Obliteration Of Fistula Research Articles

Use of a sternocleidomastoid rotational and cervical-fascial advancement flap for closure of a persistent mastoid cutaneous fistula.

Post-auricular mastoid fistula is a rare occurrence. It typically appears following repeated soft tissue injury, and is commonly caused by chronic suppurative otitis media and repeated surgical treatments. Management is challenging, with few reported successful surgical techniques, which often have limited applicability. This paper presents the case of a 58-year-old male with a persistent right-sided post-auricular cutaneous mastoid fistula resulting from two previous mastoidectomies. Although the patient underwent two simple primary closures, the fistula recurred. This was successfully treated with a new technique utilising a sternocleidomastoid rotational and cervical-fascial advancement flap, which was completely healed at the one-year follow up without a recurrence of the fistula. This novel technique provided definitive obliteration of a persistent cutaneous mastoid fistula. Utilising a double-layered flap and a facelift incision results in excellent functional and cosmetic outcomes.

Anterior Cranial Fossa Dural Arteriovenous Fistulae - Angioarchitecture and Intervention.

Anterior cranial fossa (ACF) dural arteriovenous fistulae (DAVF) are rare, unique, and ominous. While surgical disconnection is considered as the favored management option, endovascular treatment has lately gained importance. We present asingle institution experience of seven cases. Aretrospective analysis was performed on the institutional patient database. Features analyzed were demographic details, symptoms, angioarchitecture, treatment course, angiographic results, procedural complications, and follow-up. This study included seven patients. The age at presentation ranged from 5-67years. Clinical symptomatology was as intracranial hemorrhage in 4patients and headache, chemosis and seizures in one patient each. The fistulae were paramedian at the ACF base. All DAVFs were Cognard type4. The arterial feeders were from the anterior ethmoidal branches of the ophthalmic artery in all cases (bilateral in n = 5), frontal branches of the middle meningeal artery (MMA) (n = 6), and multiple ECA branches. The arterial route was the choice for access. Complete fistula obliteration was achieved in all but one patient. Atraversed vein underwent rupture in one patient. One patient suffered postsurgical hemorrhage. No clinical or angiographic recurrence was noted. The DAVFs of the ACF are inherently high-grade lesions. Transorbital ECA-ICA branch anastomoses may be recruited as feeders. They may be best managed by multidisciplinary means personalized on an angioarchitectural basis. Endovascular embolization is safe and efficacious when performed through anavigable feeder from the frontal division of the MMA, which according to our interpretation is in anastomosis with the anterior falcine branch of the anterior ethmoidal artery.

V07-07 REVISION VAGINOPLASTY WITH ROBOTIC ASSISTANCE FOR NEOVAGINAL OBLITERATION SECONDARY TO RECURRENT RECTO-NEOVAGINAL FISTULA

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-07 REVISION VAGINOPLASTY WITH ROBOTIC ASSISTANCE FOR NEOVAGINAL OBLITERATION SECONDARY TO RECURRENT RECTO-NEOVAGINAL FISTULA Alexandr Pinkhasov*, Kathryn Scott, Prashant Upadhyaya, Gennady Bratslavsky, and Dmitriy Nikolavsky Alexandr Pinkhasov*Alexandr Pinkhasov* More articles by this author , Kathryn ScottKathryn Scott More articles by this author , Prashant UpadhyayaPrashant Upadhyaya More articles by this author , Gennady BratslavskyGennady Bratslavsky More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To describe a case of neovagina revision following vaginal stenosis and complete obliteration in a patient 1 year post gender affirmation surgery. METHODS: The patient was a 23 year old transgender female who underwent combined penile and urethral inversion vaginoplasty in 2017. The initial postoperative course was complicated by unrecognized rectovaginal fistula formation. She subsequently underwent multiple repairs which impaired her ability to perform vaginal dilation. Dilations were stopped with eventual development of vaginal stenosis and ultimately obliteration. The patient underwent reconstruction with a combined perineal and robotic approach. The surgical steps included: 1) dissection of the urethral plate to be used in later neovaginal creation 2) robotic pelvic dissection; a plane between the prostate and rectum was developed for implantation of the neo-vagina 3) revision urethroplasty and meatal repositioning 4) creation of neovagina from local flaps; the ventral plate of the penile urethra was used to construct the anterior vaginal wall while the posterior was composed of excess scrotal skin in combination with perineal flaps 5) robotic fixation of neovagina. The reconstructed neo-vagina was inverted into the pelvis where robotic assisted dissection had developed a cavity. The neovagina was secured to the perivesical and peritoneal tissues. The patient underwent revision clitoroplasty and labioplasty for esthetic complaints. RESULTS: The patient was discharged on postoperative day 1 and vaginal packing removed on day 7. She was followed with regular exams and questionnaires. At two month follow-up she was performing vaginal dilations without difficulty or pain and by six months she was found to have a vaingal depth of 12 cm. On global response assessment survey she rated herself as “markedly improved” CONCLUSIONS: Revision vaginoplasty with neo-vaginal reconstruction may be used to correct complications related to prior fistula and/or cavity obliteration. A combined perineal and robotic approach is recommended to allow for careful dissection in a previously operated field. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e645-e645 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandr Pinkhasov* More articles by this author Kathryn Scott More articles by this author Prashant Upadhyaya More articles by this author Gennady Bratslavsky More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Application of hybrid operating rooms for treating spinal dural arteriovenous fistula.

BACKGROUNDA hybrid operating room (hybrid-OR) is a surgical space that combines a conventional operating room with advanced medical imaging devices.AIMTo explore and summarize the technical features and effectiveness of the application of a hybrid-OR in dealing with spinal dural arteriovenous fistulas (SDAVFs).METHODSEleven patients with SDAVFs were treated with the use of a hybrid-OR at the Department of Neurosurgery of our hospital between January 2015 and December 2018. The dual-marker localization technique was used in the hybrid-OR to locate the SDAVFs and skin incision, and the interoperative digital subtraction angiography (DSA) technique was used before and after microsurgical ligation of the fistulae in the hybrid-OR to verify the accuracy of obliteration. The patients were followed for an average of 2 years after the operation, and the preoperative American Spinal Cord Injury Association (ASIA) score and postoperative ASIA score at 6 mo after the operation were compared.RESULTSThe location and skin incision of the SDAVFs were accurately obtained by using the dual-marker localization technique in the hybrid-OR in all patients, and there were no cases that required expansion of the range of the bone window in order to expose the lesions. Intraoperative error obliteration occurred and was identified in two patients by using the intraoperative DSA technique; therefore, the findings provided by the intraoperative DSA system significantly changed the surgical procedure in these two patients. With the assistance of the hybrid-OR, the feeding artery was correctly ligated in all cases, and the intraoperative error obliteration rate decreased from 18.2% (2/11) to 0%. All 11 patients were followed for an average of 2 years. The ASIA score at 6 mo after the operation was significantly improved compared with the preoperative ASIA score, and there were no patients with late recurrence during the follow-up.CONCLUSIONCompared with intra-arterial embolization for the treatment of SDAVFs, hybrid-ORs can solve the problem of a higher incidence of initial failure and late recurrence. Compared with direct occlusion of SDAVFs in microsurgery, hybrid-ORs can take advantage of the intraoperative DSA system for locating the shunt and verifying the obliteration of fistulae in order to reduce the error obliteration rate. At this point, our experience suggests that the safety and ease of use make hybrid-ORs combined with microsurgery and intraoperative DSA systems an attractive modality for dealing with SDAVFs.

Patient Outcomes Following Obliteration of Spinal Dural Arteriovenous Fistula and the Role of Indocyanine Green Angiography Videoangiography (ICG‑VA) During Surgery.

Spinal dural arteriovenous fistula (SDAVF) is a known cause of progressive myelopathy which can be treated either by surgery or embolization. Indocyanine green angiography videoangiography (ICG-VA) during surgery can locate the exact location of AV shunting. To determine the clinical outcome following obliteration of the fistula and to study the role of ICG in identifying the presence and location of SDAVF; to add a comparative study of patients treated by embolization. Patients treated for SDAVF in our centre from 2005 to 2015 were studied for clinical and radiological features, and outcome following obliteration of fistula. Of the total 33 patients (27 males, six females), 19 patients were operated without the use of ICG, nine were operated with the use of ICG and successful embolization was done in five. Acute presentation was seen in five. Single feeder was seen in 20 patients, multiple in 13. Mean follow-up was 58 months. All patients in ICG group improved. Three out of 19 patients in the non-ICG group (15.78%) required re-operation. With the use of ICG, the improvement in Aminoff Logue score was significantly better (P < 0.005). Embolization was tried in 13 cases, but successful in five (38%). Surgery with intraoperative ICG shows the exact location of AVF. This decreases the chance of postoperative clinical deterioration and improves patient outcome.

Gamma Knife Radiosurgery: The Gold Standard Treatment for Intracranial Dural Arteriovenous Fistulas without Cortical Venous Drainage.

Endovascular therapy is currently the most common treatment approach for intracranial dural arteriovenous fistula (DAVF), followed by microsurgery. Gamma Knife radiosurgery (GKS) is usually reserved as the last modality of treatment of intracranial DAVF. To evaluate the clinical and radiological outcome of GKS in the treatment of DAVF without CVD. This series includes patients who underwent GKS for intracranial DAVF without CVD over 10 years (Jan 2007 to Dec 2016) in All India Institute of Medical Sciences, New Delhi. Their demographic profile, clinical presentation, imaging details, GKS details, and follow-up clinical status were obtained retrospectively. Clinical follow-up, along with radiological assessment using MRI every 6 months was done after GKS. DSA was performed once MRI strongly suggested obliteration of DAVF. Patients who had a clinical follow-up of less than 1 year were excluded from the study. 5 patients (4 males and 1 female) who had DAVF without CVD were included the study. The mean age was 44.8 years. All patients had complete obliteration of fistula on digital subtraction angiography (DSA) at a mean duration of 24 months post GKS. All patients had complete resolution of symptoms at the last follow-up. Gamma Knife surgery is the most effective and the safest treatment modality for dealing with DAVFs without CVD. Instead of reserving it as the last resort for patients with DAVF without CVD, it should be considered as the gold standard treatment for DAVFs without CVD.

Complex Arteriovenous Malformation in a Kidney with Multiple Renal Arteries: A Case Report

The abnormal communications between arteries and veins outside the capillary level are called Arteriovenous Malformation (AVM). A 25-year-old known hypertensive on irregular medications, presented with acute stroke (Computed Tomography (CT) brain revealed left putamen haemorrhage). On evaluation, all routine investigations were normal except for microscopic haematuria. Ultrasound (USG) KUB showed right AVM and on further evaluation with 320 slice Contrast Enhanced Computed Tomography (CECT) abdomen with angiogram and 3D reconstruction revealed right kidney supplied by three renal arteries. The second renal artery was dilated (1.1 cm diameter) and communicates directly with aneurysmally dilated right renal vein (2.9 cm diameter). Digital Subtraction Angiography (DSA) with angioembolisation was done four days’ postadmission. Large second renal artery with a direct Arteriovenous Fistula (AVF) draining into the renal vein with aneurysmal venous sacs was occluded with 16 mm, 12 mm and 10 mm coils. Complete obliteration of fistula was confirmed. Then the inferior most third renal artery was accessed and angiogram revealed RAVM with multiple feeders shunting into the venous sacs and it was occluded with 40% glue. Postoperative day one USG showed thrombosed venous aneurysmal sacs and occlusion of the arterial fistulae. He was discharged at four weeks with antihypertensive and antiseizure medications. During the follow-up there was no loss in the function of the kidney and micro or macroscopic haematuria was not detected.

Endonasal Arteriovenous Fistula Following Transsphenoidal Resection of Pituitary Adenoma Treated with N-Butyl-2-Cyanoacrylate

AbstractVascular lesions of the external carotid artery after transsphenoidal pituitary surgery are rare. Immediate diagnosis must be done and endovascular embolization is the treatment of choice.We report the case of a 53-year-old woman with visual complaints who underwent transsphenoidal surgery of a pituitary adenoma with good clinical and radiological evolution. Five days after surgery nasal tampons were removed and suddenly the patient started to bleed: nasal packing and air way protection were required. Digital subtraction angiography revealed an endonasal arteriovenous fistula with a feeder from the sphenopalatine artery and drainage to sphenopalatine veins. Embolization with N-butyl-2-cyanoacrylate was performed with total obliteration of the arteriovenous fistula. We suggest that endovascular treatment of external carotid artery lesions after transsphenoidal surgery is the best alternative in cases of active bleeding.

Comparison between different modalities of Endovascular treatment in Carotid Cavernous Fistula (CCF) and its short term outcome – Our Experience

Introduction: Endovascular treatment offers different technique (Balloon assisted coiling / simple coiling, glue embolization) to treat Carotid Cavernous Fistula (CCF). This less invasive approach avoids morbidity and residual fistulas. The choice of treatment depends on the anatomy of the fistulas and cost effectiveness. Objective: To describe different endovascular treatment option of Carotid Cavernous fistulas (CCF), its short term outcome (clinical and angiographical) and to compare between trans-venous coiling and trans-arterial balloon assisted sinus coiling. Method: We have treated nine (9) cases of CCF during a period of three years. Out of them eight patients had direct CCF and one had indirect CCF. In two patients simple coiling done through trans-venous route and in another three patients through trans-arterial route. Balloon assisted coiling through trans-arterial route done in three patients. In two patients trans-arterial glue embolization was done. Results: Successful obliteration of fistula was achieved in all cases. Vision was improved in eight (8) patients. Postoperatively some proptosis remains in two patients. In one patient there was reappearance of proptosis two months after treatment, then balloon assisted coiling was done. One patient died from complication of glue (NBCA). Conclusion: Endovascular treatment is the mainstay of treatment in CCF. Trans-venous is the treatment of choice but recently balloon assisted sinus coiling through trans-arterial route is adopted. Bang. J Neurosurgery 2019; 8(2): 68-76

Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium.

In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome. Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose. A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5-18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration. GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

Venous outflow restriction as a predictor of cavernous sinus dural arteriovenous fistula obliteration after Gamma Knife surgery.

Gamma Knife surgery (GKS) obliterates 65%-87% of cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, the hemodynamic effect on GKS outcomes is relatively unknown. The authors thus used the classification scheme developed by Suh et al. to explore this effect. The authors retrospectively (1993-2016) included 123 patients with CSDAVFs who received GKS alone at the institute and classified them as proliferative type (PT; n = 23), restrictive type (RT; n = 61), or late restrictive type (LRT; n = 39) after analyzing their pre-GKS angiography images. Treatment parameters, the presence of numerous arterial feeders, and venous drainage numbers were compared across the CSDAVF types. Patients' follow-up MR images were evaluated for the presence of complete obliteration. A Kaplan-Meier analysis was conducted to determine the correlation between CSDAVF types and outcomes. The 36-month probability of complete obliteration was 74.3% for all patients, with no significant differences across types (p = 0.56). PT had the largest radiation volume (6.5 cm3, p < 0.001), the most isocenters (5, p = 0.015) and venous drainage routes (3, p < 0.001), and the lowest peripheral dose (16.6 Gy, p = 0.011) and isodose level coverage (64.3%, p = 0.006). CSDAVFs presenting with ocular patterns were less likely to be completely obliterated (hazard ratio 0.531, p = 0.009). After adjustment for age, CSDAVFs with more venous drainage routes were less likely to be completely obliterated (hazard ratio 0.784, p = 0.039). GKS is an equally effective treatment option for all 3 CSDAVF types. Furthermore, the number of venous drainage routes may help in predicting treatment outcomes and making therapeutic decisions.

Clipping of spinal arteriovenous fistula of the filum terminale under intraoperative angiography guidance

Arteriovenous fistula of the filum terminale (AVFFT) is an uncommon disease. We reported a case of this rare condition and we used intraoperative angiography to identify the completeness of fistula obliteration. A 53-year-old man presented with a history of low back pain and radiating pain of bilateral legs for 2 months. Lumbar spine magnetic resonance imaging revealed edema of conus medullaris at the T10–L1 level; engorged vein was also identified from L1 to L4. Digital subtraction angiography confirmed the diagnosis of AVFFT. Clipping of fistula was successfully performed, and complete obliteration was confirmed by intraoperative angiography. Magnetic resonance imaging follow-up showed no edema postoperatively. The patient's symptoms/signs improved tremendously. Both radiological and clinical outcomes were good after complete occlusion of the fistula was done. Hence, we suggested intraoperative angiography in hybrid OR as a useful tool to identify the fistulous point and confirm complete occlusion the fistula.

Endoscopic Obliteration of GI Fistulas with Cyanoacrylate Glue - Our experience

GI fistula as both Internal and enterocutaneous are important cause for morbidity post operatively. They cause significant mortality due to sepsis and Nutritional electrolyte disturbances. Many expensive modalities of endoscopic closure of persistent fistulas after conservative treatment developed. Cyanoacrylate glue Injection is less commonly done. Here we are sharing our experience with less expensive cyanoacrylate glue In GI fistulas. Good results with endoscopic therapy suggest that this technique is best in achieving closure.

Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review.

Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.

Iatrogenic Arteriovenous Fistula after Ultrasonography-Guided Core Needle Biopsy for Breast Lesion

Ultrasonography-guided core needle biopsy has been standard of care for diagnosing suspicious breast lesion. The procedure is safe and has a low rate of complications. Most common complication might be bleeding or hematoma, which could be avoided by careful process or changing it to excisional biopsy or managed by proper management. Rarely, Post-procedural arteriovenous fistula is reported in almost all body fields, which is life quality threatening, not life-threatening. Most of them occur with obvious vessel injury, and their primary end-point of management is the obliteration of fistula by thrombosis. However, we experienced a case of iatrogenic arteriovenous fistula after core needle biopsy for breast lesion with small vessel injury which was not but small ones, and its thrill did not disappear even after thrombosis. We would like to share our clinical learnings from surgical management process of this rare complication. Keywords: Arteriovenous fistula; Biopsy; Breast; Iatrogenic disease; Surgical procedures

Evaluation of endoscopic coblation treatment for obliteration of congenital pyriform sinus fistula

Background: Congenital pyriform sinus fistula is a very rare branchial apparatus malformation. Conventional open surgery for fistulectomy might fail to excise the lesion completely, leading to continual recurrence. The aim of this study was to provide an innovative endoscopic coblation technique for patients with pyriform sinus fistula and evaluate its intermediate-term effectiveness.Methods: Retrospective case series with 112 patients (age range 3–36 years) between 2013 and 2016 and underwent endoscopic coblation of the sinus fistula. Data collected including patient demographics, presenting symptoms, diagnostic methods, prior and subsequent treatments, length of hospital stay, and recurrence were analyzed.Results: Of the 112 cases, there were no postoperative complications observed except temporary reddish swelling in three patients. Four cases were lost to follow-up. Of 108 patients, 106 experienced no recurrence after their first endoscopic coblation of the sinus tract. The remaining two patients with recurrence in the follow-up were ultimately treated with recoblation without complications or further recurrences. Also, Endoscopic coblation can be used to treat seven patients with recurrence who had experienced open resection. In our series, median follow-up period was 1.5 years.Conclusion: Endoscopic coblation is an effective approach for most patients. We advocate using this minimally invasive technique as first line of treatment for pyriform sinus fistula.

Spontaneous Closure of Bronchopleural Fistula Following Anti-tuberculous Treatment

This case report highlights a 55 year old gentleman of Malay descent who presented to the hospital with chronic cough, dyspnoea and night sweats. He is a chronic smoker and works in a rubber plantation. On examination, he was tachypnoeic and tachycardia, febrile and in type 1 respiratory failure. Physical examination was consistent with a right sided spontaneous pneumothorax which was confirmed on a chest radiograph. The chest radiograph also showed evidence of active tuberculosis involving the right upper and middle lobes. His sputum samples smear and culture revealed Mycobacterium tuberculosis complex. He was immediately placed on an intercostal drain with air leak persisting after two weeks. A high resolution CT scan of the thorax showed a bronchopleural fistula measuring 7 mm in diameter in the anterior segment of the right lower lobe. With careful management of the chest drain and early administration of antituberculous chemotherapy, the air leak ceased and the repeated CT scan of the thorax showed obliteration of the fistula. He continued to improve and currently on the 5th month of treatment. Conclusion: An underlying tuberculosis infection resulting in a bronchopleural fistula should not be missed in a patient from a tuberculous endemic area. Effective careful management of the chest drain and early administration of antituberculous treatment are vital to facilitate the healing of a bronchopleural fistula.

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: its clinical and angiographic perspectives

To assess the efficacy of stereotactic radiosurgery (SRS) for intracranial dural arteriovenous fistulas (DAVFs), the authors retrospectively reviewed our 7-year experience. We evaluated the obliteration rate, improvement in clinical symptoms, and complications. Thirty patients with DAVF underwent SRS using a Gamma Knife between 2009 and 2015. Twenty-three patients were treated with SRS alone, and seven patients underwent SRS for residual or recurrent DAVFs after embolization or surgery. Chemosis, diplopia, and pulsating tinnitus were the most common symptoms. Median target volume was 2.9cm3 (range, 0.8-13.6cm3), and median radiation dose to the target was 17Gy (range, 12-20Gy). Median follow-up period was 33months (range, 6-82months). At the last neuroimaging follow-up, DAVFs were totally obliterated in 23 patients (77%) and subtotally in 7 (23%). At the last clinical follow-up, 21 patients (70%) showed complete recovery, and 9 (30%) showed incomplete recovery in symptoms or signs. None experienced worsening symptoms or signs. Asymptomatic perilesional edema after SRS occurred in one patient (3%). Total obliteration rates after SRS were 43% at 1year, 79% at 2years, and 95% at 5years. Improvement rates of neurological function after SRS were 12% at 1month, 52% at 2months, 72% at 3months, and 96% at 6months. A multivariate analysis revealed that Borden type 1 (p=0.019, hazard ratio, 3.254, 95% confidence interval, 1.216-8.707) was significantly associated with symptom improvement. SRS for intracranial DAVFs provided a high obliteration rate and a relatively low risk of radiation-induced complications. In selected benign cases without cortical venous drainage, SRS is a safe and effective treatment for symptom relief and fistula obliteration, even though the time course of improvement is longer than those of embolization and surgery.

Value of Dural Patches in Obliteration of Cranio-Ethmoidal Traumatic CSF Fistulas

During traumatic events or neurosurgical interventions abnormal communications between the CSF-containing subarachnoid space and other extradural spaces may occur and CSF fistulas may develop. As non-traumatic lesions, CSF fistulas are some of the most severe complications of spinal (LDH, extradural and intradural tumors, intramedular tumors) and cranial (cranio-durocerebral tumors, intracranial meningioma, cerebral tumors, vascular malformations of the brain) neurosurgery. There are four types of materials used for dural defects repair: autogenic (from the same patient`s body, usually the fascia lata, periosteum, temporalis fascia or the gales are preferred for cosmetic and morbidity reasons), allogenic (the graft originates from another human), xenogenic (the graft originates from a different species like bovines or pigs) or alloplastic (the graft is inorganic). Biomaterials used as dural substitutes are used to prevent CSF leaks and fistulas and allow the surgeon to make openings in the dura which will heal postoperatively. Dural substitutes can be either biological or synthetic, and are applied just by simple positioning or by suturing them to the defect. The authors consider that prevention of CSF fistulas by using biomaterials similar to the structure of the meninges should be used more frequently and widely, as soon as possible, due to their impact on limiting complications in neurosurgery.

Efficiency of tacrolimus therapy for perianal Crohn's disease

To determine the efficacy of 0.1% tacrolimus ointment in patients with perianal Crohn's disease (CD). This prospective randomized trial enrolled 20 patients with perianal CD as anal fissures and rectal fistulas. The inclusion criteria were rectovaginal or extrasphincteric fistulas and purulent leakages. A study group comprised 11 patients, including 9 with anal fissures and 2 with fistulas. A control group included 9 patients, including 8 with fissures and 1 with fistulas. The study group received systemic therapy with azathioprine 2 mg/kg/day and tacrolimus ointment 2 mg/day; the control group had systemic therapy with azathioprine 2 mg/kg/day, hormone ointment 1 mg/day, and metronidazole suppositories 250 mg/day. Control examination and perianal CD activity index (PCDAI) determination were done 6 and 12 weeks after therapy initiation. At 6 weeks after beginning the study, local examination revealed the signs of anal fissure epithelialization in 5 (45.5%) of the 11 patients in the study group and in 3 (33.3%) of the 9 patients in the control one. At 12 weeks, fissure epithelialization and fistula obliteration were stated in 6 (54%) patients in the study group and in 3 (33%) of the 9 patients in the control group. At 12 weeks, PCDAI in the study and control groups was 2.00 and 4.44 scores (p = 0.01). The findings suggest that topical 0.1% tacrolimus ointment versus antibacterial suppositories and hormone ointments is effective in treating patients with perianal CD. Topical 0.1% tacrolimus ointment therapy caused a reduction in PCDAI.