirming equivalence (p = 0.47). Fecal continence rates and the overall safety profile were similar between the two interventions. There were trends for lower pain scores at the time of surgery and 2 weeks postoperatively, and higher overall quality of life in the plug group. The surgical time required for the plug procedure was, on average, 34% shorter than the time required for the advancement flap. Regardless of treatment group, higher healing rates were observed in patients with a higher body mass index (p = 0.03), shorter fistula length (p = 0.01), and fewer previous colorectal surgeries (p < 0.001), while prior colorectal surgeries were associated with lower healing rates (p = 0.026). ConclusionsThe plug and advancement flap were equally effective treatments for complex anorectal fistula, with the plug associated with significantly less surgical time and a favorable safety profile. Clinical trial registrationNCT00545441.

Assessment of Microbiota and Their Drug Resistance in Chronic Fistulous Tracts.

Bacteria colonizing an enterocutaneous fistula tract have not been clarified. The aims of this study were to investigate the pathogen spectra of fistulous tracts and their resistance to antibiotics in patients with chronic fistulas. We conducted a one-year prospective single-center study. In the absence of significant sepsis, consecutively stabilized patients with chronic enterocutaneous fistula were included. Microbiology and antimicrobial susceptibility of isolates from the tracts were analyzed. The correlations between the existence of bacteria and various clinical values were investigated further. Forty-one patients were enrolled, of whom eight had a negative culture. A total of 48 bacterial strains were harvested, including 42 strains of gram-negative bacteria and six strains of gram-positive bacteria, most of which were multiple-drug-resistant. The three bacteria cultured most often were Escherichia coli (11 strains; 22.9%), Pseudomonas aeruginosa (eight strains; 16.7%), and Klebsiella pneumoniae (eight strains). Binary logistic regression analysis with forward (conditional) stepwise selection found that fistula length correlated with positive bacterial results (p=0.018). Other variables, namely entire length of hospitalization and fistula duration and location, were unrelated to the presence of micro-organisms in fistula tracts. Multiple-drug-resistant gram-negative bacteria were the main pathogens colonizing chronic fistula tracts. Fistula length was significantly associated with the presence of pathogens in a multivariable logistic regression model.

Fibrin glue closure for intractable pancreatic fistulae after pancreaticoduodenectomy.

Treatment of pancreatic fistulae after pancreaticoduodenectomy is extremely important because it determines the patient's postoperative course. In particular, treatment of grade B cases should be conducted in a timely manner to avoid deterioration to grade C. We report the successful treatment of six cases of postoperative intractable, grade B pancreatic fistulae, in which fistula closure was achieved through the use of tissue adhesive. Six subjects presented at our hospital with grade B pancreatic fistulae after pancreaticoduodenectomy. In all cases, the drain amylase values were high immediately after the operation, and the replacement of the drain was enforced. Closure of the fistula was performed by pouring tissue adhesive into the fistula from the drain, after the fistula had been straightened. Closure of the fistula was achieved in all six cases at the first attempt. The average fistula length was 13.2 cm, the average volume of pancreatic fluid discharge just before treatment was 63.3 mL, the average amylase value in the drainage was 40,338.5 IU/L, and the subjects were discharged from hospital an average of 8.8 days after treatment. There were no recurrences after treatment. Intractable pancreatic fistulae can be effectively treated using the tissue adhesive method.

Comparison of Binary Models for the Associated Factors Affecting Recovery Status of Vesico-vaginal Obstetrics Fistula Patients: A Case of Mettu Hamlin Fistula Center, South West Ethiopian

Background: Obstetric fistula or vaginal fistula is a medical condition in which a fistula (hole) develops between either the rectum or vagina or between the bladder and vagina after severe or failed childbirth, when adequate medical care is not available. It is the most tragic of preventable childbirth complications in the developing world, as affected women are often abandoned by their husbands and family, and forced to live in shame. Objective: The main objective the study was to determine an appropriate binary model for the recovery status of the vesico-vaginal patients. Furthermore, the study explores factors affecting the recovery status of the patients during the time period of the study. Methods: The study consists of 206 vesico-vaginal fistula patients having all required information who were taking treatment at Mettu Hamlin Fistula center from November 2010 to June 2014. The chi-square test of association was employed to explore the association between the recovery status and categorical independent variables. After exploring the association between the variables, different binary models were employed to have an appropriate model for the recovery status of the patients based on Akaki information criteria of the model. Results: The chi-square test of association showed that width of fistula length of fistula and bladder size categories were significantly associated with recovery status of the patients at 5% of level of significance. The study showed among the candidate binary models logistic model was considers an appropriate model. Furthermore, the fitted model showed width, length of fistula and bladder size categories were the factors that have significant effect on the recovery status of the patients at 5% level of significance. Conclusion: Logistic regression model was the better fit of the data whereas the fistula patients with width and length fistula category group between three up to five centimeter were less likely to be recovered comparison with the fistula patients group with width and length of fistula less than or equal to two centimeters. Similarly, the none bladder size category patients where less likely recover in comparison with fair bladder size fair bladder size group patients.

A Prospective Evaluation of the Ligation of the Intersphincteric Tract Procedure for Complex Anal Fistula in Patients With Crohn's Disease

To evaluate 2- and 12-month outcomes after ligation of the intersphincteric fistula tract (LIFT) in Crohn's disease (CD). Surgical approaches to perianal fistulas in CD are frequently ineffective and hampered by concerns over adequate wound healing and sphincter injury. The efficacy of LIFT in CD patients is unknown. Consecutive cases of CD patients with transsphincteric fistulas were prospectively analyzed. Fistula healing and 2 validated quality-of-life indices were assessed. Fifteen CD patients (9 women; mean age = 34.8 years) were identified. Location of the fistula was lateral (n = 10; 67%) or midline (n = 5; 33%). LIFT site healing was seen in 9 patients (60%) at 2-month follow-up. No patient developed fecal incontinence. LIFT site healing was seen in 8 of the 12 patients (67%) with complete 12-month follow-up. Significant factors for long-term LIFT site healing were lateral versus midline location (P = 0.02) and longer mean fistula length (P = 0.02). Patients who had successful operations significantly improved both their mean Wexner Perianal Crohn's Disease Activity Index and McMaster Perianal Crohn's Disease Activity Index quality-of-life scores at 2-month follow-up (14.0-3.8, P = 0.001, and 10.4-1.8, P = 0.0001, respectively). CD-associated anal fistulas may be treated with LIFT. This surgical procedure is a safe, outpatient procedure that minimizes both perianal wound creation and sphincter injury.

MRI predictors of treatment response for perianal fistulizing Crohn disease in children and young adults

Magnetic resonance imaging (MRI) is considered the imaging standard for diagnosis and characterization of perianal complications associated with Crohn disease in children and adults. To define MRI criteria that could act as potential predictors of treatment response in fistulizing Crohn disease in children, in order to guide more informed study interpretation. We performed a retrospective database query to identify all children and young adults with Crohn disease who underwent serial MRI studies for assessment of perianal symptoms between 2003 and 2010. We examined imaging features of perianal disease including fistula number, type and length, presence and size of associated abscess, and disease response/progression on follow-up MRI. We reviewed imaging studies and electronic medical records. Statistical analysis, including logistic regression, was performed to associate MR imaging features with treatment response and disease progression. We included 36 patients (22 male, 14 female; age range 8-21years). Of these, 32 had a second MRI exam and 4 had clinical evidence of complete response, obviating the need for repeat imaging. Of the parameters analyzed, presence of abscess, type of fistula according to the Parks classification, and multiplicity were not predictors of treatment outcome. Maximum length of the dominant fistula and aggregate fistula length in the case of multiple fistulae were the best predictors of treatment outcome. Maximum fistula length <2.5cm was a predictor of treatment response, while aggregate fistula length ≥2.5cm was a predictor of disease progression. Perianal fistula length is an important imaging feature to assess on MRI of fistulizing Crohn disease.

Right coronary artery fistula into left ventricle: dynamic compression shown by multislice computed tomography

1010-7940/$ — see front matter # 2007 European Association for Cardio-Thoracic doi:10.1016/j.ejcts.2007.08.027 A 44-year-old male with inferior-posterior myocardial ischemia during ECG stress test was referred to 64-slice computed tomography (CT). CT showed a right coronary artery (RCA) fistula draining into the left ventricle (Fig. 1, Video 1) with dynamic compression of the fistula orifice during systole (Fig. 2). CT provides helpful information about fistula location and length before surgery.

Transconjunctival Application of Mitomycin C in Combination with Laser Sclerostomy ab interno: A Long-Term Morphological Study of the Postoperative Healing Process

The precise mechanism whereby mitomycin C enhances IOP reduction in glaucoma filtering surgery still eludes us. Ten rabbits received full-thickness Nd:YAG laser sclerostomy ab interno and adjunctive intraoperative treatment with mitomycin C (MMC) applied topically over the intact conjunctiva (0.5 mg ml−1for 5 min). A systematic ultrastructural analysis of the fistulas and surrounding tissue was then conducted in conjunction with clinical observations, over the ensuing 10 weeks. In order to investigate also the extent to which MMC impedes fistula occlusion in the absence of percolating aqueous humour, we created non-perforating (‘half-thickness’) sclerostomies ab interno in three additional rabbits, one with and two without MMC therapy. Transconjunctival MMC application resulted in no serious complications. Eight of the ten full-thickness fistulas remained patent throughout the study, maintaining significant IOP reduction; the other two sclerostomies were compromised by iris incarceration. The MMC-treated, half-thickness canal remained as a tissue-free cul de sac; the two non-treated ones became completely occluded within one week without having recourse to extraocular cell populations. MMC suppressed the migration and proliferation of fibroblasts, macrophages and clump cells from the episclera, sclera, ciliary body and iris root. Repolymerization of heat-damaged collagen was abortive; neosynthesis was not observed. Myofibroblasts were encountered in the vicinity of the sclerostomy canals, and, after the fifth week, these cells were also found to be deployed as a canal-lining layer, delimiting the lumen from the surrounding stroma along most of the fistula length. Towards the external ostium, this layer of myofibroblasts was incomplete or absent. Near the internal ostium, lining cells were derived from the corneal endothelium.The transconjunctival mode of applying MMC appears to be efficient. This antifibrotic drug exerts its inhibitory influence by suppressing not only cell migration and proliferation, but also phagocytic and synthetic activities. However, exposed tissues are not acellular, and amongst the populations present, myofibroblasts are found to dominate the scene. The canal-delimiting cellular lining may play a role in maintaining fistula patency in MMC-treated eyes.