Fistulous Opening Research Articles

Cardiac Tamponade following Mitral Valve Replacement for Active Infective Endocarditis with Ring Abscess

Periannular extension and abscess formation are rare but deadly complications of infective endocarditis (IE) with high mortality. Multimodality cardiac imaging, invasive and noninvasive, is needed to accurately define the extent of the disease. Debridement, reconstruction, and valve replacement, often performed in an emergent setting, remain the treatment of choice. Here we present a case of severe IE in a 29-year-old intravenous drug user who after undergoing debridement of the abscess, annular reconstruction, and mitral valve replacement (MVR) presented with recurrence of shortness of breath and pedal edema. Transthoracic echocardiogram (TTE) showed a 6.2 × 5.5 cm cavity, posterior to and communicating with the left ventricle through a 3 cm wide fistulous opening, in proximity of the reconstructed mitral annulus. The patient underwent a redo MVR with patch closure of the fistulous opening, with good clinical outcome. This case highlights the classic TTE findings and the necessity for close follow-up in the perioperative period in patients undergoing surgery for periannular extension of infection. A cardiac magnetic resonance imaging can be considered, preoperatively, in such cases to identify the extent of myocardial involvement and surgical planning.

English

We report a very uncommon manifestation of renal tuberculosis as nephrocolocutaneous fistula (NCCF). Patient presented with chronic discharging sinus. Radiological studies of sinus tract revealed fistulous communication of tract with colon and a completely disorganized non-functional renal unit. Colonoscopy confirmed fistulous opening in descending colon. Patient was explored retroperitoneally after starting antituberculous therapy (ATT) empirically. Nephrectomy was done but colonic fistula could not be traced due to dense adhesion in colonic area. Incision was closed after putting drain. Histopathology of excised mass was suggestive of tuberculous infection. Patient got uneventful recovery with anti tuberculous chemotherapy

Congenital urethrovaginal fistula associated with imperforate hymen causing fetal urinary ascites and abdominal cystic lesions: A case report and literature review

Abstract A primipara presented to our hospital due to fetal ascites, bilateral hydronephrosis and hydrometrocolpos. The female baby had two giant abdominal cysts, a single atrium and foot polydactyly. Absence of the vaginal orifice was noticed, and the hymen was broken through; the left cyst collapsed after fluid drainage. The right cyst was punctured and drained, which improved the hydronephrosis. Contrast imaging showed medium pouring into the abdominal cavity via the uterine tube; the right cyst was a 6 × 5 cm closed cavity. Vaginal uroplania persisted even after hospital discharge. At the age of 4 years, cystoscopy showed a fistulous opening on the urethra 5 mm distal from the internal urethral orifice. A catheter inserted via the opening was found in the vagina. In our case, urine poured into the abdominal cavity through the fistula and uterine tube; following obstruction of the uterine tube, giant hydrometrocolpos and hydrosalpinx appeared. Three cases of congenital urethrovaginal fistula (CUVF) with imperforate hymen have been reported. A remnant of communication between the uterovaginal primordium and urogenital sinus may be responsible for CUVF.

Cytomegalovirus-Associated Esophagopulmonary Fistula in an AIDS Patient Successfully Treated with Esophageal Stenting

Introduction: A 46-year-old man with AIDS and poor antiretroviral adherence presented with a 12-day history of chest pain, dyspnea, cough, and fever. Examination revealed tachycardia, cachexia, and thrush. One month prior, CD4 count was 9/mm3 and HIV viral load was 57,647 copies/mL. Chest CT noted a dominant cavitary mass in the right upper lobe, several smaller pulmonary cavitations, and proximal esophageal dilatation. Treatment for bacterial pneumonia and candidiasis was started. Initial infectious studies, including acid-fast sputum smears, were negative. Despite 7 days of broad-spectrum antibiotics, his cough worsened, serial chest imaging noted disease progression, and sputum culture grew MRSA and commensal bacteria. Three weeks into his course, he developed dysphagia and odynophagia. Serum PCR for Cytomegalovirus (CMV) was 701 copies/mL. EGD noted a cratered 5-cm longitudinal ulcer in the proximal esophagus (Figure 1A) and a 1-mm fistulous opening within the ulcer (Figure 1B). Barium esophagram revealed a communication between the proximal esophagus and right hemithorax (Figure 1C). Chest CT demonstrated tracking of barium from the esophagus into the dominant pulmonary cavity (Figure 1D). These findings were consistent with the diagnosis of an esophagopulmonary fistula. On repeat EGD, biopsies of the ulcer were obtained, followed by placement of a 12-cm fully-covered metal stent across the fistula. Pathology showed esophageal squamous epithelium, inflamed reactive stroma, and acutely inflamed columnar respiratory-type mucosa with scattered CMV-positive cells, confirmed on immunohistochemistry (Figure 1E). The patient received valgancyclovir for 21 days and the stent was removed 35 days after placement with resolution of the ulcer. Repeat barium esophagram showed no structural abnormalities. We present the first reported case of a CMV-associated esophagopulmonary fistula successfully treated with antiviral therapy and a fully-covered metal esophageal stent. Esophagorespiratory fistulas are rare and usually associated with malignancy or post-operative complications. Use of fully-covered metal stents has been described in the treatment of esophageal fistulas and leaks with variable success.Figure 1

Successful Endoscopic Closure of Rectovesical Fistula with OVESCO Clip

SymbolIntroduction: Rectovesical fistula is usually a complication of inflammatory bowel disease, radiation, colorectal malignancy or trauma during surgery particularly after prostatectomy. The preferred management for fistulae is primary resection with anastomosis. However, with approval of over-the-scope larger endoscopic clips, endoscopic closure of these type of fistulae is gaining in practice. We present a case of rectovesical fistula that was successfully closed endoscopically by OVESCO clip.SymbolCase Report: A 57-year-old male with prostate cancer started passing urine from rectum 2 weeks after robotic-assisted laparoscopic radical prostatectomy. Fluorocystogram showed extensive extravasation of contrast confirming the presence of a large rectovesical fistula. Initially, conservative management was attempted, but he did not tolerate an indwelling foley. GI was consulted for colonoscopy prior to planned surgery. A 1 cm mature fistulous opening was noted in the rectum. The size of the fistula was deemed compatible to closure with OVESCO clip. After completion of colonoscopy, adult gastroscope was introduced through the rectum and Ovesco clip device was mounted on the gastroscope. Using OTSC™(over-the- scope clip) twin grasper, the edges of fistula was drawn into the OVESCO clip device, along with suction and then clip was deployed. Good closure of the fistulous opening was confirmed with 200 cc of methylene blue dye injected through the suprapubic catheter with no leak into the rectum suggesting adequate closure of the fistula. Post procedure, fluorocystogram showed no leakage of contrast into the rectum. Patient was seen in 2 weeks and had continued relief of his symptoms. Discussion: Latrogenic Rectovesical fistulae pose a major management challenge. Creating a temporary or permanent diverting ostomy is burdened by high morbidity and mortality. With advancement in endoscopic techniques, these fistulae can be successfully closed by OVESCO technique, thereby avoiding invasive surgery and its complications. This would also be extremely helpful both from treatment and palliative aspect in patients with metastatic cancer who have fistulae due to local spread of cancer. We conclude that Endoscopy with OVESCO clip placement can be used as an alternative to surgical management for rectovesical fistula in selected patients.

Esophageal Bronchopleural Fistula (EBF) Arising From Barrett’s Esophagus Without Dysplasia: A Rare but Life-Threatening Complication

Introduction: An EBF is very uncommon and it is formed secondary to instrumentation, malignancy, surgery or post-pneumectomy complication. Barrett’s esophagus refers to the replacement of normal squamous epithelium by columnar epithelia caused by chronic gastric acidic secretions. We report an unusual case of a benign EBF arising from Barrett’s esophagus without dysplasia. A 63-year-old female with PMH of HTN, CKD stage 4, COPD came in with complaints of knee pain, vomiting, fever and chills. During the work-up for septic arthritis, a mild pneumonia was noted and treated as community-acquired pneumonia. After a week of IV antibiotics, the patient continued to have a productive cough with poor oral intake and cachexia. Review of old CT chest scans showed chronic distal esophageal thickening and right lower lobe atelectasis, therefore a chronic aspiration pneumonia was suspected. A repeated CT Chest showed extensive bronchiectatic changes of the lower right lobe and an abnormal distal esophagus concerning for a spontaneous esophageal perforation. Differential diagnosis included iatrogenic perforation, malignancy, and Boerhaave’s Syndrome. Upper gastrointestinal series with gastrografin showed leakage of contrast material from esophagus that accumulated inside the thoracic cavity. The patient was kept strict nothing by mouth and a bronchoscopy was performed to evaluate for possible tracheo-esophageal fistula, but did not show any pathology. Patient continued to have increasing cough and secretions with a high suspicion of a connection between the thoracic cavity and the esophagus. An EGD was performed which showed a large subepithelial mass extending from mid-esophagus to the gastroesophageal junction with superficial ulcerations along with a large fistulous tract opening at the right posterior esophageal wall. Biopsies of the subepithelial mass revealed granulation tissue with extensive intestinal metaplasia consistent with Barrett’s esophagus without dysplasia, same as present with prior EGD. There was evidence of foreign body pigmentation within the Barrett’s esophageal tissue suggestive of pill esophagitis from oral iron. This patient may also have undiagnosed esophageal dysmotility. Patient was a poor surgical candidate and a surgical jejunostomy feeding tube was placed for better nutrition supplementation. Patient underwent an esophageal self-expandable metallic stenting and was managed conservatively. To our knowledge, this is the third reported case of acquired benign EBF associated with Barrett’s esophagus. Albeit this is rare, extensive and friable Barrett’s esophagus in the setting of esophageal dysmotility-induced stasis is a perfect setup for a pill-induced benign EBF.

Pediatric recurrent acute suppurative thyroiditis of third branchial arch origin—Our experience in 17 cases

ObjectiveTo describe clinical presentations, management and treatment outcomes of 17 cases of congenital pyriform sinus fistula (PSF) of third branchial arch origin presenting as left recurrent acute suppurative thyroiditis with cervical abscess. MethodMedical record of these 17 cases (5-males, 12-females) presented during 2009–2013 were reviewed. ResultsAverage age was 9.6 years (range 3–15 years). Fistulous opening in neck was present in 10 cases (58.8%). Average number of episode of infection from first presentation to definitive diagnosis was 3 (range 2–5). All patient had history of incision and drainage (ID) of abscess (average 2, range 1–3). All cases had barium swallow and CT scan. Sixteen cases had telescopic hypopharyngoscopy. Barium swallow and telescopic hypopharyngoscopy detected PSF in 88.23% (15/17) and 100% (16/16) cases respectively. Fourteen cases were treated by transcervical excision (TE) (fistulectomy with left hemithyroidectomy), two cases were treated by endoscopic chemical cauterization (ECC) of internal opening at pyriform sinus using silver nitrate and only ID of abscess was done in one case. Success rate of TE and ECC was 93% and 100% respectively. Recurrence in one case initially treated by TE was managed successfully by ECC. ConclusionPresence of congenital PFS should be suspected when left-sided intra-thyroidal abscess formation occurs as gland is resistant to infection. Strong clinical suspicion, barium swallow study, telescopic pharyngoscopy and CT scan are the key to diagnosis. Both TE and ECC has comparable success rate. ECC may prove a useful and equally effective method of treatment for congenital PFS in future.

Preliminary experiences of endoscopic CO₂ laser cauterization for treatment of congenital pyriform sinus fistula

To evaluate the effectiveness of endoscopic CO₂ laser cauterization (ECLC) as a definitive treatment of congenital pyriform sinus fistula (CPSF). Eleven patients with CPSF underwent ECLC between January 2011 to March 2013 at Guangdong General Hospital. Of the 11 patients aging from 20 to 672 months (median: 60 months), there were 4 males and 7 females; 10 lesions located in the left necks and 1 located in the right; 6 untreated previously and 5 recurrent; 10 sinus (with internal opening) and 1 fistula. The presentations included reduplicative neck swelling, pain, or a fistulous opening with purulent discharge at the anterior neck region. Preoperative examinations included barium esophagogram, CT, MRI and so on. Six patients had at least received one time incision and drainage procedure previously. All patients had been treated with antibiotics in acute infection period. After inflammation subsided, the openings of pyriform sinus fistula were confirmed by esophagoscopy and then ECLC on internal opening was routinely performed.Esophagoscopy was carried out again by 3 months later in every patient, the same technique would be performed immediately if the internal opening was not completely closed. The existence of an orifice in the pyriform fossa was identified by esophagoscopy in 11 patients. In 9 patients, the treatment was successful and the internal opening completely closed after the first ECLC. However, the other 2 patients received the second cauterization 3 months later because of the incomplete close of the internal opening. The average number of treatments was 1.2 times. No complications such as dysphagia, hoarseness occurred with the endoscopic procedure. Both the patients and their families were satisfied with the cervical appearance. All the patients had an uneventful recovery and remained no symptom from 11 to 35 months (median: 24 months). The endoscopic CO₂ laser cauterization is safe, effective, repeatable and minimally invasive, which can be suggested as first-line treatment for congenital pyriform sinus fistula.

Gallstone Bezoar Following Cholecystogastric Fistula: a Rare Sequelae of Cholelithiasis.

Cholecystogastric fistula is a rare biliary-enteric fistula with a variable clinical presentation. Despite modern diagnostic tools, a high index of suspicion is needed to diagnose it preoperatively. Stone migration into stomach forming gallstone bezoar is very rare. Stones more than 2.5cm are likely to cause obstruction. We report a case of gallstone bezoar of size 9 × 5cm lying in the stomach with a small fistulous opening in the prepyloric region of the stomach. Patient was thoroughly investigated and successfully treated with retrieval of bezoar and cholecystectomy.

Management of congenital lacrimal (anlage) fistula

Background/aimsTo review management choices and outcomes for congenital lacrimal (anlage duct) fistulae performed by a single ophthalmologist over a 10-year interval.MethodsAll cases of congenital lacrimal fistulae with minimum follow-up of...

Index of Suspicion in the Nursery

A 34-week preterm baby (triplet C) is born of a triplet gestation to a 29-year-old gravida 2 para 3 mother after conception by in vitro fertilization. The mother is on thyroxine hormone for hypothyroidism and glyburide for diabetes mellitus. Delivery is by cesarean delivery at 34 weeks’ gestation due to progressively worsening maternal hypertension and a low biophysical profile of triplet B. Delivery room stabilization includes positive pressure ventilation, intubation, and surfactant administration. Apgar scores are 6 at 1 minute and 8 at 5 minutes. Birthweight is 2,380 g (50th–75th percentile), length is 46 cm (50th–75th percentile), and head circumference is 33.4 cm (75th–90th percentile). He is extubated to continuous positive airway pressure in a few hours, and respiratory support is weaned to humidified high flow through nasal canula. Feedings are commenced when he is 4 days old and gradually advanced. He vomits and has desaturation with worsening respiratory distress and requires increased respiratory support with each attempt to increase feeds. Radiologic evaluation reveals progressively worsening parenchymal haziness (Figs 1 and 2). After feeds are stopped, his respiratory status improves, and he is weaned down to baseline respiratory support. Radiologic evaluation leads to suspicion of the diagnosis followed by a confirmatory test.An upper gastrointestinal contrast study reveals contrast in the tracheobronchial tree, suggestive of either aspiration or a tracheoesophageal fistula (TEF) (Fig 3). Rigid bronchoscopy and esophagoscopy is deferred to allow for somatic growth while the child is enterally fed through a nasojejunal tube. Subsequent rigid bronchoscopy reveals a normal carina and right and left mainstem bronchi. Inspection of the anterior aspect of the trachea shows no abnormalities. Inspection of the posterior trachea reveals a fistulous opening (Click here to see the video clip) approximately 2.7 cm proximal to the carina that increases in size with positive pressure. A 2F Fogarty catheter is introduced through the working port of the rigid bronchoscope and passes easily through the fistulous opening. Simultaneous flexible esophagoscopy with a neonatal esophagoscope demonstrates a normal-appearing esophagus, an indwelling orogastric tube, and the presence of the Fogarty catheter within the esophageal lumen, confirming the H-type TEF. Echocardiogram shows a small, septum secundum atrial septal defect (ASD). Skeletal survey and head, spinal, and renal ultrasounds are normal.TEF is an abnormal communication between the trachea and the esophagus. It was classified by Gross into the following types:The H type is the least common variant of TEF and accounts for only approximately 4% to 5% of total cases. The commonest level at which it occurs is the second thoracic vertebra. It has the lowest incidence of associated congenital anomalies and the best prognosis among all varieties of TEF. Polyhydramnios is rare, and intrauterine growth is usually normal. Clinically, it is characterized by the classic triad of recurrent episodes of choking and coughing with feeding, lower respiratory tract infections, and abdominal distension as air passes through the fistula into the stomach.In any infant presenting with these symptoms, an H type TEF should be suspected. Bronchoscopy with or without esophagoscopy is the diagnostic gold standard. Surgical treatment consists of ligation and repair of the fistula, usually through a cervical approach although a thoracoscopic approach, or thoracotomy may be required depending on the level of the fistula.The fistula was repaired through a right-sided cervical approach. The patient developed stridor, with increased work of breathing in the immediate postoperative period that steadily improved over the next few days. Oral feedings were commenced on postoperative day 4, well tolerated, and gradually increased to goal. Flexible nasolaryngoscopy was performed 2 weeks after the surgery for persistent stridor, which showed right vocal cord paresis. The stridor continued to improve, and he was discharged home. Follow-up nasolaryngoscopy showed return of right vocal cord function.Recurrent episodes of choking, coughing, and respiratory distress with feeds can be caused by an H-type TEF. It has the best prognosis among all types of TEF.

Congenital fistula of the penile urethra: A case report

Urethral fistulous opening to the penile shaft with or without chordee is extremely rare. Here, a 4-year-old boy with congenital urethral fistula is reported. English literature was reviewed for the former similar cases. Historical analysis showed that no appropriate nomenclature occurred for this isolated anomaly.

Coronary arteriovenous fistula causing hydrops fetalis.

Fetal heart failure and hydrops fetalis may occur due to systemic arteriovenous fistula because of increased cardiac output. Arteriovenous fistula of the central nervous system, liver, bone or vascular tumors such as sacrococcygeal teratoma were previously reported to be causes of intrauterine heart failure. However, coronary arteriovenous fistula was not reported as a cause of fetal heart failure previously. It is a rare pathology comprising 0.2–0.4% of all congenital heart diseases even during postnatal life. Some may remain asymptomatic for many years and diagnosed by auscultation of a continuous murmur during a routine examination, while a larger fistulous coronary artery opening to a low pressure cardiac chamber may cause ischemia of the affected myocardial region due to steal phenomenon and may present with cardiomyopathy or congestive heart failure during childhood. We herein report a neonate with coronary arteriovenous fistula between the left main coronary artery and the right ventricular apex, who presented with hydrops fetalis during the third trimester of pregnancy.

Congenital parotid duct fistula: A case report and review of literature

Parotid duct fistula is uncommon but difficult-to-treat complication that often results from a penetrating trauma. While there is general consensus in the literature as to the management of acute parotid injuries, treatment of chronic fistulas remains controversial. Congenital parotid duct fistula is a rare entity. Herein we present a 20-year-old female who presented with a parotid duct fistula since birth. Clinical evaluation revealed no accessory parotid gland or duct. Patient was found to have a combination of more prominent Plica semilunaris of the left eye, a finding not so far reported in the literature. Following complete examination and investigations, intra oral transposition of the fistulous opening and tract was done. We present this case for its rarity and the gratifying outcome of the surgical procedure.

Fournierʼs Gangrene Complicating Inflammatory Bowel Disease: Is it Ulcerative Colitis or Crohnʼs Disease?

Purpose: A 62-year-old man with history of ulcerative colitis presented with scrotal pain and swelling. Patient denied pneumaturia, abdominal pain, diarrhea, fever/chills, or overt GI bleeding. Past medical history was significant for type 2 diabetes and ulcerative colitis. He reported multiple perineal fistulas with recent Fournier gangrene requiring serial debridements over the last 2 months. He was afebrile with stable vitals. Abdominal exam was notable for suprapubic tenderness, multiple open ulcers and discharging fistulas in the perineum. Several scars from prior fistulas were noted. MRI showed horseshoe shaped perirectal abscess and multiple perineal fistulas. Colonoscopy showed anal stenosis and a fistulous opening in the rectum. Remaining colon appeared normal. Rectal biopsies showed mildly increased plasma cells and eosinophils within lamina propria with mild architectural distortion, and patchy mild acute inflammation without granulomas. Based on clinical presentation and findings, patient was diagnosed with fistulizing Crohn's perianal disease with rectal involvement. He underwent surgical debridement with suprapubic catheter placement and was started on metronidazole, ciprofloxacin and inflixmab with good response. Discussion: Perianal Crohn's disease affects 25-40% of all Crohn's patients and includes anal fissures, perianal fistulas, anorectal abscesses, and anal stenosis. Perianal fistula affects 20-30% of all Crohn's patients. Diagnostic tests include: exam under anesthesia with probing, fistulography, barium studies, CT, pelvic MRI, and anorectal EUS. Oral metronidazole for 6-12 months followed by gradual taper can be used as initial therapy for mild to moderate disease. For severe or refractory disease, anti-TNFs agents such as infliximab or adalimubab, have been shown to reduce the number of draining fistulas and even achieve complete closure. Response is rapid with median time to response of 2 weeks. Immumodulators such as 6-MP or azathioprine have also been shown to achieve complete healing or decrease discharge but response is much slower. Only three cases of IBD complicated with Fournier's gangrene have been reported in the literature. Of these two had undiagnosed Crohn's disease and one had ulcerative pancolitis who developed Fournier's gangrene after perianal surgery. Management involves serial debridements, broad spectrum antibiotics, anti-inflammatory therapy for IBD, and diversion colostomy in severe cases.

Transesophageal H-Type TEF Evaluation and Cannulation Using a Side-Viewing Flexible Endoscope: A Novel Technique for Guidewire Placement and Repair

Introduction: Congenital tracheoesophageal fistula without esophageal atresia (H-type TEF) is an unusual entity that typically presents in the first months of life with clinical signs of aspiration. Surgical repair is usually facilitated by placement of a catheter or wire through the fistula during rigid bronchoscopy.1,2 This cannulation allows the surgeon to identify the fistula during dissection of the neck.3 We describe a case of H-type TEF in which, the fistula could not be identified on rigid bronchoscopy, but was only visible on esophagoscopy. Cannulation of the fistula was therefore achieved using video esophagoscopy. The video depicts the placement of the guidewire under a video esophagoscope using an ultraslim (pediatric) side-viewing duodenoscope. Fluoroscopic images confirming fistula cannulation are also shown. The video runtime is 1:44. Materials and Methods: The patient is a male born prematurely at 34 weeks, birth weight 2.0 kg. Respiratory distress was noted on the first day of life and a contrast study revealed the H-type TEF. Rigid bronchoscopy failed to identify the fistula. The fistula was noted on rigid esophagoscopy, but could not be cannulated given the acute angle of the fistulous opening on the esophageal side. A repeat procedure was undertaken with video esophagoscopy. The forward-view endoscope, Olympus N180 (Olympus Medical), was used for initial examination and determination of the fistula position within the esophagus. Once the exact measurement was obtained, an Olympus PGF160 (Olympus Medical) was introduced transorally and advanced to the predetermined depth within the esophagus. The H-type fistula opening was identified and cannulated using a slim (5F) tapered ERCP cannula (Mini-Tome; Wilson-Cook). A 0.018-inch soft GI guidewire (Pathfinder wire) (Boston Scientific) was then placed through the ERCP cannula. The wire placement was done under video and fluoroscopic control. The tip of the guidewire crumpled on the bronchial side of the fistula and was felt to be too flexible and soft, so it was exchanged for a 0.021-inch guidewire (Wilson-Cook). The surgical repair was then performed with the guidewire in place. Results and Conclusions: Primary repair of an H-type TEF is usually aided by placing a cannula or guidewire through the fistula under bronchoscopy. In this case, failure to place a wire was due to high takeoff of the fistula within the hypopharynx and difficulty visualizing the opening from the tracheal side. Transesophageal evaluation and guidewire placement using a side-viewing duodenoscope was undertaken and was successful. Placement was relatively smooth and atraumatic when compared with rigid bronchoscopy. This index case validates the use of this technique. Expanded experience with this technique would be needed to clarify questions regarding safety and reproducibility. In complex cases with difficult fistula cannulation during bronchoscopy, this technique offers another option for TEF guidewire placement before repair. No competing financial interests exist. Runtime of video: 1 min and 44 secs

Post Caesarean Vesicouterine Fistula Causing Menouria

Vesicouterine fistula is an uncommon urogenital fistula. The incidence is on the rise because of increasing incidence of Caesarean sections. Cyclical Haematuria or Menouria is an important clinical feature of this fistula which may or may not be associated with urinary incontinence depending on the location of the fistulous tract. We present a case report of Post caesarean section Vesicouterine fistula following 2 Caesarean sections. This was successfully managed by laparotomy with repair of fistulous tract in bladder wall and Total Abdominal Hysterectomy for multiple Fibroid uterus done. Menouria is a rare event in Gynecology and one should always keep this possibility in mind when there is cyclical haematuria. A 42 year old Bangladeshi woman was hospitalized with complaints of menorrhagia, lower abdominal pain for last 8 years, cyclical hematuria for last 20 years. She was mildly anemic, haemodynamically stable and regularly menstruating women. The primary Ultrasound scans suggested multiple fibroid with cystic ovary in left side. Cystoscopy was done and findings are a fistulous opening in the bladder measuring around 7mm in size. It was supratrigonal in position. The patient had no history of Endometriosis, Pelvic irradiation therapy, Inflammatory disease, Trauma or Malignancy. Initially there was dilemma in her diagnosis and the patient was diagnosed as a case of bladder Endometriosis besides fibroid uterus. So surgery was planned and Total Abdominal Hysterectomy & bilateral salphingo-oophorectomy done. There was a fistula about 3cm × 2cm in the lower part of the body of uterus connecting with the base of Bladder. Fistula repaired after dissection, patient follow up done and catheter removed after 14 days without any complications. Vesicouterine fistula can be prevented if care is taken to separate the bladder from the uterus during repeat Caesarean sections. DOI: http://dx.doi.org/10.3329/medtoday.v25i1.16072 Medicine Today 2013 Vol.25(1): 46-48

Primary Repair of Broad Bilateral Complete Cleft Palate With Hard Palate Rotation Flap

It was hard to achieve primary repair for infants with broad bilateral complete cleft palate, and usually multiple procedures are demanded, resulting in multiple injuries and scar hyperplasia, which could influence infants' long-term phonetic function. In this study, primary repair was carried out on 12 cases of 18- to 30-month-old infants who had complete cleft palate by using rotated hard palate flap with a pedicle on the edge of the fissure modified on the basis of traditional von Langenbeck palatoplasty. Eight infants were subjected to initial phonetic sound evaluation at 1 to 2 years after the operation. All the 12 cases of infant complete cheilopalatognathus had fine healing, and no complications such as dyspnea and fistulous opening in palate were observed. The effects of phonetic sound in 8 infants who had this disease were significantly improved as observed in the long-term follow-up. Thus, we consider it as a reliable and feasible procedure to perform hard palate mucosa rotation flap for the primary repair of broad bilateral complete cleft palate. The procedure is simple, while it produces satisfactory therapeutic effects, by which the patients with complete cleft palate could achieve good recovery in their phonetic functions.

V405 ROBOTIC TRANSVESICAL RECTOURETHRAL FISTULA REPAIR FOLLOWING A ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyMale Voiding Dysfunction and Infection1 Apr 2013V405 ROBOTIC TRANSVESICAL RECTOURETHRAL FISTULA REPAIR FOLLOWING A ROBOTIC RADICAL PROSTATECTOMY Brian Linder, Igor Frank, Eric Dozois, and Daniel Elliott Brian LinderBrian Linder Rochester, MN More articles by this author , Igor FrankIgor Frank Rochester, MN More articles by this author , Eric DozoisEric Dozois Rochester, MN More articles by this author , and Daniel ElliottDaniel Elliott Rochester, MN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1794AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Rectourethral fistulas in men are most commonly seen following therapeutic interventions for prostate cancer, whether via prostatectomy, radiation therapy or cryotherapy. We present a video of a robotic assisted technique for surgical repair of recto-urethral fistula. METHODS A 61-year old male developed a rectourethral fistula near the bladder neck following a robotic assisted radical prostatectomy, likely secondary to an unrecognized rectal injury. After failure of conservative measures, including an indwelling Foley catheter and a suprapubic tube, he was referred to our center for surgical repair. Utilizing a 6-port transperitoneal setup, similar to that described for a robotic prostatectomy, we performed a robotic assisted transvesical rectourethral fistula repair. We initially proceeded with cystoscopy to identify the fistula and its location with respect to the ureteral orifices. Following port placement and lysis of adhesions, the bladder dome was identified through retrograde filling through the patientÆs catheter. Then, a horizontal cystotomy was made and the camera and working arms were advanced transvesically to the fistulous opening. A ureteral catheter was placed to aid in protection of the ureteral orifice during dissection. The fistula was then circumferentially mobilized to the base of the tract. The rectal wall and the bladder were closed individually using a 3-0 Maxon suture. Following this, the patientÆs suprapubic tube was exchanged and the cystotomy at the bladder dome was closed in two layers. The cystotomy closure was verified to be water-tight with bladder irrigation. Our colleagues in Colon and Rectal Surgery then performed a temporary loop-ileostomy. RESULTS The operative time was 200 minutes, including cystoscopy and temporary loop ileostomy formation. The patient had an uncomplicated postoperative course and was discharged on hospital day two. The indwelling Foley catheter and suprapubic tubes were removed at three weeks post-operatively following a cystogram showing no residual extravasation. CONCLUSIONS Given this result, a transvesical robotic assisted repair of a rectourethral fistula repair appears technically feasible in appropriately selected candidates. Longer follow up and larger case series will be needed to validate this finding. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e164-e165 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Linder Rochester, MN More articles by this author Igor Frank Rochester, MN More articles by this author Eric Dozois Rochester, MN More articles by this author Daniel Elliott Rochester, MN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Crushed Muscle Tissue Graft: A Efficient Repair Technique for Intraoperative Chylous Fistulas

ABSTRACT Background/objectives Chylous fistula is an uncommon but serious complication of radical neck dissections and is a complication which can be better avoided than treated. Presence of amber colored lymph in the postoperative closed wound suction drainage is defined as chylous fistula. Materials and methods The study was done over 18 months analyzing neck dissections done for 245 cases for complications of chyle leak. Six cases of chyle leak were identified during the course of the study. Results All the six cases were repaired with crushed muscle tissue graft harvested from the remaining portion of the sternocleidomastoid muscle was spread out and sealed. No chyle leak complications were seen in the drains after the repair. Conclusion The use of crushed local muscle tissue grafts offers better chances of success for closure of chylous fistulae in the neck, especially when the fistulous opening was difficult to ligate and the site of leak was only packed with sponge gel or Surgicel®. This complication should be better avoided than repaired. How to cite this article Naik SM, Chavan P, Halkud R, Shenoy AM, Nanjundappa A, Gupta S. Crushed Muscle Tissue Graft: A Efficient Repair Technique for Intraoperative Chylous Fistulas. Int J Phonosurg Laryngol 2013;3(1):1-5.