Fistulous Orifice Research Articles

Pyloro-duodenal hernia with formation of enterocutaneous fistula in a buffalo calf following a dog attack

A body wall hernia entrapping abomasum and concurrent duodenal fistula in a buffalo calf aged about 8 months, secondary to a dog bite was successfully treated by closure of fistulous orifice and ventro lateral herniorrhaphy.

Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice

Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice

The Value of Cholangiography through Jackson-Pratt Drains in the Management of Postoperative Biliary Injuries

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

A Case of Recurrent Liver Abscess Due to Choledochoduodenal Fistula

Cholelithiasis, duodenal ulcer, duodenal perforation and tumor invasion may lead to choledochoduodenal fistula (CDF). CDF often has no specific symptoms and may be incidentally detected in an upper gastrointestinal radiographic study or endoscopy; but in some cases, it may be accompanied by recurrent cholangitis and liver abscess. In this paper, a case of recurrent liver abscess caused by CDF is reported. A 62-year-old female was admitted to the authors’ hospital because of right upper quadrant pain and fever. The abdominal computed tomography showed a liver abscess in the right lobe. A duodenal fistulous orifice was detected with endoscopy, and a contrast was injected through the duodenal orifice using a catheter under fluoroscopy. The injection of the contrast revealed a fistulous track between the duodenal bulb and the common hepatic duct. In fistulas complicated by recurrent liver abscess, surgery or medical management may be needed. The CDF in this case study was treated via endoscopic clipping.

Neoplasia mucinosa papilar intraductal com fistulização gástrica e duodenal: uma forma rara de apresentação

Intraductal papillary mucinous neoplasm (IPMN) is a rare pancreatic cystic neoplasm with high risk of malignancy. We present the case of a 64-year-old male with steatorrhea and weight loss (17% total body weight). Colonoscopy detected presence of oil droplets in stools. Esophagogastroduodenoscopy revealed a fistulous orifice with mucous drainage in the duodenal bulb and a bulging ampulla of Vater, possibly by external compression; Abdominal CT showed the presence of a cystic lesion in the pancreatic head, 5.8cm in diameter, significant dilation of wirsung and slight dilation of common bile duct. EUS revealed a multicystic lesion with irregular contours in the pancreatic head, suggestive of IPMN. EUS guided fine needle citologic examination confirmed IPMN. Abdominal MRI detected fistulization to the duodenum and stomach. Pancreatoduodenectomy was performed and a pathological diagnosis of mucinous adenocarcinoma in IPMN was obtained. There has been no evidence of recurrence during 14 months of follow-up. Most patients diagnosed with IPMN are assymptomatic, steatorrhea is the less frequent form of presentation. Fistulization to adjacent organs occurs in 7-15% cases, combined fistula to duodenum and stomach in only 6%.

Tuberculosis of the Breast: A Case Report

INTRODUCTION: Tuberculosis of the breast is a rare condition, with an incidence ranging from 0. 1% to 0.52% even in countries where the case rate of tuberculosis is high1. It affects virtually only women, particularly those aged 20 to 50 years, and occurs more commonly in blacks than in whites. Similar to the skeletal muscle and spleen, breast tissue seems to be resistant to Mycobacterium tuberculosis, which may justify the low incidence of disease in these sites2. Microbiologic and histopathologic tests are the gold standard for diagnosis of breast tuberculosis, by identifying acid-fast bacilli (AFB) and granuloma with caseation necrosis and histiocytic inflammatory infiltration, respectively4. We report a case of breast tuberculosis in a female patient. CASE REPORT: A 76-year old female patient sought the breast disorder service due to the appearance of a red patch and increased volume of the left breast for two months. She had no fever and reported drainage of purulent secretion with fistulous orifices. On physical examination, the patient presented with a bloodstained area measuring 6x6cm at the junction of the upper quadrants of the left breast, with fistulizing and necrotic areas surrounding the main lesion. The patient was gravida 0, para 0 and had a positive history of smoking, hypertension and Alzheimer’s disease. History of alcoholism and diabetes was negative. Chest tomography was normal and PPD test was negative. Histopathologic analysis of the lesion showed a chronic granulomatous inflammatory process, with foci of necrosis, although not caseous necrosis. Cephalexin, ciprofloxacin and anti-inflammatory drugs had been administered to the patient but treatment was unsuccessful. The option was a therapeutic test for tuberculosis, since clinical presentation of the lesion was suggestive of tuberculosis. Antituberculous therapy was begun with ethambutol, 275mg/d; rifampin, 150mg/d; and isoniazid, 75mg/d, 3 pills daily. There was a good clinical response with resolution of the breast lesion and complete wound healing. At one-year follow-up, the patient remains well and has no further lesions or complaints. DISCUSSION: Despite being a rare infection, tuberculosis of the breast should always be considered in patients presenting with a palpable breast lump or fistulizing inflammatory process, who test negative for malignancy. Histopathologic evaluation is essential for diagnostic confirmation. Furthermore, in the absence of a histologic diagnosis, a therapeutic test may be necessary, as occurred in the present case.

Management of intrathoracic leakage after radical total gastrectomy.

Intrathoracic anastomotic leakage resulted from radical total gastrectomy with an end-to-side esophagojejunostomy are exclusively abdominal. We report the case of a 64-year-old male who underwent radical total gastrectomy and intraabdominal end-to-side esophagojejunostomy for gastric cardiac carcinoma. Anastomotic leakage to the thoracic cavity occurred which was confirmed by contrast radiography 18 days after the operation. The symptoms included coughing and fever, with elevated white blood cells over 10×10(9)/L. Coughing and fever disappeared after successful sealing of the fistulous orifice with an endoscopically placed covered metallic stent with the applications of antibiotics and drainage of the pleural effusion. The patient was recovered and discharged from the hospital approximately two months after the occurrence of the leakage without any symptoms except intermittent esophageal reflux which could be resolved by treatment with cisapride, or by intaking less liquid food. The patient then received 4 cycles of adjuvant chemotherapy with regimen of FOLFOX4 (fluorouracil, leucovorin and oxaliplatin). Unfortunately, he died of a disease- or treatment- unrelated accidence 5 months after the discharge. The thorough drainage combined with antibiotic treatment is able to eliminate empyema without the need for a specific thoracoscopy or thoracic surgery for patients with intrathoracic leakage.

Endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate

Objective To explore the method and safety of endovascular treatment of traumatic direct carotid cavernous fistulas with n - Butyl - 2 - Cyanoacrylate. Method A total of 11 patients with traumatic direct carotid cavernous fistulas treated by endovascular embolization with n - Butyl -2 - Cyanoacrylate( n - BCA ) were retrospectively analyzed, including the clinical presentations, methods of treatment and results of follow - up. Results In the 11 patients treated with n - BCA embolization, 3 with recurrent fistula because of premature balloon deflation or migration,4 with residual fistula after the balloons or microcoils detached, 3 unable to guide balloon into the small fistulous orifice and 1 repeated puncture of the detachable balloon by the bony fragment. The concentration of n - BCA ranged from 25% to 50%,protective balloon was used in 4 cases and there was no adhesion fo the n - BCA to the protective balloon or the microcatheter or n - BCA reflux into the parent arteries. Complete angiographic obliteration was documented in all patients right after the embolization. There was no permanent procedure - related morbidity. Clinical cure was achieved in all case and the clinical follow - up period ranged from 3 months to 5 years, all the patients restored to their normal life. Conclusions Endovascular embolization with n - BCA is a safe,efficient method for the treatment of traumatic direct carotid cavernous fistulas when angiographic cure and parent artery preservation are not achieved by detachable balloon embolization. Key words: Embolization; Carotid cavernous fistulas; Glue; Trauma

Prevention of post-surgical recurrence with adalimumab in a patient with complicated Crohn's disease

We describe the case of a young woman with fistulising Crohn’s disease of the ileum and colon. The disease was diagnosed at the age of 19 years. About 6 years after the initial diagnosis, the patient underwent partial resection of the transverse colon because of gastro-colonic and jejunal-colonic fistulae. In March 2006, following weight loss of about 6 kg and the appearance of an entero-cutaneous fistula draining faecal material, the patient was admitted to hospital where she was treated with systemic steroids, antibiotics and total parenteral nutrition. Treatment with intravenous infliximab was attempted but was unsuccessful (the drug had to be stopped because of the development of an adverse reaction). In June 2008, the patient was referred to us for the first time. The patient smoked about 20 cigarettes/day and did not have a family history of chronic inflammatory bowel disorders. Clinical examination showed clear signs of malnutrition (height: 160 cm; weight: 39 kg; body mass index: 15.2 kg/m2), a mild state of dehydration, muscle hypotrophy, and two fistulous orifices draining faecal material in the left iliac fossa. There was widespread tenderness to palpation in all quadrants of the abdomen. Laboratory tests revealed mild anaemia, neutrophil leukocytosis, and increased levels

Endoscopic retrieval of a surgical gauze from the right colon

A 33-year-old man, who had been operated on a congenital bridle 14 years ago, was admitted to our hospital for evaluation of a 3 month recurrent abdominal pain. CT scan and colonoscopy were performed in another medical centre, in which a chronic inflammatory process surrounding a foreign body was described in the right colon. He was referred to our endoscopy unit, as a tertiary reference hospital, in order to evaluate its extraction. During the endoscopic procedure was visualized a surgical gauze wrapped to an inflammatory intestinal mucosa (with edema and friability) and externalized to the colon lumen (Fig. 1.). Using an endoscopic grasping forceps it was slowly removed until its complete extraction, with a 60 cm total length (Fig. 2.). It revealed a fistulous orifice (Fig. 3) which was communicated with a cavity, without any evidence of active haemorrhage. He had a good clinical evolution and outcome; no more episodes of abdominal pain were referred. A control CT scan was performed 3 months later, which showed slight residual inflammatory changes. It is not unusual to find surgical foreign bodies after a surgical intervention (1,2). They are usually symptomatic; presenting PICTURES IN DIGESTIVE PATHOLOGY

Resolution of Posttraumatic Recurrent Nasal Fistula Using Temporoparietal Fascia

Temporoparietal fascial grafts have been used for both nasal and facial contouring, for vascularized tissue coverage, and to augment the nose and lip. The temporoparietal fascial graft provides thin, broad, pliable, easily neovascularized, adequate coverage, contour, and bulk on the cartilage dorsum of the nose, as well as an inconspicuous donor site. A 23-year-old female motorcyclist had an accident with 1 angular laceration wound on the dorsum of the nose in 2006. There was intermittent discharge in the dorsal nose 2 weeks after primary repair. Six months later, the open-tip rhinoplasty was applied to the recurrent fistula of the nose dorsum. There were 2 fistulous orifices and 1 fibrotic cavity with hair ingrowth. After replacement of the rolled temporoparietal fascia, external nasal splinting was applied to mold the shape for 1 week. There was neither graft exposure nor recurrent infection. The procedure is a useful method to eliminate inflammatory squeals. The smooth nasal dorsum skin was regained with adequate nasal projection.

Over-the-scope clip closure of two chronic fistulas after gastric band penetration

Gastrointestinal perforations are conservatively managed at endoscopy by through-the-scope endoclips and covered self expandable stents, according to the size and tissue features of the perforation. This is believed to be the first report of successful closure of two gastro-cutaneous fistulas with over-the-scope clips (OTSCs). After laparoscopic gastric banding, a 45-year old woman presented with band erosion and penetration. Despite surgical band removal and gastric wall suturing, external drainage of enteric material persisted for 2 wk, and esophagogastroduodenoscopy demonstrated two adjacent 10-mm and 15-mm fistulous orifices at the esophagogastric junction. After cauterization of the margins, the 10-mm fistulous tract was grasped by the OTSC anchor, invaginated into the applicator cap, and closed by a traumatic OTSC. The other 15-mm fistula was too large to be firmly grasped, and a fully-covered metal stent was temporarily placed. No leak occurred during the following 6 wk. At stent removal: the OTSC was completely embedded in hyperplastic overgrowth; the 15-mm fistula significantly reduced in diameter, and it was closed by another traumatic OTSC. After the procedure, no external fistula recurred and both OTSCs were lost spontaneously after 4 wk. The use of the anchor and the OTSC seem highly effective for successful closure of small chronic perforations.

Colovesical, coloenteric, colocutaneous fistula, and hip septic arthritis secondary to sigmoid diverticulitis

Dear Editor: Diverticulitis associated with free perforation and fecal or purulent peritonitis is a surgical emergency, with an associated mortality of up to 35%. Diverticular perforation into an adjacent organ can be followed by fistula formation. We report the case of a patient referred to our hospital with sigmoid diverticulitis and fecal peritonitis, which subsequently developed a complex fistula, as well as left hip septic arthritis. A 41-year-old male patient was transferred to our hospital after an acute episode of purulent sigmoid diverticulitis 2 months before; a transverse colostomy and drainage were performed. The patient was transferred due to a painful left lower extremity deformity and recurrent urinary tract infections despite antibiotic during the last 6 weeks. He showed physical signs of malnutrition, a left lower extremity flexion and adduction deformity, very limited hip motion due to pain and thigh muscular contracture, a fistulous sinus in the left lower quadrant with fecal discharge, and turbid urine through a urinary catheter. The patient denied any previous history of hip or extremity affection. Urine cultures were positive for Escherichia coli. On radiographs, a left adduction deformity and femoral head destruction suggested septic hip arthritis. The Department of Orthopedic Surgery recommended no urgent drainage since no septic state was found. A cystography showed contrast material passage to the sigmoid and left hip cavity. After a 10-day period of nutrition and systemic antibiotics, the patient was scheduled for a laparotomy. Surgical findings: a paracolic abscess and an inflammatory process affecting the sigmoid, dense adhesions to the bladder fundus, an ileum segment, iliac bone and lateral pelvis abdominal wall; fistulous communications medially from the sigmoid to the bladder and ileum 40 cm from the ileocecal valve, and laterally to the iliac bone, where the sigmoid was densely adhered to and below the inguinal ligament. Approximately 0.5 L of purulent material was drained through a communication with the hip joint cavity. An anastomosis was not considered due to the inflammatory and infectious process. Resection of the sigmoid and left colon distal to the transverse colostomy plus a Hartmann's procedure was performed. The segment of affected ileum and fistulous orifice in the bladder were resected. Ileum anastomosis and bladder repairs were practiced. Pathologic exam revealed perforated sigmoid diverticulitis, colon diverticulosis, fibrous reaction surrounding the bladder wall and ileum fistulous orifices, and absence of malignancy. After an uneventful recovery, the patient is under physical therapy. Hip replacement and bowel continuity reestablishment will be practiced. Hinchey et al. described a grading system for colonic diverticulitis. Stage I diverticulitis involves a pericolic abscess; Stage II, a distant abscess, retroperitoneal or pelvic; Stage III, purulent peritonitis; and Stage IV, fecal peritonitis. Stages III and IV are surgical emergencies, with associated mortalities of up to 35%, depending on the degree of fecal contamination, sepsis and surgical intervenNo disclaimers. There was no financial support. The paper was not presented in any meeting. It includes a list of contribution of each author/coauthor. The three authors participated in conception and design, acquisition of data, critical revision of the article, and final approval. C. M. Nuno-Guzman : J. M. Hernandez-Carlin : F. I. Almaguer Antiguo Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Calle Hospital 278, Guadalajara, Jalisco, Mexico 44280

Uso de terapia biológica na doença de Crohn metastática: relato de caso e revisão da literatura

A doença de Crohn metastática envolve a infiltração cutânea granulomatosa em locais anatomicamente separados do trato gastrointestinal, com tendência à cronicidade. É relatado caso de paciente masculino, 20 anos, há seis meses com dor e eliminação de secreção purulenta de úlceras em região perianal, inguinal direita e genital, sem melhora com o uso metronidazol e ciprofloxacina. Antecedente de proctocolectomia em 2002. Ao exame, à inspeção, evidenciava-se orifício fistuloso posterior a 2,0 cm da borda anal, úlcera de 5,0 cm na base do escroto e outra úlcera circundando a base do pênis; ao toque, ânus fibrótico e encarcerado. Realizada fistulotomia, biópsia e curetagem das úlceras genital e inguinal. O resultado histopatológico evidenciou processo inflamatório granuloso não caseoso. Em virtude da falha terapêutica dos antimicrobianos, foi optado pelo tratamento com infliximabe na dose 5 mg/kg nas semanas 0, 2 e 6, e azatioprina 2 mg/kg/dia. Ao término da fase de indução, o paciente apresentava cicatrização parcial das lesões ulceradas, ausência de secreção e alívio da dor. Atualmente em acompanhamento ambulatorial com infusões de infliximabe a cada oito semanas.

Transarterial Embolization of Direct Carotid Cavernous Fistulas with the Double-Balloon Technique

Treatment of direct carotid cavernous fistulas (CCF) has progressed from surgical ligation to surgical trapping to endovascular techniques. Endovascular therapies are advantageous as they allow for occlusion of the fistula whilst preserving flow in the parent carotid artery. However, technical difficulties are not uncommon and occur when the fistulous orifice is too small or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Both circumstances may lead to technical failure or an unplanned sacrifice of the parent internal carotid artery (ICA). Here we describe a double-balloon technique used in the embolization of CCF in four patients that were successfully treated with complete immediate occlusion whilst preserving the parent ICA.

Experiência inicial no tratamento endoscópico de fístulas gastrocutâneas pós-gastroplastia vertical redutora através da aplicação de matriz acelular fibrogênica

Roux-en-Y gastric bypass is one of the most commonly performed bariatric surgeries in Brazil. Gastric leaks are relatively uncommon and potentially dangerous complications. The initial management of gastric leaks consists in adequate drainage, nutritional support, antibiotics and acid suppression. In almost 30% of the cases the fistula will become chronic. A novel peroral endoscopic treatment of gastric leaks in Roux-en-Y gastric bypassed patients is presented. An acellular biomaterial was endoscopically placed in the fistulous orifice in order to promote healing and avoid surgery in 25 patients. The time between fistula diagnosis and endoscopic treatment varied from 4 to 25 weeks (median: 7 weeks). Endoscopic treatment was successful in 20 (80%) patients. Fistula closure was obtained after one, two and three sessions in 6 (30%), 11 (55%) and 3 (15%) patients, respectively. No procedure related complications were observed. Endoscopic repair of gastric leak after Roux-en-Y gastric bypass by using an acellular biomaterial is safe and effective. However two or three endoscopic sessions are usually needed.

Migración y fistulización a través de la piel de cuerpo extraño faríngeo (espina de pescado)

Foreign bodies ingestion is a common problem seen at emergency rooms and mostly involved are fish and chicken bones. The diagnosis can be difficult because of the age of the patient (children and older patients with dental prosthesis). The shape of the foreign body leds to the course of the pathology, with possible mayor complications like migration into the fascial spaces of the neck, retropharyngeal abscess and perforation of the pharynx or esophagus which have the potential to cause morbidity and mortality. We present a 88-year-old lady who swallowed a 3 cm linear sharp fish bone which migrated from the pharynx to the skin of the neck, surfaced through a fistulous orifice and threw out six weeks later. No intervention was needed. A discussion of the management of migrated foreign bodies follows.

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management

Mirizzi syndrome is a rare complication of prolonged cholelithiasis, characterized by narrowing of the common hepatic duct due to mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct. To describe a series of eight consecutive patients with Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment. Four women and four men, with a mean age of 61.6 years (42 to 82 years), presenting Mirizzi syndrome were operated between 1997 and 2003. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. The most frequent symptoms were abdominal pain (87.5%) and jaundice (87.5%). All the patients presented altered hepatic function tests. The diagnosis of Mirizzi syndrome was intra-operative in seven (87.5%) patients, and preoperative in one (12.5%). Cholecystocholedochal fistula associated with choledocholithiasis was observed in three (37.5%) cases. Mirizzi syndrome was classified as Csendes type I in five (62.5%) patients, type II in one (12.5%), type III in one (12,5%) and type IV in another (12.5%). Cholecystectomy, as an isolated surgical procedure, was performed in four (50.0%) patients. One (12.5%) patient was submitted to partial cholecystectomy and closure of the fistulous orifice with the central part of the infundibula. Two (25.0%) patients were submitted to cholecystectomy and side-to-side choledochoduodenostomy and another (12.5%) to side-to-side choledochoduodenostomy remaining the gallbladder in situ. Seven (87.5%) patients had an uneventful recovery and were discharged in good conditions. One (12.5%) patient presented a postoperative sepsis due to a sub-hepatic abscess, and was reoperated. There was no operative mortality. The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid lesions of the biliary tree. The problem may only become evident during the operation due to firm adherences around Calot's triangle. The success of the treatment is related to a precocious recognition of the condition, even at the time of surgery, and adapting the management considering to the individual characteristics of each case.

3395 Clinical usefulness of primary endoscopic choledochoduodenal fistulotomy in patients with ampullary cancer.

Background: In patients with ampullary cancer, the use of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) between the bulged suprapapillary intraduodenal part of the bile duct and the duodenum by needle-knife sphincterotome (NKS) has been reported sporadically as an alternative to failed bile duct cannulation and subsequent endocopic biliary drainage such as biliary stenting or endoscopic sphincterotomy (EST). However, endoscopic fistulotomy can be performed primarily, for both successful biliary drainage and avoidance of recurrent symptoms by possible stent dysfunction or fatal bleeding by EST, in patients especially with suprapapillary bulged, distorted, or friable to bleeding papilla causing failed endoscopic biliary drainage procedures. Aim: To evaluate safety and clinical usefulness of primary endoscopic fistulotomy in patients with ampullary cancer. Methods: Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients(44.8%) with suprapapillary bulged papilla underwent fistulotomy using NKS (HPC-2, Wilson-Cook Medical Co, NC) alone or followed by upward extension of the fistulous orifice using standard sphincterotome (fistulotomy group). The remaining 16 patients underwent transpapillary stenting with standard techniques (transpapillary stenting group). In both groups, the success rate of bile duct cannulation and effective biliary drainage was assessed and compared. Results: Bile duct cannulation was successful in 12 patients (92.3%) of the fistulotomy group and 13 patients (81.3%) of the transpapillary stenting group (p>0.05), and complication was mild bleeding in 1 patient (7.7%) and cholangitis by stent occlusion in 1 patient (6.3%), respectively (p>0.05). The success rate of initial biliary drainage by endoscopic fistulotomy and transpapillary stenting was 100% and 84.6% (p>0.05), respectively. In 13 patients, biliary drainage was used as a definite treatment and the symptom-free duration was 3.2 months in 7 patients (52.8%)of the fistulotomy group and 3.9 months in 6 patients (37.5%) of the transpapillary stenting group (p>0.05). Conclusions: Endoscopic fistulotomy is as effective as transpapillary stenting in preoperative or palliative decompression of the obstructed bile duct due to the ampullary cancer. Without the need of biliary stenting, this can be employed primarily with safety in selective patitients when bulged suprapapillary intraduodenal part of the bile duct is observed definitely.

Infected Knee Prosthesis

Studies have shown the usefulness of labeled leukocyte scintigraphy as a specific tracer to detect inflammatory-infectious conditions in orthopedic surgery. The authors submit the case of a 69-year-old woman who had a total left knee prosthesis implanted 2 months earlier. At the time of exploration, the patient complained of knee pain and local clinical signs of soft tissue infection adjacent to the surgical scar. A fistulous orifice on the front of the leg, immediately below the knee, with abundant suppuration was observed.