Location Of Fistula Research Articles

Clinical and genetic characteristics of 131 cases of congenital preauricular fistula

Objective:To investigate the clinical and genetic characteristics of congenital preauricular fistula. Method:The clinical data of 131 patients（143 ears） with congenital preauricular fistula. The patient's age distribution, sex ratio, side of fistula, number of fistula, location of fistula, concomitant malformation, course of infection, previous infection history, previous treatment history and family history were counted. Result:In this study, 54 cases（41.2%） were juveniles, 77 cases（58.8%） were adults, 118 cases（90.1%） were under 40 years old, and 13 cases were（9.9%） over 40 years old. The male to female ratio is 1：1.85, and the ratio of unilateral to bilateral patients is 3.7：1. The male to female ratio was 1：2.03 in unilateral patients and 1：1.33 in bilateral patients. The preauricular skin pit of 124 cases（94.7%） located at the anterior margin of the ascending limb of the helix, and The pit of 7 cases（5.3%） located at other areas such as the crus of helix（3 cases, 2.3%）, the anterosuperior wall of the external auditory canal（3 cases, 2.3%）, and the lower edge of the lobule（1 case, 0.7%）. 2 cases（1.4%） showed 2 fistulas in the anterosuperior wall of the external auditory canal, and 1 case showed a false fistula in front of the ascending limb of the helix, 141 ears（98.6%） showed a single fistula. Two cases were accompanied with accessory auricles, and one case with mild microtia. Before operation, 18 ears were non-infectious（12.6%） and 125 ears were infected（87.4%）. Among the infected ears, the course of infection ranged from 3 days to 1 year, 110 ears（76.9%） were in the course from 0 to 3 months. 14 ears had pre-operation history（9.8%） and 62 ears had incision and exclusion history（43.4%）. 84 people（64.1%） had no family history and 47 people（35.9%） had family history. There were 26（19.8%） families showed vertical inheritance, 7（5.3%） families showed atavistic pattern, and 14（10.7%） families showed familial susceptibility. Conclusion:CPF is more common in female, and usually unilateral and occasionally bilateral. there is no significant difference between the left and right sides. The vast majority of patients showed a single fistula at the anterior margin of the ascending limb of the helix. Very few patients had fistula at the crus of helix, the upper wall of the external auditory canal, and the lower edge of the lobule. CPF can be accompanied with accessory auricles and mild microtia. The clinical features of special type of preauricular fistula and syndromic preauricular fistula should be emphasized. Most patients are in an acute infection period, and drainage of the abscess is the main treatment for the infection. CPF is often sporadic. It may be inherited as an autosomal dominant incomplete pattern with variable power of expression.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

68Ga-NEB PET/CT can be a new method for diagnosing chylous fistula

Rationale:We hypothesize that with the determination of lymph fistula location 3-dimensionally, application of appropriate pressure would promote fistula healing, and a secondary surgery may be avoided. 68Ga-labeled 1,4,7-triazacyclononane-N, N’, N”-triacetic acid (NOTA) conjugated with truncated Evan blue (NEB) forms a complex with serum albumin in the interstitial fluid after it is locally injected and allows rapid visualization of the lymphatic system.Patient concerns:A 44-year-old woman had a chief complaint of left nipple discharge. A 38-year-old woman came to the hospital after sensing a right breast mass.Diagnoses:The 2 patients were diagnosed with chylous fistula after breast cancer surgery based on the findings of a novel method, 68Ga-NOTA-Evans Blue (NEB) positron emission tomography/computed tomography.Interventions:We successfully obtained clear images to locate the fistula using 68Ga-NEB positron emission tomography/computed tomography (PET/CT) for both patients. The lymphatic vessels and lymph nodes could be clearly visualized owing to the 68Ga-NEB activity during PET/CT.Outcomes:Three-dimensional positioning to locate the fistula could direct the application of the pressure dressing and reduce drainage markedly.Lessons:68Ga-NEB PET/CT may be a new method for diagnosing chylous fistula and providing guidance for treatment.

Rectourethral and rectovesical fistula as serious and rare complications after Hirschsprung disease operation: Experience in seven patients

AimTo present the features and treatment of rectourethral fistula (RUF) and rectovesical fistula (RVF) after Hirschsprung disease (HD) operation. MethodsA retrospective analysis was performed on patients with RUF and RVF after HD operation, who received repair surgery from a single surgeon between January 2005 and December 2019. Bowel function was assessed using the Rintala score. ResultsSeven patients were included. Six patients were referred to us after transanal endorectal pull-through (TEPT) in other centers; one RVF patient had fecal diversion at admission. Bladder-neck injury was detected during redo TEPT in our hospital in the remaining one patient and instant repair was given. 11 days later, RVF and sepsis were detected.Fecal and urine diversion was performed immediately. The fistula openings were prostatic urethra (3), membranous urethra (2), bladder triangle (1), and bladder-neck (1). Anastomotic stricture (4), bladder stone (3), hydronephrosis and ureterovesical junction obstruction (2), pelvic infection (2), distal colonic dilatation (1) and other fistulas (1) were identified before repair surgery. Fecal and urine diversion was performed before repair surgery in one RUF and one RVF patient respectively, to treat pelvic infection owing to fecal or urine leaks and accompanying problems. Five RUFs were repaired by transperineal approach, and two RVFs were repaired using the transabdominal and transanal approach respectively. Four patients with anastomotic stricture underwent redo TEPT with simultaneous fistula repair. Aside from one RUF patient, the fistula in all patients successfully resolved. Median follow up time was 81 months (range, 5–116 months). No recurrence was observed. Median bowel function score was 17.5 (range, 17–18). ConclusionThe location of fistula, presence of anastomotic stricture and the association of urinary complications have significant impacts on the treatment strategy in such rare complications after TEPT for HD. The type of studyTreatment study. Level of evidenceLevel IV.

Pial arteriovenous fistula: A clinical and neuro-interventional experience of outcomes in a rare entity

Purpose:Pial arteriovenous fistulae (PAVF) are rare intracranial vascular malformations, predominantly seen in children and distinct from arteriovenous malformations and dural arteriovenous fistulae. PAVF often leads to high morbidity and mortality. The aim of our study was to describe the clinical features and endovascular management of PAVF at various intracranial locations; to analyze the use of liquid embolic agents and coils alone or in combination in the treatment of PAVF and to analyze the outcome of embolization.Materials and Methods:Retrospective review of diagnostic angiography and neurointerventional database of our institution identified a cohort of 15 patients with non-galenic PAVF from 2008 to 2014 out of 6750 patients. Fourteen patients were treated endovascularly with coils and liquid embolic materials in combination or alone. Patients were followed up for evaluation of prognosis.Results:Age of the patients ranged from 3 to 37 years. Most patients were male and most common presentation was headache followed by seizure. Most common location of fistula was frontal lobe. The most common type was single artery single hole fistula with venous varix. Satisfactory obliteration was seen in all cases. One patient developed intraparenchymal hematoma on the first post procedural day and outcome was poor.Conclusions:PAVF are rare intracranial vascular malformations which can effectively be managed endovascularly with liquid embolic, coils alone, or in combination. Complete occlusion of the fistula can be achieved in most cases in a single sitting with a reasonable morbidity related to the procedure, compared with the natural history of this disease.

Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes

IntroductionCranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes. MethodsTwenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months. ResultsFour patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5. ConclusionsComplex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.

Outcome of urethrocutaneous fistula repair after hypospadias surgery

Background: Urethrocutaneous fistula is the most prevalent complication after urethroplasty. Many methods have been developed for correction, and the best technique is determined based on the size, location, and number of fistulas, as well as the status of the surrounding skin.
 Objective: To compare the outcome of local dartos flap and tunnelled tunica vaginalis coverage in cases of repair of urethrocutaneous fistula.
 Materials and Methods: In the period of 2015-2018, 51 patients with 51 fistulas with an average age of 81.3 months (range 21-156 months) were classified into coronal-19, distal penile-11, mid penile-14, proximal penile-5 and penoscrotal-2. Thirty six patients were repaired with local dartos flap coverage and 15 patients were repaired with tunnelled tunica vaginalis coverage.
 Results: The repair was successful in all patients of tunica vaginalis coverage but 7 patients of dartos flap coverage developed recurrent fistulas (p value 0.066). There was no patient of scrotal complications. There were no statistically significant differences regarding age (p=0.83), location of fistula (p=0.40), size of fistula (p=0.29).
 Conclusions: Though the result of this study with such a small sample was not statistically significant, tunica vaginalis coverage seems to be better than dartos flap coverage in preventing recurrence.
 Bang Med J (Khulna) 2019; 52 : 3-6

56: Evaluating risk factors associated with need for blood transfusions after urogenital fistula repair in Uganda

Urogenital fistulae are a devastating condition prevalent in countries where women do not readily have access to emergency obstetric services. In this study, our primary objective was to determine the incidence of and risk factors for perioperative blood transfusions after urogenital fistulae repair in Uganda. An IRB approved retrospective cohort study was conducted to identify the incidence of and risk factors for blood transfusions after urogenital fistula repair. Inclusion criteria included women who underwent repair of urogenital fistula at Kitovu Hospital in Masaka, Uganda between 2013 and 2018. All types of urogenital fistula were included (vesicovaginal, urethrovaginal, vesicouterine, and those with ureteral involvement). Descriptive statistics were calculated for demographic and clinical covariates. Logistic regression was used to calculate the crude odds ratios (ORs) and 95% confidence intervals (CIs) for each risk factor of interest. A final model was constructed using stepwise multivariable logistic regression in which risk factors with a significance level <0.05 remained in the model. All statistical tests were two-sided and declared significant at p < 0.05. A total of 546 patients treated for urogenital fistulae were identified. The median age was 31.3 ± 13.2. Median duration of labor was 48 hours (interquartile range: 36-72 hours). Median parity was 3 (interquartile range: 1-6). Approximately 94% of fistulae were caused by obstetric means, while 4% were related to gynecologic surgery. Less than a third of patients had previous fistula repairs (25.5%). Most VVF patients delivered via Cesarean section (58.6%), and 23.8% delivered via spontaneous vaginal delivery. The most common location of fistulae were juxta-cervical or vault fistulas (20.7%). A vaginal surgical approach was used in the majority of patients (84.6%) compared to abdominal (11.7%) or combined approaches (3.5%). Complications occurred in 3.5% of surgical repairs, and the incidence of blood transfusions was 6.2%. Multivariable analyses identified time with fistula, surgical approach, and delivery outcomes as statistically significant risk factors of a need for blood transfusions. Patients who delivered stillbirths were 3.84 (95% CI: 1.23–11.97) times more likely to require postoperative blood transfusions than live births, while surgical fistula repairs approached abdominally (non-vaginally) were 8.10 (95% CI: 3.53–18.60) times more likely to require transfusions than vaginal operations. Furthermore, patients who had been living with the condition for less than three months had a higher risk of a blood transfusion. This study identified an incidence of blood transfusions among urogenital fistula repairs in our population of approximately 6%. Time with fistula, delivery outcomes and surgical approach were significant risk factors for the need for blood transfusions.

Steroid-Associated Acute Clinical Worsening and Poor Outcome in Patients With Spinal Dural Arteriovenous Fistulas: A Prospective Cohort Study.

A prospective cohort study. We conducted a prospective cohort study to identify the association between steroids and clinical worsening and compare outcomes between patients with and without preoperative steroid administration. Patients with spinal dural arteriovenous fistulas (SDAVFs) often were misdiagnosed and treated with steroids which led to acute worsening. Patients with angiographically confirmed SDAVFs were recruited consecutively between March 2013 and December 2014 in two referral centers. We reviewed the history of all the patients to identify those patients who were treated with steroids before exclusion of the fistulas. Modified Aminoff & Logue scale (mALS) was used to evaluate the spinal cord function at different time points: before and after steroid administration, before operation, and at 1-year follow-up. Paired t tests were used to assess the mALS of patients with steroid administration at different time points. Unpaired t tests and Pearson chi-square test were used to assess differences between patients with and without steroid administration. Eighteen patients with (18.2%) and 81 patients without (81.8%) steroid administration were included in this study. At baseline, there were no difference between both patient groups, in regards to age, sex, duration, location of fistula, treatment, and preoperative mALS. Patients without steroid administration, however, had statistically significant better outcome according to their mALS at 1-year follow-up (P < 0.05). Steroid administration can induce acute clinical worsening in patients with SDAVFs that may persist despite successful obliteration of the fistula and should thus be avoided. 3.

Diagnosis and treatment of spinal dural arteriovenous fistula: A report of 14 cases

Objective To analyze the diagnosis and treatment of spinal dural arteriovenous fistula (SDAVF). Methods The clinical data of 14 patients with SDAVF admitted to Department of Neurosurgery, General Hospital of the Eastern Theater Command from May 2008 to May 2018 were analyzed retrospectively. All patients underwent the examinations of preoperative spinal cord MRI and spinal cord angiography to identify the region of SDAVF and the location of fistula. Microsurgical resection of SDAVF was conducted via semi-lamina approach. The modified Aminoff-Logue score was used to evaluate the spinal function before operation, after operation and during the follow-up period. Results No abnormal fistulas or tortuous dilated drainage veins were detected by spinal cord angiography after operation in 14 patients. The modified Aminoff-Logue score [median (upper and lower quartiles)] before operation and post operation in those 14 patients were as follows: gait: 2.0 (1.0, 3.0) points vs. 2.0 (1.0, 2.0) points, urinate: 2.0 (0, 2.0) points vs. 1.0 (0, 2.0) points, defecate: 1.0 (0, 2.0) points vs. 0.5 (0, 1.0) points. The postoperative scores were improved compared to preoperative scores (all P<0.05). Of those 14 patients, 6 were lost to follow-up and 8 were followed up for 7.5 (4.5, 12.0) months. The gait, urinate and defecate scores were 0.5 (0, 1.0), 0 (0, 0.7) and 0 (0, 0.5) respectively, which have improved compared with those before operation (all P<0.05). No recurrence of the lesion was found in 8 patients during the last follow-up. Conclusions Spinal cord angiography is the gold standard for the diagnosis of SDAVF. Microsurgery via semi-lamina approach is an effective method for the treatment of SDAVF. The spinal cord function of patients can be improved significantly. Key words: Arteriovenous fistula; Spinal dura; Microsurgery; Clinical characteristics; Spinal cord function

Management of spinal dural arterio venous fistula with peri-medullar drainage

Introduction: Spinal Dural Arterio Venous Fistula (SDAVF) is an arteriovenous communication on the spinal dura with peri-medullar venous drainage. It is a curable cause of myelopathy and the most common form of spinal arterio venous malformation (AVM). The average age of revelation is the fifth decade; it is a diagnostic and therapeutic emergency.&#x0D; Materials and methods: This is a retrospective study conducted in the neuro surgical department of CHU Bab El Oued in Algiers during a five years time from November 2013 to September 2018. We assessed the clinical status of patients according to the Aminoff-Logue disability score before and after surgery. All patients did a total spine MRI followed by a Medullar angiography which facilitated the pin-pointing of the exact location of the dural fistula. The mean follow-up is 30 months.&#x0D; Results: There were five males and two females, all of them older than 45 years of age. At the admission, patients presented with signs of neurological deficits. After the diagnosis of SDAVF the surgical intervention consisted of a disconnection of the arteriovenous communication by coagulation and section of the fistula at the foot of the vein after a laminectomy. Functional rehabilitation was prescribed for all patients and they were regularly followed-up.&#x0D; Conclusion: Treatment of AVF is surgical or endovascular. Results depend largely on preoperative neurological status.

Effect of General Anesthesia Versus Regional Brachial Plexus Block on Patency of Vascular Access for Hemodialysis

Primary arteriovenous fistula (AVF) remains the best vascular access for hemodialysis since it has the best long-term primary patency rate, requires less interventions/maintenance, and has the lowest incidence of morbidity and mortality. For this reason, the National Kidney Foundation began the “Fistula First Breakthrough Initiative”, which seeks to increase the amount of successful AVFs placed. Multiple factors play a role in primary AVFs creation; Vein diameter/quality, artery diameter/quality, central venous disease, hypercoagulable states and fistula location. Multiple studies have demonstrated the benefits of creating AVFs under regional anesthesia; Avoiding hemodynamic instability and stress response of general anesthesia and vasodilatation cause and effects. Due to the fact that vein diameter is the major limiting factor for primary AVFs creation and maturation, our aim is to investigate if the vasodilation that accompanies regional anesthesia leads to improved patency and maturation rate of autologous AVF and graft.

Surgical repair of rectovaginal fistulas: predictors of fistula closure

Introduction and hypothesisWe report the clinical outcome of surgical repair for rectovaginal fistula (RVF) carried out by one operative team. We also investigate the predictive factors for fistula healing.MethodsA retrospective cohort of 63 patients underwent local surgical repair of RVF during January 2008 and December 2017 by one operative group. The clinical features of the patients were reviewed. The association between fistula closure and diverse clinical parameters, including operative method, fistula location, prior repair, and diverting stoma, was analyzed.ResultsSixty-three consecutive patients underwent 80 local surgical repairs by our surgical team. Forty-five patients eventually healed after an average of 1.22 procedures. The overall success rate per procedure was 71.2%, whereas the closure rate of the first operation was 55.5% (n = 35). The etiology of the fistula did not impact on the success rate of surgical repair. The history of prior repair predicted a lower success rate on both overall procedure (RR = 0.59, 95% CI 0.41–0.85, p = 0.008) and the first repair in our institution (RR = 0.50, 95% CI 0.31–0.80, p = 0.003). There was no difference in closure rate between the stoma group and the non-stoma group. Nevertheless, among the 15 patients who underwent more than one operation in our center, a diverting stoma seemed to be necessary (10 patients healed in the stoma group and none of the patients healed in the non-stoma group, p = 0.02).ConclusionsHistory of prior surgical repair is a risk factor for failure. Diverting stoma did not increase the overall closure rate, but it seemed to be necessary for patients in whom the first operation failed.

Hurdles in managing tracheoesophageal fistula: case report

Congenital tracheoesophageal fistula (TOF) is a rare anomaly. With the development of endoscopic techniques, the diagnosis of TOF has made marked progress. It requires surgical repair in infancy by either open or thoracoscopic approach. Diagnosing and locating the location of fistula may be difficult particularly in smaller fistula. We report three cases of TOF, to highlight the role of bronchoscopy and endoscopy and also the challenges in managing the aforementioned cases, which may present with airway embarrassment.

On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair.

The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development. Systematic review. Various primary cleft and craniofacial centers in the world. Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery. Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports. The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty. The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate-hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor. Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.

Transvaginal Repair of Vesico Vaginal Fistula: A 10-Year Experience with Analysis of Factors Affecting Outcomes

Objectives: To highlight the transvaginal route as an excellent approach for repair of a simple trigonal, supra-trigonal vesico-vaginal and urethrovaginal fistulae without compromising on the successful patient outcomes. We also determine factors affecting outcomes in such patients. Materials and Methods: A retrospective analysis was carried out on 58 patients with simple trigonal, supra trigonal and urethrovaginal fistula who underwent transvaginal repair in the last 10 years. Simple fistulas were defined as fistula less than 3 cm in size or recurrent fistulae less than 1.5–2 cm in size and located either supra-trigonally (above the bar of mercier) or sub-trigonally (below the bar of mercier) as determined by cystoscopy. Results: Obstetric cause, due to obstructed labour, was the most common cause of fistula formation (68.96%), while remaining (29.31%) were attributed to hysterectomy. Primary fistulae were found in 68.9% of patients and recurrent fiistulae in 31.1% patients. The mean age of patients was 33.4 years. Average fistula size was 1.5 cm. The success rate of primary operation was 84.12% (50/58). On using a multivariate regression model, the underlying aetiology (OR 2.2), fistula location (OR 2.5) and history of previous repair (OR 2.4) were found to be significant factors affecting outcome. Conclusion: The transvaginal approach is less invasive and achieves comparable success rates as compared to other methods of vesico-vaginal fistula repair. This surgery with Foley catheter has a high success rate with reduced morbidity. We postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible vesico vaginal fistulae, both of obstetrical and gynaecological origin.

Steroid Associated Acute Clinical Worsening and Poor Outcome in Patients with Spinal Dural Arteriovenous Fistulas: A Prospective Cohort Study

Background: Steroid induced clinical worsening in patients with spinal dural arteriovenous fistulas (SDAVFs) has previously been reported in some case reports. However, it is not clear whether steroid administration also affects postoperative outcome. Objective: We conducted a prospective cohort study to identify the association between steroids and clinical worsening and compare outcomes between patients with and without preoperative steroid administration. Methods: Patients with angiographically-confirmed SDAVFs were recruited consecutively between March 2013 and December 2014 in two referral centers. We reviewed the history of all the patients to identify those patients who were treated with steroids prior to exclusion of the fistulas. Modified Aminoff & Logue's scale (mALS) was used to evaluate the spinal cord function at different time points: before and after steroid administration, before operation and at 1-year follow-up. Paired t tests were used to assess the mALS of patients with steroid administration at different time points. Unpaired t tests and Pearson chi-square test were used to assess differences between patients with and without steroid administration. Results: 18 patients with (18.2%) and 81 patients without (81.8%) steroid administration were included in this study. At baseline, there were no difference between both patient groups, in regards to age, gender, duration, location of fistula, treatment and preoperative mALS. However, patients without steroid administration had statistically significant better outcome according to their mALS at 1-year follow-up (P<0.05). Conclusion: Steroid administration can induce acute clinical worsening in patients with SDAVFs that may persist despite successful obliteration of the fistula and should thus be avoided. Funding: This work was supported by the National Natural Science Foundation of China (Award Number: 81171165;81671202); Beijing Municipal Science and Technology Commission (Award Number: D161100003816001). Declaration of Interest: None declared. Ethical Approval: This study was approved by the Institutional Ethics Committees at each site. Informed consent was obtained from each patient.

Comparison of diagnostic accuracy for fistulae at ultrasound and voiding cystourethrogram in neonates with anorectal malformation

Recently, it has been reported that anorectal malformation with rectourethral fistula in male neonates can be managed by primary neonatal reconstruction without colostomy. To prevent urethral injury during anorectoplasty, the fistula's location is important. To date, the use of voiding cystourethrograms to determine the presence and location of fistulas in neonates with anorectal malformations has not been studied. To compare the accuracy of ultrasound (US) and voiding cystourethrogram for determining the presence and location of fistulas in neonates with anorectal malformation. We included 21 male neonates with anorectal malformation with rectourethral fistula (n=16), rectovesical fistula (n=1) or no fistula (n=4) who underwent US and voiding cystourethrogram preoperatively on the day of surgery. Fistula imaging was classified into three grades (0-2), and grades 1-2 were considered fistula positive. We compared the imaging-based location of the fistula with surgical findings. US performed significantly better than voiding cystourethrogram for determining the presence of fistulas (area under the receiver operating characteristic curve, 0.90 vs. 0.71, respectively; P=0.044) (diagnostic accuracy 85.7%, 95% confidence interval [95% CI] 63.7-97.0% and 52.4%, 95% CI 29.8-74.3%, respectively). In cases with fistulas detected by either modality, the accuracy of locating the fistula by US was 50.0% (95% CI 24.7-75.3%) and by voiding cystourethrogram was 100% (95% CI: 59.0-100%). US accurately detected, but did not accurately locate, fistulas in neonates with anorectal malformation. When planning primary neonatal reconstruction of anorectal malformation without colostomy, voiding cystourethrogram could provide additional information about fistula location.

Utilizing real-time contrast medium to detect the fistula of giant spinal arachnoid cyst and treat with minimal invasive surgery

BackgroundSpinal arachnoid cysts are rare and have varied clinical manifestations depending on the affected spinal region and nerve roots. A complete cyst excision with fistula closure is the first choice of treatment. However, it might be difficult to localize the specific position of the fistula because previous images have no enhancements or the fistula is too tiny to be detected.Case presentationThis case is a giant lumbar extradural arachnoid cyst. We administered a lumbar injection with contrast medium into subarachnoid space under digital subtraction angiography (DSA) and disclosed the fistula. Confirming the location of fistula enabled us to perform minimally invasive surgery to ligate the fistula. Surgical intervention for a spinal arachnoid cyst might encounter the problem of the formation of a postoperative cerebrospinal fluid (CSF) fistula. We propose the option of detecting the fistula preoperatively for minimal invasive surgery. Recurrence depends on the long-term follow-up, and more cases are needed to further evaluate our technique.ConclusionsThe real-time contrast medium technique for spinal arachnoid cysts contributes to the complete ligation with minimally invasive surgery.

Distal Microcatheter Placement Using the ASAHI CHIKAI 008 Microguidewire for Liquid Embolic Material Delivery

Management of vascular malformations requires microcatheter manipulation through distal tortuous arterial feeders <1 mm in diameter to permit safe and effective embolization at the fistula or nidus location. The ASAHI CHIKAI 008 microguidewire (ACM) recently introduced in the United States was used to evaluate microcatheter torque, support, and safety in distal microcatheter navigation. The use of the ACM in conjunction with flow-directed and over-the-wire microcatheters was evaluated in 25 neuroendovascular cases performed by a single operator for endovascular microcatheter embolization of intracranial vascular malformations over a 1-year period. The study evaluated angiographic evidence of distal microcatheter positioning, subsequent obliteration of the fistula at the location, and any complications. The microguidewire was used in microcatheter embolization of 10 vein of Galen malformations, 11 brain and head and neck arteriovenous malformations, 2 spinal dural arteriovenous fistulas, and 2 cranial dural arteriovenous fistulas. Good flow-directed and over-the-wire microcatheter placement using the ACM was possible across the spectrum of cases achieving optimal catheterization and safe embolization in all. There were no microguidewire- or microcatheter-related vessel spasms, dissections, or perforations during combined or individual manipulation and no contrast or embolic extravasation on fluoroscopy or postembolization angiography. The ACM is a safe, sturdy microguidewire that provides good torque in distal arterial anatomy, while providing microcatheter support and maintaining tip configuration on repeated use.