Sinus Orifice Research Articles

Pediatric Endoscopic Pilonidal Sinus Treatment: An Effective Procedure for Children with Recurrent Pilonidal Sinus Disease After Failed Open Surgery.

Background: The traditional open excision of pilonidal sinus disease (PSD) is associated with a painful postoperative course and high recurrence rates. We recently published our technique of pediatric endoscopic pilonidal sinus treatment (PEPSiT). We aimed to report our long-term outcome including using PEPSiT for recurrent PSD after failed open repair. Methods: All patients with recurrent PSD after open excision who underwent PEPSiT in our unit over the past 2 years were included in the study. During surgery a fistuloscope was introduced through the fistula's orifice. All identifiable hairs were removed using endoscopic forceps. Thereafter, the cavity was debrided with endobrush and ablated with monopolar electrode. External openings were not closed. Results: In the past 2 years, 40 patients with PSD underwent PEPSiT. Ten of 40 patients (6 boys and 4 girls with an average age of 16.8 years [range = 14-18]) had recurrent PSD after open surgery and were included in the study. The average operative time was 27.7 minutes (range = 24-43). No perioperative complications occurred. The average analgesic requirement was 20 hours (range = 16-26) and the average hospitalization was 22.4 hours (range = 18-36). The average time to return to full daily activities was 2.3 days (range = 1-5) and all patients were highly satisfied of postoperative course. At 1 month postoperatively, the external openings were completely healed. No recurrence was recorded at a mean follow-up of 18 months (range = 6-24). Conclusions: Our results demonstrated that PEPSiT is an excellent technique for surgical treatment of PSD in children and teenagers. In fact, it is technically easy and fast to perform, with a short and painless hospital stay and it allows to the operated patients an early return to full daily activities without any physical limitations compared with open repair. In addition, it is also effective for treatment of recurrent PSD after failed open repair.

Acute hyperkalaemia in a captive Persian leopard (Panthera pardus saxicolor) immobilised with a ketamine-medetomidine combination

A 12-year-old captive male Persian leopard (Panthera pardus saxicolor) required general anaesthesia for examination and treatment of a recurrent oral fistula. Medetomidine (0.065 mg/kg) and ketamine (3.6 mg/kg) administered intramuscularly...

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas

Background and Aims: Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas. Methods: This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence. Results: The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4–145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1–10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15–72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50–205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence. Conclusions: A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically. Key Messages: Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.

Postoperation of preauricular fistula cellulitis caused by methicillin-resistant staphylococcus aureus infection

A one-year-old baby girl with one-month history of recurrent pus fluid exuding from her left preauricular sinus orifice, who failed multiple courses of surgical drainage of the abscess and persistent debridement for the wound, presented with MRSA infection. The patient was treated with linezolid for three days. Her pain and paresthesia resolved, and C-reactive protein decreased to normal.

Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success.

Nonmalignant esophago-respiratory fistulas (ERF) are frightening clinical situations, involving surgery with high morbi-mortality rate. We described the endoscopic management of benign ERF. The aim of the study was to describe outcomes of endoscopic treatment of nonmalignant ERF and to analyze factors associated with its success. This is a retrospective study involving patients managed for benign ERF in our center between 2012 and 2016. The ERFs were classified into three groups of sizes: (I) punctiform, (II) medium, and (III) large. The primary aim was to document the endoscopic success (= fistula's healing after 6 months). The secondary objectives were characteristics of endoscopic treatment, the functional success and death, and identifying factors associated with success and death. 22 patients were included. The etiologies of ERF were surgery in 12 patients, esophageal dilatation in 3, invasive ventilation in 3, radiation therapy in 2, and tracheostomy in 2. Ninety-three procedures were performed (mean of number: 4.2 ± 4.5/patient). Twenty-one patients had stent placement, eight over-the-scope clips (OTSC), and seven a combined therapy. The endoscopic success rate was 45.5% (n = 10; 67% in punctiform, 50% in medium, and 14% in large ERF), and the functional success was 55% (n = 12). Serious adverse events occurred in 9 patients (40.9%). Six patients died (27%). The persistence of the orifice after 6 months of endoscopic treatment was associated with failure (OR 44; IC95: 3.38-573.4; p = 0.004 multivariate analysis). The orifice's size was associated with mortality [71% of death if large fistulas (p = 0.001) univariate analysis]. Endoscopic treatment of ERF leads to 45.5% of successful endoscopic closure and 55.5% of functional success, depending on fistula's orifice size. After 6 months without healing, the chances for success dramatically decrease.

Consequences of gallbladder inflammation: spontaneous cholecystocutaneous fistula: a case report

One of the most unusual complications in gall bladder disease is spontaneous cholecystocutaneous fistula (SCF), which has only been reported a few times in the literature. We report the case of a 67-year-old man who presented with a right hypochondrium discharging sinus. Identification of a cholecystocutaneous fistula was made by computed tomography with contrast media, followed by MRCP. This confirmed the presence of a fistulous pathway between the gallbladder and the skin. The patient underwent exploratory laparotomy with subtotal cholecystectomy with en block aponeurotic muscle, skin and fistula orifice excision.

Laparoscopic repair of vesicovaginal fistulae with a transperitoneal approach at Universitas Gadjah Mada Urological Institute: a case report

BackgroundA vesicovaginal fistula is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In addition, the sequelae from these fistulae have a profound effect on the patients in view of their physical, psychological, and social dimensions. The treatment of vesicovaginal fistula is surgical in most cases and the choice of the repair technique is controversial. We evaluated the benefits of a laparoscopic approach in a patient with vesicovaginal fistulae. Here, we present our first experience using a simplified laparoscopic approach technique to repair vesicovaginal fistulae in our country.Case presentationA 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy 3 months earlier and received laparoscopic repair. A cystoscopy was performed to confirm the fistula orifice and a stent was inserted into the fistula tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina. She had adhesions; therefore, adhesiolysis was performed using a combination of sharp and blunt dissection to expose the vaginal stump and the superior aspect of her bladder. A simple cystotomy was performed and extended to include the fistulae site, and then the defect was repaired by using a running stitch. A second layer of closure was performed in an imbricating fashion with the same suture. The vagina defect was not closed separately but covered with an omental flap. This procedure takes approximately 2.5 hours; estimated blood loss was minimal and there were no intraoperative complications. She had no recurrent symptoms 6 months after surgery.ConclusionOur case report concludes that the simplified laparoscopic approach to vesicovaginal fistulae is a viable option for successful repair and that it reduces the size of bladder opening, causes minimal bleeding, and gives successful relief.

Primary fistulectomy of congenital lacrimal fistula: A case report

A 13-month-old male patient presenting with epiphora and discharge in his left eye present since birth was assessed in our clinic. Epiphora and an orifice of fistulae next to the left nasal root were identified via physical examination. Punctual mucoid discharge was observed following a massage of the left lacrimal sac. Chronic lacrimal fistulae were diagnosed in terms of stain outflow from the fistula orifice following a trypan blue injection to the lacrimal sac under general anesthesia. The patency of the distal nasolacrimal duct was confirmed by performing lavage following the fistulectomy procedure. The epiphora disappeared and the nasolacrimal passage was open in post-operative care.

A Case of Unroofed Coronary Sinus with Coronary Sinus Orifice Atresia: Use of Multimodality Imaging.

A Case of Unroofed Coronary Sinus with Coronary Sinus Orifice Atresia: Use of Multimodality Imaging.

Double palatal flap for oro-nasal fistula closure.

The management of oral fistula to the nose depends on its etiology, its size and its location. Here, we describe a simple technique, inspired by the ones initially developed by Bardach for cleft palates repair. The surgical alternatives are discussed. The double palatal flap is a simple technique, allowing closure in a single session of a central or centro-lateral palate fistula. The key of this technique is the dissection between nasal and palate mucous layers, providing a sufficient amount of laxity to close the defect without tension. The double palatal flap can cover centro-lateral palate mucosal fistulae. It provides both aesthetic and functional results in a single stage. Reliability, simplicity and quickness are its main advantages. Outcomes are usually simple; Velar insufficiency may occur, that can be corrected by speech therapy.

Case Report: Spontaneous cholecystocutaneous fistula, a rare cholethiasis complication.

One of the most unusual complications in cholethiasis is spontaneous cholecystocutaneous fistula, which has only been reported a few times in the literature. We report the case of a 76 year old man who presented with a right hypochondrium subcutaneous abscess, with pain evoked through palpation. No comorbidity in the patient's medical history were noted. Confirmation of cholecystocutaneous fistula was made using the proper diagnostic process, which is computed tomography with contrast media, followed by hepatobiliary MRI. This confirmed the presence of a fistulous pathway between the gallbladder and the skin. The patient underwent cholecystectomy surgery and open laparotomy with en block aponeurotic muscle, skin and fistula orifice excision.

Cystoscope-Assisted Laparoscopic Resection of Mullerian Duct Remnant in a Male Presenting with Uterus and Vagina

Background and Aim: Mullerian duct remnant (MDR) is a rare condition and is sometimes accidentally diagnosed during surgery for an inguinal hernia and undescended testes. MDR is always found near the seminal duct and conservatively preserved, preventing injury of the seminal duct. However, recent reports have revealed that MDR has the potential to become malignant.1,2 Cases of deaths among male adolescents have also been reported. As such, surgical extirpation of MDR is recommended. Laparoscopic and robotic approaches have been applied as surgical intervention.3,4 In this video, the combination of laparoscopy and cystoscopy to safely extirpate an MDR is shown. Materials and Methods: Case: A four-month-old boy was initially found to have coronal hypospadias and undescended testes. Laparoscopy was performed at 11 months of age because of nonpalpable testes. A left streak gonad and MDR were found to be presenting as a complete uterus and vagina. Chromosomal examination revealed mixed gonadal dysplasia (46XY (23)/45X (7)). A cystoscope showed that the MDR was connected to the prostatic urethra. At 18 months of age, this patient underwent extirpation of the left streak gonad and urethroplasty for hypospadias. Subsequently, resection of the MDR was planned because of repeated urinary tract infections. Operative Findings and Procedure: The patient was placed in a lithotomy position and a cystoscope was used to confirm the fistula orifice at the urethra. A 5 mm, 30° laparoscope was inserted through the umbilical longitudinal incision. Pneumoperitoneum was established at 8 mmHg CO2 inflation. Two 5 mm ports (left upper abdomen and left lower abdomen) and one 3 mm port (right lower abdomen) were inserted. MDR presenting as a complete uterus and vagina was recognized. The bladder was suspended using extracorporeal 3-0 proline insertion. The bilateral uterus ligaments were coagulated and divided using a vessel sealing system (LigaSure Maryland; Medtronic, Inc., Dublin, Ireland). After opening the peritoneal reflection, the distal side of the MDR was carefully dissected using a 3 mm bipolar (RoBi, KarlStorz, Tuttling, Deutschland) to prevent thermal injury of the pelvic nerve. The distal mullerian duct had a vaginal appearance and was connected to the urethra as a fistula. Before ligation of the fistula, the depth of dissection was confirmed using a cystoscope. Under inspection with the cystoscope, the dissected fistula was retracted, and the level of dissection was confirmed. A transfixing 4-0 PDS (Ethicon, Cincinnati, OH) suture was used to ligate the fistula, which was then resected using a vessel sealing system and ligated using an Endoloop (Ethicon). No injury to the bilateral ureter or urethra was recognized. Results and Conclusion: The postoperative course was uneventful. A pathological diagnosis revealed that the resected MDR showed age-appropriate development. The patient has had a good clinical course since the operation. A laparoscopic approach is feasible and low invasive for the extirpation of an MDR, even in infants. The fistula was safely ligated using a combination of laparoscopy and a cystoscope. This combination approach is useful for preventing injury to the urethra. Acknowledgments: We thank Brian Quinn for his comments and help with the article. This study was supported by grants-in-aid for scientific research from the Japan Society for the Promotion of Science (JSPS, No. 25293360 and No. 26670765), JFE (The Japanese Foundation for Research and Promotion of Endoscopy), J-CASE (Japanese Consortium of Advanced Surgical Endoscopy), Foundation for Promotion of Cancer Research, Foundation for Shinnihon Zaidan, a research grant from the President's Discretionary Expenses of Kagoshima University, a research grant from The UBE Foundation, and a research grant from Japan Medical Education Foundation. No competing financial interests exist. Runtime of video: 6 mins 49 secs

Case Report: Endoscopic Management of Sleeve Gastrectomy Fistula

Abstract Background. Morbid obesity is an important cause of morbidity and mortality. Bariatric surgery is the best option to manage obesity. Vertical gastrectomy is safe and effective but sometimes complicate with hemorrhage, fistulas and stenosis. Fistulas can be solved by conventional surgery or interventional endoscopy. Case presentation. We describe a morbidly obese patient with vertical gastrectomy who developed complications after surgery. Immediately after surgery the patient developed sepsis. Upper gastrointestinal endoscopy excluded fistula. One month later a peri-gastric abscess developed due to a fistula orifice in the distal esophagus, treated with argon plasma and two double pigtail plastic stents placed endoscopically to drain the abscess. The stents were removed two weeks later and was placed a covered metallic stent in the distal esophagus. Six weeks later the metallic stent was removed and the orifice closed. Four months later the patient developed sepsis. Computer tomography revealed a subdiaphragmatic abscess and endoscopy revealed a 2 mm fistula orifice at the previous site, treated with argon plasma and two trough-the-scope clips that closed it. There were no further incidents after two years of follow-up. Conclusions. Early diagnosis and endoscopic approach can resolve these complications without the morbidity and increased mortality risk of surgical re-interventions.

Case Report: Intraoperative Management Using Inferior Based Rotation Flap of Sternocleidomastoid Muscle for Chyle Fistula

Chyle fistula is one of the complications of neck dissections. Although immediate surgical repair seems to be the best choice when chyle leakage is observed during the operation, some operators can be embarrassed when chyle leakage is heavy and not controlled during surgery. In this case, chyle leakage was occurred after extensive resection of lymph nodes in left level IV, and was not controlled in any way. The clavicular head of sternocleidomastoid muscle was dissected and inferior-based muscular flap was rotated to cover the suspected region of fistula orifice. Amount of drainage was checked less than 20 ml per day in the following days, and drain tube was taken out on the 3rd postoperative days. We present the technique using the inferior based sternocleidomastoid muscle flap for intraoperative management of chyle leakage not easily controlled.

Fourth branchial cleft deformity with skin orifice: a series of 10 cases

Objective: To report rare cases of congenital neck cutaneous sinus with an orifice near the sternoclavicular joint and to investigate their origins and managements. Methods: A total of ten patients with congenital neck cutaneous sinus having an orifice near the sternoclavicular joint treated in the Guangdong General Hospital from January 2010 to June 2015 were retrospectively analyzed. Results: There four boys and six girls, aging from 11 months to 96 months with an average of 33.4 months, and they had a common feature showing a congenital cutaneous sinus with an orifice near sternoclavicular joint. Discharge of pus from the orifice or abscess formation was commonly seen soon after infection. With bacteriological study, staphylococcus aureus was positive in five cases and klebsiella pneumonia in a case. Another orifice of fistula/sinus was not depicted in pyriform with barium swallow X-ray in five cases Ultrasound studies of three cases demonstrated anechoic (i.e., nearly black) and solid-cystic lesion near sternoclavicular joint with posterior acoustic enhancement. Magnetic resonance imaging (MRI) showed isointensity of the lesion on T1 and T2 weighted images with heterogeneous enhancement and a close relationship with sternoclavicular joint. All patients underwent laryngoscopic examination, which showed no orifice of sinus in pyriform at same side. Surgical resection of fistula/sinus was performed in all cases. The lengths of the fistula varied from 5 mm to 22 mm with an average of 11 mm. Postoperative pathological examination showed all specimens were accordance with fistula. No complications were noticed. Recurrence was not observed in the cases by following-up of 6 months to 70 months (median: 33 months). Conclusion: Congenital neck cutaneous sinus with orifice near the sternoclavicular joint maybe a special clinical phenotype of the fourth branchial cleft sinus with skin orifice in cervicothoracic junction. Differential diagnoses between low cervical diseases are required. The curative treatment is a complete excision during inflammatory quiescent period.

Ozone Treatment for Chronic Anal Fistula: It Is Not Promising.

The aim of this study is to assess the effect of ozone gas in the treatment of anorectal fistulae. The tip of a 20G intravenous cannula was inserted from the fistula orifice. Medical ozone was introduced into the fistula. A total of 10 sessions of ozone gas insufflation was performed on alternate days. Treatment was considered to be successful if fistula discharge ceased and the outer fistula orifice closed; however, if discharge was continued or outer fistula orifice was open, the treatment considered to be failed. A total of 12 adult patients were included in the study. The fistula was closed in three patients (25%), in nine patients (75%) without closure. In one patient who had fistula closure, the fistula recurred after 2months. Patients did not express any discomfort during ozone insufflation. There were no side effects or complications due to ozone insufflation. The success rate of ozone insufflation in anorectal fistulae closure is low.

The free scapular flap with latissimus muscle reduces fistulas in mandibular reconstruction

The free scapular chimeric flap is a less common choice for facial reconstruction. This study aimed to evaluate the versatility and safety of the flap, the procedure for a two-team approach, the safety of the osteotomies, the possibility of dental implants and donor-site sequelae and complications. We analysed 34 consecutive patients with oral cancer undergoing large resections in the maxillofacial region as well as scapular chimeric free flap reconstruction. We performed 26 mandibular, six maxillary and two orbital reconstructions using a two-team approach, mainly without repositioning the patient. No flaps were lost. Three patients with a scapular bone and fasciocutaneous flap developed a post-operative fistula, whereas no fistulas developed when the flaps included a muscular component. All osteotomies showed confirmed osseal consolidation. Seven patients received a total of 23 dental implants for oral rehabilitation; no implants were lost. The scapular flap is reliable and contains sufficient bone to tolerate both multiple osteotomies and osseointegrated dental implants. The flap can be harvested in a slightly tilted decubital position, thus shortening the theatre time. The use of a separate muscle around the scapular bone in mandibular reconstruction is associated with a lower risk of oral fistulas.

Resection of the recurrent third branchial fistula under gastroscope with assistance of yellow zebra guidewire

To investigate clinical aspects and a new operative method for resecting third branchial fistula. The clinical aspects of 4 patients with third branchial fistula were retrospectively analyzed. It is difficult to locate the inner orifice of fistula through neck path due to tiny diameter of inner orifice. The inner orifice could be found and closed effectively by inserting yellow zebra guidewire from sinus piriformis with gastroscope. The mucous membrane of sinus piriformis could not be damaged due to the soft pointed end of yellow zebra guidewire. 4 cases were treated successfully without pharyngeal fistula or recurrent laryngeal nerve injury. No recurrent infections were found in all cases with follows-up of 6-66 months. Ineffectiveness of radiography with meglumine diatrizoate or oral administration of methylene blue before operation indicates tiny fistula. In this case, resection of third branchial fistula with the assistance of gastroscope and yellow zebra guidewire under general anesthesia can be performed. This innovative method of diagnosis and treatment is worth of application clinically.

Hematemesis from Bleeding Pancreatic Pseudocyst Ruptured into the Duodenum

A 44-year-old alcoholic man with a history of multiple episodes of acute pancreatitis was transferred to our hospital with complaints of intense mid-epigastric pain and hematemesis for 3 h. He was diagnosed as pancreatic pseudocyst by abdominal CT examination (Figure 1a and 1b) 6 months ago. The abdomen was markedly tender, and an impulsatile mass measuring 10 cm × 15 cm was palpable. Emergent abdominal CT revealed giant hyper-attenuation cyst communicating with duodenum, suggestive of blood presence. Large amount of blood was also noted in stomach, duodenum and small bowel (Figure 1c). Conservative treatment, including parenteral nutrition and blood transfusion, was consecutively administered for 5 days. Follow-up CT show marked shrinkage of pancreatic pseudocyst and direct orifice of fistula (Figure 1d). Hemorrhagic complications are reported to occur in 6% to 31% of patients with pancreatic pseudocyst and bleeding into a pseudocyst may arise from a pseudoaneurysm or from vessels within its wall. Sequential CT can describe dynamic process of pancreatic pseudocyst complicating with gastrointestinal hemorrhage.

Pulling Seton: Combination of mechanisms.

Background:Seton-based techniques are among popular methods for treating high type anal fistula. These techniques are categorized to cutting and noncutting regarding their mechanism of action. In this report we are about to describe a new technique, which is a combination of both mechanisms; we call it Pulling Seton.Materials and Methods:In this technique after determining internal and external orifice of fistula, fistulectomy is done from both ends to the level of external sphincteric muscle. Finally, a remnant of fistula, which remains beneath external sphincteric muscle is excised, and Seton is passed instead of it and tied externally. After the wound heals, patient is asked to pull down the Seton for 3–4 min, 4 times a day. We prospectively enrolled 201 patients with high type anal fistula in this study.Results:Seton gradually passes through external sphincteric muscle till it is displaced outwards or removed by a surgeon via a small incision. 94% of patients treated by this method accomplished their treatment completely without recurrence. None of the patients developed permanent fecal or gas incontinence. Only 5% of patients developed with recurrence of fistula. Since Seton traction is not permanent in this technique, Seton cuts external sphincter slowly, and minimal rate of incontinence is reported.Conclusion:Pulling Seton seems to be an efficient way in treating high type anal fistula with minimal rate of recurrence and complications such as incontinence and authors suggest further randomized studies to compare its efficacy with other Seton-based techniques.