Incidence Of Fistula Formation Research Articles

The outcome of gracilis muscle flap wrapping around the neourethra-native urethral anastomosis after radial forearm free flap phalloplasty on the incidence of fistula formation

ABSTRACT Introduction The radial artery-based free-flap phalloplasty (RFFP) is accompanied by high rates of fistula formation and urological complications. We thought to investigate the impact of pedicled gracilis muscle flap wrapping around the urethral anastomosis on the occurrence of fistula at the neourethra-native urethral junction. Materials and Methods Prospective study was conducted at the urology department of Cairo University Hospitals. Patients presenting with micropenis (stretched penile length ≤7 cm) underwent RFFP. The RFF was harvested from the non-dominant forearm after ensuring of good collateral supply to the hand. All patients underwent RFFP with pedicled gracilis muscle flap wrapping. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein and the medial and the lateral ante-brachial nerves with the ilioinguinal nerve and the dorsal penile nerve, respectively. Data were reviewed for demographics and perioperative outcomes. Results Nineteen patients were included in the study with a median follow up of 11 months (3, 22). Median age of 26 yrs (16, 43), hospital stay was 7 days (7, 30) and. Indications for RFFP were: micropenis (40%), post-surgery crippled penis (25%), amputated penis (20%), aphallia (5%), epispadias (5%) and gender dysphoria (5%). Median ischemia time was 88 mins (60, 120), ebl was 600 cc (300, 2000) and operative time 11 hrs (8, 14). Intraoperative complications were a case of transection of the radial artery during graft harvesting, failure to tubularize the graft and significant blood loss during vaginectomy. Overall success rate was 70%. 5 cases had a complete success, only one case had a fistula at the neo-uretheral native urethral anastomosis, one patient had a distal fistula and another patient had a ring stricture at site of anastomosis. 8 cases were complicated by complete disruption of the urethra. 6 cases were complicated by total graft loss (2 cases due to arterial causes and 4 cases due to venous congestion). No donor site morbidity was noted. During follow up patients reported shortness in the mean length of the phallus was 2.1cms. All patients reported recovery of both general and erogenous sensations in the neo-phallus. The recovery of the general sensation (tactile stimulation and two-point discriminations) ranged between 2 to 4 weeks post-operatively while recovery of the erogenous sensation occurred between 8 to 16 weeks. Conclusion The use of pedicled garcilis flap during RFFP resulted in a fistulae rate of 20%. Disclosure Work supported by industry: no.

A Retrospective Study of Incidence of Fistula after Management of Perianal Abscess

Background: Perianal fistulas can present significant morbidity and detriment to a patient’s quality of life. Perianal fistula is among the most common anorectal diseases encountered in adults, men are more prone to be affected than women. Objective: To determine the incidence of fistula After Management of Perianal Abscess. Materials and Methods: A retrospective study of 34 patients with perianal abscess operations conducted in Dept. of Surgery, Sheikh Hasina Medical College and Hospital, Tangail, Bangladesh from January 2017 to December 2021. Their ages ranged from 20 to 68 years (40.21 ± 1.34) males (31/34) (92.64%) were more than females (3/34) (7.35%). Patients were treated with incision over the abscess under anesthesia and drainage of the abscess was done. The patients were followed up for an average 18 months (range 12–24 months) after abscess drainage or until a fistula appeared and abscess recurrence. Results: The study group comprised of 34 (92.64%) patients with perianal abscess with a median age 39 years (range 20–68 years). The mean follow-up period was identified to be 18 months (range 12–24 months). Males (31/34) (92.64%) were more than females (3/34) (7.35%). The incidence of fistula formation after follow up, the patients with perianal abscess after incision and drainage was 16/34 (47.07%) and males (15/16) (44.11%) were more than females (1/16) (2.94%). The most common site was posterior then left lateral position. The percentage of patients with recurrent abscess n = 3 (8.82%) were lower than fistula formation n =16 (47.07%). The percentage of males n = 2/3 (5.88%) were more than females 1/3 (2.94%). Conclusions: The incidence of anal fistula in a sample of Bangladeshi patients with perianal abscess was 47.05% and percentage of recurrence of perianal abscess was 8.82%. To avoid division of anal sphincter muscle, secondary fistulotomy is advised to be done later when anal fistula will be formed.

Comparison of the Interrupted and Continuous Suture Techniques for the Closure of Oral and Nasal Mucosal Layers in Cleft Palate Surgery.

BackgroundCleft lip and palate are common congenital craniofacial anomalies, treated conventionally by surgery at the ages of six to 18 months. Mostly, the interrupted suture technique is used to close the nasal and oral layers of the palate. In some studies, the interrupted suture technique was compared with continuous suture techniques for the closure of oral and nasal layers and found that there was less utilization of time and suture materials in the continuous technique. This study was designed to see the outcomes of interrupted versus continuous suture techniques.Materials & methodsA total of 36 patients were included in the study and were divided into two groups according to the type of suturing technique. The time utilized for the repair of the oral and nasal layers of the cleft palate, the number of suture packs utilized, and the incidence of fistula formation were noted and compared between the two groups. Out of 36 patients, 17 were included in group A (operated by interrupted techniques), and 19 were included in group B (operated by the continuous technique).ResultsThe mean time taken to close nasal layer in Group A was 18.12 ± 1.16 minutes and in Group B was 8.37 ± 0.89 minutes (p-value < 0.001), whereas for oral layer closure, it was 14.00 ± 1.17 minutes in group A and 6.00 ± 0.57 minutes in group B (p-value < 0.001). The average usage was 2.26 ± 0.45 suture packs for repair with the continuous technique and 4.00 ± 0.35 suture packs when repaired via interrupted stitches. There was no difference noted in postoperative outcomes in both groups in terms of postoperative fistula and wound dehiscence.ConclusionA continuous suture technique for closing the oral and nasal layers in patients with cleft palate is recommended, as it is more beneficial in terms of time, cost-effectiveness, and utilization of suture material.

Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair.

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in "early" versus "standard" cleft palate repair in a cohort of patients treated at a single craniofacial center.A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. "Early repair" is defined as palatoplasty before 6-months of age (108 patients). "Standard repair" is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors' data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.

The Effect of Buccal Fat Pad Graft in the Palatoplasty and the Risk Factor of Postoperative Palatal Fistula.

The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation. Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated. Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036). The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.

Influence of adjuvant antibiotics on fistula formation following incision and drainage of anorectal abscesses: a systematic review protocol

BackgroundDevelopment of fistula-in-ano following incision and drainage (I&D) of anorectal abscesses occurs in over 30% of patients. It is associated with significant patient morbidity and societal cost. The use of antibiotics following drainage is controversial, with randomized controlled trials reporting opposing conclusions regarding their influence on the rate of fistula formation. Given the significant burden associated with their development, it is imperative to determine strategies to minimize their occurrence. The objective of this review is to summarize the available evidence on the role of antibiotics following I&D of anorectal abscesses on fistula formation. Secondary objectives include determining if antibiotics are associated with morbidity, repeat presentation to the emergency department, and requirement for reoperation.Methods/designMEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials, http://apps.who.int/trialsearch, and clinicaltrials.gov will be searched to identify published and ongoing unpublished interventional and observational studies evaluating the role of antibiotics post I&D on the incidence of fistula formation. There will be no restriction on language, date, or journal. Title and abstracts as well as full texts will be screened in duplicate based on inclusion and exclusion criteria. The Cochrane Risk of Bias tool and ROBINS-I will be used to assess risk of bias in randomized and non-randomized studies, respectively. Our primary outcome is the incidence of fistula formation; secondary outcomes include morbidity, representation to ED, and reoperation. Study heterogeneity will be calculated with Cochran’s Q test, P value, and I2 index. SASS (version 9.4) will be used for meta-analysis.DiscussionThis is the first study to review the available evidence on adjuvant antibiotics and incidence of fistula formation following I&D of anorectal abscesses.Systematic review registrationPROSPERO CRD42018092044

Evaluation of Double Face Preputial Flap for Management of Hypospadias in Children

Background: hypospadias is a congenital anomaly in which meatal orifice opens in the vental aspect of penis instead of the glans tip. The meatal orifice may be located anywhere between the tip of the penis and the perineum.Objective: the aim of this study was to evaluate double face preputial flap for management of hypospadias in children about success rate, cosmetic result and appearance of complications such as fistula, strictures or disruption. Methodology: this study was conducted on 30 patients who were suffered from mid penile, proximal penile and peno scrotal hypospadias. The age of our cases at the time of repair were ranged between 4-12.5 years. Results: after finishing results of our study we noticed that was no statistically significant difference between results after double face preputial flap technique and ordinary transverse preputial island flap technique (Duckett's procedure) regarding fistula formation or skin infection. Conclusion: although the incidence of fistula formation was lower than that was reported in the classic Duckett repair, however, there was no statistically significant difference between results of double face preputial flap technique and current Duckett's procedure regard skin disruption and fistula formation.

Evaluation of Double Face Preputial Flap for Management of Hypospadias in Children

Background: hypospadias is a congenital anomaly in which meatal orifice opens in the vental aspect of penis instead of the glans tip. The meatal orifice may be located anywhere between the tip of the penis and the perineum.Objective: the aim of this study was to evaluate double face preputial flap for management of hypospadias in children about success rate, cosmetic result and appearance of complications such as fistula, strictures or disruption. Methodology: this study was conducted on 30 patients who were suffered from mid penile, proximal penile and peno scrotal hypospadias. The age of our cases at the time of repair were ranged between 4-12.5 years. Results: after finishing results of our study we noticed that was no statistically significant difference between results after double face preputial flap technique and ordinary transverse preputial island flap technique (Duckett's procedure) regarding fistula formation or skin infection. Conclusion: although the incidence of fistula formation was lower than that was reported in the classic Duckett repair, however, there was no statistically significant difference between results of double face preputial flap technique and current Duckett's procedure regard skin disruption and fistula formation.

Incidence of Anal Fistula and Recurrent Abscesses following Management of Perianal Abscess

Introduction: Most perianal abscesses originate from an infected anal gland. Obstruction of these glands leads to stasis, bacterial overgrowth and ultimately abscess. Approximately 10% of perirectal abscesses are thought not to be due to infected anal glands. It is unclear why some patients completely heal and others have recurrent disease.&#x0D; Objective: To assess the incidence of anal fistula and recurrent abscess after incision and drainage of perianal abscess.&#x0D; Materials and Methods: A prospective observational study was done on 140 patients operated upon for perianal abscess in Combined Military Hospital, Dhaka. They underwent for one group only drainage, for other group drainage with primary fistulotomy under general or spinal anesthesia over two years from January 2015 to December 2016. The patients were followed up for an average 13 months (range, 4-18 months) after abscess drainage or until a fistula appears and abscess recurs. Their duration of hospital stay was 1–3 days. After discharge from hospital, they were examined in follow-up within 7 to 14 days. Subsequently, they were examined on a monthly basis until drainage ceased or until it became obvious that a fistula-in-ano had developed.&#x0D; Results: Total 140 patients were treated for perianal abscess. Those patients were divided into two groups. The first group of 84 patients (60%) who underwent incision and drainage only. The second group consisted of 56(40%) patients who had low fistulas identified at the time of abscess drainage and underwent primary fistulotomy. The incidence of fistula formation after the operative procedures were 37(44.05%) in incision and drainage group and 5(8.93%) were in primary fistulotomy group. The most common site of abscess formation was posterior to anus. The incidence of recurrent abscess were 7(8.33%) in incision and drainage group; 2(3.57%) in primary fistulotomy group. The overall fistula formation (44.05% and 8.93%) and recurrence of abscess (8.33% and 3.57%) is low in primary fistulotomy group.&#x0D; Conclusion: In this study the overall incidence of anal fistula is much higher than recurrence of perianal abscess following management of perianal abscess. Primary fistulolotomy at the time of drainage for perianal abscess reslult in a fewer persistent fistulas and recurrence of abscess.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.12(2) 2016: 26-29

Perianal Abscess; Simple Drainage versus Drainage and Fistulotomy

Introduction: Perianal abscess is one of the most common general surgical emergencies encountered in clinical practice and the initial treatment is simple incision and drainage, other surgical procedures as fistulotomy may be required as a definitive measure for treating fistula because about 40% of patients present with a fistula after simple incision and drainage of their perianal abscesses. The aim of this study was to detect the outcome of simple drainage versus drainage and fistulotomy for perianal abscess as regard to abscess recurrence, fistula formation and time off from work. Patients and Methods: A total number of 200 patients of both sexes; 100 for each group, their ages ranged between 21- 65 years were enrolled to this parallel prospective randomized clinical trial where patients were divided randomly into two main groups; A and B. Group A patients [N =100] were subjected to simple incision & drainage and those of group B [N = 100] were subjected to drainage & fistulectomy for acute perianal abscess. End Points: The primary end points were abscess recurrence, fistula formation and incontinence. The secondary end points were time off from work, wound discharge, wound healing and patients’ satisfaction. Results: Patient’s satisfaction of the treatment maneuver in relation to abscess recurrence and fistula occurrence was 80 % and 95% of group A and B respectively. Conclusion: The present study showed that treatment of perianal abscess through the combined maneuver of incision – drainage with fistulotomy at the same time significantly reduced the likelihood of persistent abscess, recurrence and need for repeat surgery. Patient’s satisfaction after treatment with this combined method showed a significant value than incision – drainage only as regard disease recurrence, time of wound discharge and the incidence of fistula formation.

Risk factors, predictors and prevention of pancreatic fistula formation after pancreatoduodenectomy

Although the operative mortality and morbidity associated with pancreatoduodenectomy (PD) has been decreasing, pancreatic fistula remains a potentially fatal complication. The aim of this study was to identify risk factors and predictors of pancreatic fistula formation, and ways to prevent this in a consecutive series of PD patients in a single institution. The association between pancreatic fistula formation and various clinical parameters was investigated in 50 patients who underwent PD at Kochi Medical School from January 1991 through February 2006. The incidence of pancreatic fistula in these patients was 28%. Multivariate analysis identified three independent factors correlated with the occurrence of pancreatic fistula: (1) absence of fibrotic texture of the pancreas examined intraoperatively (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2-2.0; P = 0.01); (2) serum amylase concentration greater than 195 U/l (1.69 times the normal upper limit) on the first postoperative day (RR, 2.4; 95% CI, 1.0-5.7; P = 0.01); and (3) not having early postoperative enteral nutrition (RR, 3.2; 95% CI, 1.2-9.0; P = 0.004). Soft texture of the pancreas and increased serum amylase the day after PD are both risk factors with predictive value for pancreatic fistula. The incidence of fistula formation is reduced by early postoperative enteral nutrition.

Evaluation of a Modified Surgical Technique to Correct Urine Pooling in Cows

Urovagina of cows and horses often results in infertility by inducing necrotizing endometritis. This condition is seen most commonly in old, pluriparous cows and mares with poor vaginal and vestibular conformation. Adverse changes result from numerous pregnancies or from dysfunction of the constrictor vestibuli muscle caused by damage to this muscle during parturition. Cranioventral tipping of the pelvis, the result of numerous pregnancies, or damage to the constrictor vestibuli muscle causes the cranial portion of the vagina to be positioned ventral to the external urethral orifice, leading to collection of urine in the vaginal fornix. Various surgical techniques have been used to create a mucosal extension from the urethral orifice to the labia to correct urovagina in cows, but a fistula often forms in the extension, causing the surgical remedy to fail. The objective of the trial reported here was to determine if the incidence of fistula formation could be decreased by covering submucosal tissue on the floor of the vestibule, exposed by transposing mucosal flaps to create the extension, with a mucosal graft.

Evaluation of a modified surgical technique to correct urine pooling in cows

Various surgical techniques to correct urovagina in cows describe creating a mucosal extension from the urethral orifice to the labia; however, a fistula often forms in the mucosal extension. The objective of the present study was to determine if the incidence of fistula formation could be decreased by covering transposed submucosal tissue on the dorsal aspect of the urethral extension with a mucosal graft. Cows in both the control group (19) and the experimental group (19) received a modified McKinnon technique of urethral extension; cows in the experimental group also had a sheet of mucosa, obtained from the dorsal aspect of the vestibule, grafted to submucosa exposed during creation of the urethral extension. During histological examination of the biopsy of the graft and its recipient site (harvested 1 week after surgery), neither inosculation nor revascularization of the graft was evident in any sample. Fourteen of 19 (74%) cows in the control group and 10 of 19 (53%) cows in the experimental group developed a fistula in the extension ( P = 0.18). We concluded that application of a mucosal graft to the subcutaneous tissue exposed to the vestibule using the McKinnon technique of creating a urethral extension was of little or no benefit in preventing the formation of a fistula in the extension. Furthermore, during evaluation of the extensions, digital palpation alone was often insufficient for detection of a fistula.

A technique for the management of the open abdomen in the presence of a fistula

The third stage ofdamage control (DC III) is a critical phase of thepatient’s care. Following unpacking and restorationof gastrointestinal continuity, the final step of DC IIIis closure of the abdominal wall. Frequently, this isnotpossibleasaresultofcontinuedboweledemaorretroperitoneal hematoma. In these patients theabdomen has to be managed open, eventually fol-lowedbyeitherdelayedclosureortheplacementofan absorbable mesh and subsequent delayed skingrafting. Even with meticulous care and dailyabdominal washouts, the incidence of fistula forma-tion during this process is significant.

Prospectively Randomized Trial Using Perioperative Low Dose Octreotide to Prevent Organ Related and General Complications Following Pancreatic Surgery and Pancreatico-jejunostomy

Background : The aim of the study was to evaluate the influence of low dose perioperative Octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreatico-jejunostomy.Material and Methods : 105 patients were randomized to receive either Octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no Octreotide. The primary endpoints were the occurrence of a pancreatic fistula and/or general complications including the length of hospital stay. There were 25 surgical draining procedures performed and 80 duodeno-pancreatectomies with or without preservation of the pylorus. Twenty-six (24.8%) of the patiënts were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease and 71 (67.6%) for carcinoma. All patients underwent pancreatico-jejunostomy.Results : 56 patients received Octreotide and 49 did not. The incidence of fistula formation in the Octreotide group was 8.9% (n = 5) and in the control group 8.2% (n = 4) for a total incidence of 8.5%. The difference between the two groups was not statistically significant. There was one death in the Octreotide group and none in the control group for an overall mortality of 0.9%. The morbidity, except fistulas, was 10.7% in the Octreotide group and 12.2% in the control group. The length of hospital stay was 23.1 ± 15.1 days in the group receiving Octreotide vs 20.4 ± 8.1 days in the control group (p = 0.808). Stratifying the data for duodenopancreatectomy and for draining procedures there was no difference between the groups either.Conclusion : In patients undergoing pancreatic surgery and pancreatico-jejunostomy, the perioperative use of 3 χ 0.1 mg Octreotide for 7 days does not reduce general complications nor fistula formation.

Mercurochrome as an adjunct to local preoperative preparation in children undergoing hypospadias repair.

To determine whether the local application of mercurochrome over genital skin before surgery, in addition to soap/water scrubs, can help to decrease the incidence of infection patients undergoing hypospadias repair, and thereby the incidence of fistula formation. The study comprised 44 consecutive boys undergoing primary or repeat surgery for hypospadias between October 1999 and April 2000. They were arbitrarily divided into two groups; group 1 received a conventional local scrub with soap/water 48 h before surgery and group 2, a conventional local scrub with soap/water was followed by a local application of 2% mercurochrome for 48 h before surgery. Both groups were comparable in age, location of the meatus and stage of repair. All patients were exposed to similar conditions during and after surgery. Urine, skin and wound swabs taken before during and after surgery were assessed microbiologically, using standard precautions. The incidence of infection and complications was then compared. Mercurochrome significantly decreased local infection, especially before surgery, but its effect in decreasing fistula formation, although appreciable, was not statistically significant. The local application of mercurochrome after a soap/water scrub for at least 48 h before surgery is a simple, economic and effective means to decrease postoperative wound infection. Future studies are needed, keeping other determinants of fistula formation constant, to evaluate its role in decreasing fistula formation in patients undergoing hypospadias repair.

Pharyngo-cutaneous fistula after total laryngectomy

The charts of 319 consecutive patients who underwent total laryngectomy at the Cancer Institute Hospital from 1971 to 1994 were reviewed in order to clarify the relationship between pharyngo-cutaneous fistula formation and age, the dose of pre-operative radiation and radical neck dissection, as well as the need for subsequent surgical repair. The patients did not need to undergo reconstruction by flaps at the time of laryngectomy. Radiation sources were limited to X ray radiotherapy and Cobalt 60. Of the 319 patients 204 (63.9%) underwent neck dissection. Both radical neck dissection and modified radical neck dissection were classified as neck dissection. The chi-square test was used to construct a table of the three parameters age, dose of radiation and neck dissection. With respect to age, the incidence of fistula formation was 13.4% (16 patients of 119) in patients at the age of 59 and below, 5.9% (7/118) in those from 60 to 69, and 8.5% (7/82) in those at 70 years and above. Our analysis reveals that the age at the time of surgery is not a predisposing factor for fistula formation in the three age groups (59 and below, between 60 and 69, and 70 and above). Similarly the need for subsequent surgical repair is also not age-related. With respect to radiation, the incidence of fistula formation was 8.0% (4/50) for patients who received radiotherapy less than 20 Gy, 6.3% (2/32) in those who received between 20 and 40 Gy, 2.6% (2/77) in those who received between 40 and 60 Gy, 13.2% (20/152) in those who received between 60 and 80 Gy and 25.0% (2/8) in those who received over 80 Gy. When the preoperative dose of radiation was divided into three classes, that is, less than 40 Gy, 40 to 60 Gy and over 60 Gy, we observed that the incidence of fistula formation increased significantly in the patients who received over 60 Gy. Surgical repair was also indicated more frequently for those patients who received over 60 Gy than for those who received less than 60 Gy. With respect to neck dissection, the incidence of fistula formation was 12.2% (14/115) for the patients who did not undergo neck dissection or those who underwent only lymphadenectomy, 7.8% (9/115) for the patients who underwent unilateral neck dissection, and 7.9% (7/89) for those who underwent bilateral neck dissection. These data reveal that neck dissection, whether unilateral or bilateral, dose not increase the incidence of fistula formation, nor the need for subsequent surgical repair. Fistulae were present in 30 patients (9.4%) for 24 years, and 14 of these 30 patients did not need subsequent surgery. In these 30 patients with fistulae, we did not find patients with systemic disease such as diabetes mellitus prior to the surgery. When the period of 24 years was divided into 4 periods, the incidence of fistula formation was 19.0% (from 1971 to 1976), 6.9% (from 1977 to 1982), 10.3% (from 1983 to 1989) and 2.6% (from 1989 to 1994), that of the latest period was the lowest with gradual improvement. The average dose of preoperative radiation was 57.7 Gy (from 1971 to 1976), 50.8 Gy (from 1977 to 1982), 39.6 Gy (from 1982 to 1988) and 45.7 Gy (from 1989 to 1994) and reduction in dose of radiation seemed to be one of the reasons for the lower frequency of fistula. Several surgeons performed the operations for different patients, but the procedure of laryngectomy was recently directed by an experienced surgeon. The study also indicates that the risk of fistula formation is reduced not only by the dose of radiation but also by improved surgical skill.

One-Stage Closure of the Entire Primary Palate

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.

Pediatric Urethral Reconstruction Without Proximal Diversion

A new method of transurethral drainage was used in 36 consecutive patients who underwent urethral reconstruction for repair of hypospadias and epispadias. The surgical procedures included 16 island flap urethroplasties, 15 distal urethral repairs with Mathieu’s technique, 3 epispadias repairs and 2 urethroplasties with a modified Thiersch-Duplay technique. To accomplish urinary drainage in all cases a 7 or 10F silicone tube with multiple perforations was inserted proximal to the bladder neck and through the repair, and cut 2mm. distal to the urethral meatus. The tube was secured to the meatus with loosely tied 4-zero polypropylene sutures and allowed to drain into a diaper.Satisfactory results were obtained in all patients. Complications included a small urethrocutaneous fistula in 6 children, a distal urethral stricture in 1 and severe bladder spasms in 2. The incidence of fistula formation did not appear to increase with this method of urinary drainage. Advantages of the method included a decreased hospital stay and minimal discomfort.

Results of decortication in chronic empyema with special reference to paragonimiasis

During a recent 6 years period, we managed chronic empyema by decortication, either alone or in combination with thoracoplasty, in 58 patients: In 16 patients, the empyema was a complication of Paragonimus westermani infestation (PWI), in 20, tuberculosis (TB), and in 22, of varied origins. There were no operative deaths, and satisfactory or good results were obtained in 55 patients (94.8%). We believe that the result in a patient in whom thoracoplasty is required should be called satisfactory, not good. Only 55% of the TB group achieved a good result, compared with 89% of the other patients. Of the 10 patients who required a thoracoplasty, seven were in the TB group. Empyema complicating TB is associated with a higher incidence of fistula formation and is more difficult to treat than other empyemas. The empyema associated with PWI develops more slowly, tends to form fewer fistulas, and eventuates in a good result more often than empyema associated with TB. Two of our three poor results stemmed from failure to do a thoracoplasty when the lung did not expand. We recommend thoracoplasty when the lung does not expand well at operation; it should be done at the time of decortication to avoid the necessity for a second major procedure. Chronic empyema is a common complication of paragonimiasis in Korea and by inference in other parts of the world where PWI is endemic. As international travel increases, some patients with PWI and complicating empyema may be seen in the United States. American thoracic surgeons should be aware of this disease, its treatment and its chest complications.