Internal Fistula Research Articles

Results of surgical treatment of chronic pancreatitis with a high risk of developing pancreatic cancer

Objective. To analyze the results of surgical treatment of patients with pancreatic insufficiency and a high risk of developing pancreatic cancer. Materials and methods. The study included 39 patients treated in 2019–2023. In 20 (51%) patients, it was difficult to clearly differentiate between chronic pancreatitis and pancreatic cancer. In 19 (49%) patients, the diagnosis of chronic pancreatitis was not in doubt. All patients with complicated forms of chronic pancreatitis and suspected pancreatic tumor underwent a set of laboratory tests, and routine screening methods of instrumental diagnostics were used. In addition to standard methods of examination, the levels of matrix metalloproteinases and tissue inhibitor of metalloproteinases in the blood plasma were studied. Results. The method of intraoperative multiple biopsy, improved by us, was an obligatory component of surgical care for a clear differential diagnosis of chronic pancreatitis and pancreatic cancer. In the presence of complicated chronic pancreatitis, during surgery, the biopsy was taken using a special punch instrument that resembles a pen, along the entire length of the main pancreatic duct along the upper and lower edges of the dissection in a checkerboard pattern. There were no complications of punch biopsy. Of the 20 patients in whom it was not possible to clearly differentiate between chronic pancreatitis and pancreatic cancer, 12 (60%) were diagnosed with diabetes mellitus. The characteristic changes in the pancreatic tissue gave grounds for performing extended resection interventions in these patients. In the remaining 8 (40%) patients without morphological changes inherent in malignancy, Whipple operation (2), longitudinal pancreaticoduodenectomy (2), Frey operation (2), and our proposed central pancreatic resection with preservation of the left anatomical segment (2) were performed. Drainage and resectional surgical interventions were performed in 19 (49%) patients with complicated forms of chronic pancreatitis. After radical surgical interventions for pancreatic cancer, 1 patient developed gastrostasis, and on the 11th day he underwent a relaparotomy with reconstruction of the gastroenteroanastomosis, and on the 30th day a subhepatic abscess was diagnosed in 1 patient, who underwent drainage with a subcostal mini–access with a positive effect. In 2 patients, after left–sided pancreatic resection, subdiaphragmatic abscesses were diagnosed on the left, they were treated minimally invasively with punctures and drainage under ultrasound control. Multiple organ failure occurred in 1 patient after surgery for internal pancreatic fistula, infected ascites as a complication of neglected chronic pancreatitis. The patient died. Infection of the median laparotomy wound occurred in 4 patients, and healing was achieved by controlled primary tension. Class B pancreatic fistulas occurred in 3 patients: 2 – after left–sided pancreatic resection, 1 – after longitudinal pancreaticoduodenostomy. In 1 patient, a class C permanent pancreatic fistula was formed after a combined (resection and drainage) intervention. Relaparotomy, subtotal resection with Roux–en–Y loop closure was performed. Conclusions. Morphological changes in the pancreatic tissue in chronic pancreatitis in combination with diabetes mellitus, corresponding to the development of PanIN, are direct predictors of adenocarcinoma. Multiple intraoperative pancreatic biopsies are effective in verifying pancreatic malignancy. Pre– and intraoperative diagnostics make it possible to optimize the surgical treatment of complicated forms of chronic pancreatitis and prevent the development of postoperative pancreatic fistula.

Minimally invasive treatment of an internal pancreaticopleural fistula with massive pleural effusion: a case report

BackgroundA pancreatic duct rupture can lead to various complications such as a fistula, pseudocyst, ascites, or walled-off necrosis. Due to pleural effusion, pancreaticopleural fistula typically causes dyspnea and chest pain. Leaks of enzyme-rich pancreatic fluid forming a pleural effusion can be verified in a thoracocentesis following radiological imaging such as computed tomography or magnetic resonance tomography. While management strategies range from a conservative to endoscopic and surgical approach, we report a case with successful minimally invasive treatment of pancreaticopleural fistula and effusion.Case presentationWe present a case of a patient with pancreaticopleural fistula and successful minimally invasive surgical treatment. A 62-year old Caucasian man presented with acute chest pain and dyspnea. A computed tomography scan identified a left-sided cystoid formation, extending from the abdominal cavity into the left hemithorax with concomitant pleural effusion. Pleural effusion analysis indicated significantly elevated pancreatic enzymes. Magnetic resonance cholangiopancreatography revealed a rupture of the pancreatic duct and nearby fluid accumulation. Endosonography later confirmed proximity to the tail of the pancreas, suggesting a pancreatic pseudocyst with visible tract into the pancreas. We assumed a pancreatic duct rupture with a fistula from the tail of the pancreas transdiaphragmatically into the left hemithorax with a commencing pleural empyema. A visceral and parietal decortication on the left hemithorax and a laparoscopic distal pancreatectomy with splenectomy was performed. The suspected diagnosis of a fistula arising from the pancreatic duct was confirmed histologically.ConclusionPancreaticopleural fistulas often have a long course and may remain undiagnosed for a long time. At this point diagnostic management and therapy demand a high level of expertise. In instances of unclear symptomatic pleural effusion, considering an abdominal focus is crucial. If endoscopic treatment is not feasible, minimally invasive surgery should strongly be considered, especially when located in the distal pancreas.

Comparative Study of Diluted Hydrogen Peroxide and Sulfur Hexafluoride in the Contrast-Enhanced Ultrasound Assessment of Anal Fistulas.

Endoanal ultrasound for the diagnosis of anal fistulas requires the injection of hydrogen peroxide, but it is often uncomfortable for the patient and possesses potential complications. Novel ultrasound contrast is currently available. We aimed to assess the efficacy and safety of sulfur hexafluoride as an ultrasound contrast agent for the diagnosis of perianal fistula by comparing it with those of 50% diluted hydrogen peroxide. Double-blind superiority study with 4 consecutive visits to perform an ultrasound without contrast, a hydrogen peroxide-enhanced ultrasound, a sulfur hexafluoride-enhanced ultrasound and a rectal exploration in the operating room (the gold standard). The ultrasound images were independently reviewed by three expert surgeon sonographers. This study was conducted at a single university hospital. Data from 176 patients were evaluated. Demographic and exploratory data and the ultrasound findings related to the location of the internal fistula orifice, description of the primary and secondary tracts, and presence of cavities and sphincter defects were analyzed. The complications occurring before and after the contrast agent administration and the presence of pain measured using a score were considered. Eighty-eight patients were included (men: 71.5%; mean age: 48.3 years).62.5% had a complex type and 83.7% had a transsphincteric type. Sulfur hexafluoride-enhanced ultrasounds demonstrated a higher interobserver agreement in determining the secondary tracts (κ= 0.604) and anal fistula height (κ=0.604) compared with other methods. Both hydrogen peroxide-enhanced ultrasound (90.91%) and sulfur hexafluoride-enhanced ultrasound (89.77%) detected the internal orifice more frequently than ultrasounds without contrast (62.5%) (p < 0.001),with no differences between contrast agents (p = 0.810). Sulfur hexafluoride-enhanced ultrasound were less painful than peroxide-enhanced ultrasound (p < 0.001). Most of the patients had transsphincteric anal fistulas. Sulfur hexafluoride proved comparable to hydrogen peroxide in evaluating fistulous tracts and identifying the internal orifice and additionally reduced significantly pain and discomfort. Furthermore, demonstrated a higher interobserver agreement in determining the secondary tracts and anal fistula height compared with other methods. See Video Abstract.

A Decade of Single-Center Experience in Children With Congenital Pyriform Sinus Fistula (CPSF).

To investigate the efficacy and safety of carbon dioxide (CO2) laser cauterization in the treatment of pediatric congenital pyriform sinus fistula (CPSF), and to track and follow up the long-term outcome of the postoperative patients. This retrospective study was conducted at a single center, where clinical data and follow-up information of children with CPSF who underwent CO2 laser cauterization with the assistance of a suspension laryngoscope and microscope were collected and analyzed their clinical characteristics and prognosis. Subsequently, multiple logistic regression analysis was performed to identify potential predictors of the number of laser cauterization procedures. A total of 238 children diagnosed with CPSF were recruited for this study, with 235 patients successfully achieving closure of the internal fistula through one or more CO2 laser cauterization procedures without recurrence. The median duration of follow-up was 6.46 (5.20, 7.64) years. Merely three patients (1.3%) developed recurrent cervical infection and eventually underwent open neck surgery. There were no instances of permanent perioperative complications throughout the follow-up. Additionally, our analysis revealed that the age at the first operation of CO2 laser cauterization was an independent risk factor associated with the number of operations. The CO2 laser cauterization for children with CPSF is an effective and safe treatment with a low recurrence rate and minimal complications during the follow-up period. Consequently, it is advisable to consider CO2 laser cauterization as a viable therapeutic option for managing pediatric CPSF. 4 Laryngoscope, 2024.

Influence of various factors on the efficiency of trabeculectomy in pediatric patients with congenital glaucoma

AIM: The study aimed to analyze the influence of various factors on the efficiency of trabeculectomy in pediatric patients with congenital glaucoma. MATERIAL AND METHODS: The results of 945 trabeculectomies, including those with various modifications and the use of drains, in pediatric patients with congenital glaucoma were analyzed in the Department of Pediatric Eye Pathology of the Helmholtz National Medical Research Center for Eye Diseases for 1997–2023. RESULTS: The efficiency of trabeculectomy in pediatric patients with congenital glaucoma was 91.9%–98.5% in the immediate period (up to 6 months) after surgery, 75.5%–86.5% in the long term (after 5 years), and 34.2%–42.1% with repeated surgeries (up to 3–4 surgeries) during follow-up up to 10 years, which is comparable with literature data. CONCLUSION: The main factors that influence the efficiency of trabeculectomy in pediatric patients with congenital glaucoma include age at the time of detection and surgical treatment of congenital glaucoma, their somatic health, glaucoma stage, and severity of destructive changes in the eye, particularly the congenital ones, presence of repeated surgeries, erroneous choice of the trabecular site subject to excision during surgery, injury rate of trabeculectomy (quality of incision of the conjunctiva, sclera, injury rate of vessel coagulation during surgery, and skill of the surgeon), presence of intra- and postoperative complications, untimely detection and YAG laser elimination of the internal fistula fusion after trabeculectomy, and inadequate management of the postoperative period.

#2431 Vascular access outcomes among patients on maintenance hemodialysis in Perpetual Succour Hospital: a 3-year cross-sectional analysis

Abstract Background and Aims Hemodialysis (HD) is the most widely used treatment modality worldwide in the care of patients with end stage renal disease (ESRD). The success of the therapy depends largely on the quality of the VA and its proper functioning, which has a bearing on the patient's quality of life. Vascular access dysfunction remains one of the leading causes of excessive morbidity, mortality, and healthcare costs in this group. A functional vascular access is mandatory to achieve good levels of dialytic efficiency, and it is considered the lifeline of patients on maintenance HD. The ideal vascular access should have specific characteristics among which the most important are the following: ease of placement; delivery of adequate blood flow for effective dialysis; good primary patency rates; low rates of complications and side effects; long-lasting life; and low economic costs. There are 3 types of vascular accesses (VAs): the internal arteriovenous fistula (IAVF); the central venous catheter, which can be tunneled (CVC-T) or not (CVC-nT); and the synthetic vascular graft. Internal arteriovenous fistula is considered the best option because it is safer, more durable, and less expensive. The catheter is essential for emergency onset in HD but is associated with a higher number of infections, higher mortality, and greater costs. Arteriovenous fistulae (AVF) have advantages over arteriovenous grafts (AVG) and central venous catheters (CVC), but whether AVF are associated independently with better survival is unclear. The aim of this study is to determine the vascular access outcomes of ESRD patients on maintenance hemodialysis. Specifically, this study (1) described the clinicodemographic profile of the patients in terms of age, sex, primary etiology of ESRD, employment status, comorbidities, hepatitis status and family history of the disease; (2) determined the vascular access used on the HD patients (AVF/AVG, CVC or IJ; (3) identified interventions performed to maintain vascular access for hemodialysis; (4) determined the categories of the vascular access site; (5) assessed the vascular access outcome; (6) determined the reason and number for vascular access change and the (7) clinical outcome of the HD patients. Method This is a single center, cross-sectional study of ESRD patients on maintenance hemodialysis enrolled in Perpetual Succour Hospital Hemodialysis Unit from April 1, 2021, to November 30, 2023. Results There were 260 hemodialysis patients included, with successful vascular access outcome (73.13%) and were younger (57.2 ± 14.1). Those who had failed vascular access were females (54.2%), unemployed (61.4%) and had diabetes mellitus (50.6%) as the primary etiology of their ESRD. Those with failed vascular access were hypertensive (86.7%), with history of CAD and MI (57.8%) and were having diabetes mellitus (56.6%). Proportion of those with failed and successful vascular access significantly differ among hypertensives $(p = .012)$, diabetics $(p = .039)$, with chronic glomerulonephritis $(p = .011)$, and among those with malignancy $(p = .003)$. Most of those who were alive had successful vascular access (76.8%), however, among those who had failed vascular access died (57.6%). And the association of clinical outcomes (death or not) and failure or success of vascular access is statistically significant, $(p = .001)$. Conclusion Our study showed that failed vascular access were more associated with female gender, diabetes mellitus as the primary etiology of ESRD and with other co-morbid conditions such as hypertension and CAD or MI. Successful vascular outcome were among those of younger age group compared to those whose vascular access failed, probably due to better vascular condition and fewer co-morbidities. As shown in Table 2, type of access, interventions performed, and vascular access site significantly differ among HD patients with failed vascular access outcome and with those who were successful $(p = .001)$Those with failure on the vascular access were changed to CVC (44.6%) while others had changed to IJ (22.9%). Eighty of those with failed vascular (96.4%) access has changed site due to no bruit (65.0%) and thrombosis (33.8%).

Sharp needle reconstructs peripheral outflow for patients with malfunctional arteriovenous fistula

Objective To investigate the feasibility and efficacy of combining ultrasound-guided sharp needle technique with percutaneous transluminal angioplasty (PTA) for treating outflow stenosis or dysfunction in arteriovenous fistula (AVF) among hemodialysis patients. Methods From October 2021 to March 2023, patients with occluded or malfunctional fistula veins not amenable to regularly angioplasty were retrospectively enrolled in the study. They underwent ultrasound-guided sharp needle intervention followed by PTA. Data on the location and length between the two veins, technical success, clinical outcomes, and complications were collected. Patency rates post-angioplasty were calculated through Kaplan-Meier analysis. Results A total of 23 patients were included. The mean length of the reconstructed extraluminal segment was 3.18 cm. The sharp needle opening was performed on the basilic vein (60.9%), brachial vein (26.1%), or upper arm cephalic vein (13%) to create outflow channels. Postoperatively, all cases presented with mild subcutaneous hematomas around the tunneling site and minor diffuse bleeding. The immediate patency rate for the internal fistulas was 100%, with 3-month, 6-month, and 12-month patency rates at 91.3%, 78.3%, and 43.5%, respectively. Conclusion Sharp needle technology merged with PTA presents an effective and secure minimally invasive method for reconstructing the outflow tract, offering a new solution for recanalizing high-pressure or occluded fistulas.

Accuracy prediction of Goodsall's rule for anal fistulas of crypotogladular origin, is still standing?

Treatment of anal fistulas is still a challenging task because of high recurrence and risk of incontinence. Identification of internal fistula opening is paramount for successful treatment. Goodsall's rule is commonly used to predict the course of fistula and internal opening. However, its accuracy has been questioned by many investigators and its role became a controversial topic. This is a case series prospective study in which 320 consecutive patients with anal fistula with Mean age 48.9± 6 years ages (ranges from 16 to 64years) and mean body mass index 24.8± 5.5 average 18.5-30.6) were enroled. Goodsall's rule was applied to all fistulas according to the site of external fistula opening. Location of internal fistula opening as suggested by Goodsall's rule then compared to the exact location of internal opening identified by perineal or pelvic MRI and intraoperative findings. to assess the accuracy and positive predictive value of the Goodsall's rule in predicting the internal opening of the tract. The overall accuracy rate, positive predictive value (PPV), sensitivity and specificity of Goodsall's rule in this study were 74.75%, 77.1, 74.5, and 72.05, respectively. The accuracy in predicting the internal fistula opening was 52.4% in anterior tracts and 73% in posterior tracts. Goodsall's rule was found to be more accurate in posterior fistulas than anterior fistulas and in short superficial fistulas rather than in long and high fistulas. Goodsall's rule was accurate in 74.75% of anal fistulas. It was more accurate for posterior long fistulas and anterior short and superficial fistulas. Patients with long (>3cm) anterior fistulas defied Goodsall's rule when they found to have fistulas tracking to a midline anterior origin. Further, short posterior fistulas were found to open more commonly in a direct radial course rather to midline posteriorly.

Research on comprehensive analysis of patient comfort and complication rate using haemodialysis indwelling needles in AVF puncture in haemodialysis treatment.

Traditional needles for haemodialysis access can cause complications and discomfort. Indwelling needles may have advantages, but their efficacy needs to be investigated. Our study sought to compare the safety and efficacy of indwelling needles to traditional needles for haemodialysis access. A single-center retrospective study at the Pingyang County Hospital of Traditional Chinese Medicine included 70 haemodialysis patients. The intervention group used indwelling needles, whereas the control group used traditional needles. The rate of complications, limb mobility, blood chemistry, puncture success rates, operation times, haemostasis times, pain and comfort scores, and internal fistula failure rates were all compared. Overall, complication rates were slightly higher in the control group, but not statistically significant. Both groups improved their limb mobility and blood chemistry, but there were no significant differences. The intervention group had significantly higher puncture success rates (88.4% vs. 80.0%), shorter operation times (65.4 vs. 72.3 seconds), and faster haemostasis times (23.7 vs. 28.2 seconds) than the control group. Patients in the intervention group experienced less pain (3.7 vs. 4.2) and more comfort (8.1 vs. 7.5). The intervention group had slightly lower internal fistula failure rates (2.9% vs. 5.7%), but the difference was not statistically significant. Indwelling needles appear to improve puncture efficiency and patient comfort during hemodialysis.

The detours of pancreatic ducts, internal pancreatic fistulas: a rare complication of chronic pancreatitis

Internal pancreatic fistula occurs due to the disruption of the pancreatic duct, resulting in communication with it and another epithelial surface. A rare variant is the pancreaticopleural and pancreaticogastric fistula, typically associated with chronic necrotising pancreatitis, resulting from posterior disruption of the pancreatic duct. It is a complex disease with different aetiologies, varied clinical presentations and multiple management options. Unlike postoperative pancreatic fistula, internal pancreatic fistula lacks guidelines for classification and management. Once an internal fistula is suspected, further imaging work-up and biochemical analysis needs to be performed. Here, we present an unprecedented case of pancreaticopleural fistula on a background of chronic necrotising pancreatitis, and an asymptomatic pancreatico-gastric fistula. To our knowledge, no such case has been previously reported.

The first experience in the treatment of small bowel biliary obstruction using tulium laser (Tm:YAG) in a patient with Bouveret syndrome

Cholelithiasis complicated with a bilioenteral fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. To date, modern capabilities of high-tech specialized intra-luminal operative endoscopy with laser lithotripsy can prevent the routine surgical intervention, thus reducing the risk of adverse events and length of hospital stay. This clinical case describes diagnostics of the pathology and the first experience in treating the Bouveret syndrome with lithotripsy and thulium laser (Tm:YAG) light.Purpose: to improve outcomes in patients with small bowel biliary obstruction and a bilioenteral fistula using thulium laser (Tm:YAG) light as the first and final method of surgical (endoscopic) treatment.Material and methods: a patient with pains in the upper abdomen, weakness, vomiting after eating was admitted to the Botkin Hospital. Complete blood analysis, biochemical blood analysis, transabdominal ultrasound and X-ray examination of abdominal organs were made at the reception department. After that, she was transferred to the surgical department where computed tomography, magnetic resonance cholangiopancreatography and esophagogastroduodenoscopy were performed.Results: The performed instrumental diagnostics revealed a large calculus with diameter up to 4.5 cm in the bulb of the duodenum and a fistula passage connecting to the gallbladder with diameter of up 2.0 cm. Because of long disease duration and a formed internal fistula the patient was simultaneously made esophagogastroduodenoscopy and lithotripsy to resolve small bowel obstruction. The calculus was removed using thulum laser (Tm:YAG) technique, a lithotriptor basket and an endoscopic loop for fragments extraction. The performed endoscopic procedure with thulium laser light has showed its high efficiencyConclusion: The effectiveness of laser medical technique with Tm:YA in patients with Bouveret syndrome has been proven by the authors

Five years of experience in using the laser coagulation method in the treatment of trans- and extrasphincter fistulas of the rectum

THE AIM OF the STUDY was to study the results of surgical treatment of patients with trans- and extrasphincter fistulas of the rectum using laser coagulation, depending on the method of closure of the internal fistula opening.PATIENTS AND METHODS: within the framework of scientific research conducted at the NMIC of Coloproctology named after A.N. During a 5-year period, 121 patients underwent surgical interventions using laser coagulation of the fistula passage in combination with 3 different options for closing the internal fistula opening.43 patients were included in the group of laser coagulation of the fistula course in combination with its ligation in the intersphincter space (LT+PSMP), 47 – in the group of laser coagulation of the fistula with plasty of the internal fistula opening with a mucomuscular flap (LT+SML), 31 - in the group of laser thermocoagulation of the fistula course with suturing of the internal fistula opening with separate seams (LT+UVC). The average age of patients is 42 (20-70) years. Men - 82, women -39. The average follow-up period was 19 (3-52) months. In the perioperative period (before surgery, 1 and 2 months after the intervention), patients underwent ultrasound monitoring to assess the healing process of fistulas and early detection of relapses of the disease. To assess the effect of operations on the functional state of the rectal occlusion apparatus before the intervention and 3 months after the operation, patients underwent sphincterometry.RESULTS: in the LT+PSMP group, fistula healing was noted in 33/43 (76.7%) patients, in the LT+SML group - in 33/47 (70.2%) patients, in the LT+UVS group – in 17/31 (54.8%) patients (p=0.129). The only established factor that demonstrated a statistically significant effect on the frequency of positive results in the LT+PSMP group was the diameter of the internal fistula opening. Thus, with a fistula hole diameter of more than 3 mm, a positive result was achieved in 24 (54.5%) of 44 patients, and with a hole diameter of less than3.0 mm, the fistula course healed in 58 (75.3%) of 77 cases (p=0.025).The average length of a bed day (Iu) was 3.5. Complications during surgery and the immediate postoperative period were recorded in only 3 (2.5%) cases.CONCLUSION: Over the five-year period of application, the laser coagulation method has proven itself as a sphincter-sparing intervention that can compete with traditional methods of treating rectal fistulas in a selected group of patients. Regardless of the method of closing the internal fistula opening, the technique has demonstrated a high level of safety. The best rates of healing were recorded when laser coagulation was combined with ligation of the fistula in the intersphincter space (76.7%), however, the search for the most reliable way to isolate the fistula from the lumen of the rectum should be continued.

The Preventive Effect of Comprehensive Nursing Intervention on Arteriovenous Fistula Failure in Patients in the Hemodialysis Room

Objective: To explore the preventive effect of comprehensive nursing intervention on arteriovenous fistula failure in patients in the hemodialysis room. Methods: 82 patients with arteriovenous fistula in the hemodialysis chamber treated in our hospital from July 2022 to October 2023 were selected as the research subjects. The random number table method divided them into a control group and an experimental group of 41 cases each. The control group received general nursing intervention measures, while the experimental group underwent comprehensive nursing intervention. The incidence of complications (internal fistula failure, bleeding, thrombosis, infection), psychological emotions (SAS scale, SDS scale), quality of life (physical pain, physiological function, emotional function, social function), and nursing satisfaction (very satisfied, basically satisfied, satisfied, dissatisfied) were compared between the two groups of patients. Results: The incidence of complications in the experimental group (4, 9.76%) was significantly lower than that in the control group (29, 70.73%); the SAS scores and SDS scores of the patients in the experimental group after intervention were both lower than those in the control group; the quality of life score (physical pain, physiological function, emotional function, and social function) was all higher than those of the control group; the post-intervention nursing satisfaction of the experimental group (40, 97.57%) was also significantly higher than that of the control group (29, 73.17%); and the listed differences were statistically significant (P &lt; 0.01). Conclusion: For patients with hemodialysis ventricular arteriovenous fistula failure, comprehensive nursing intervention can reduce the incidence of complications, relieve anxiety and stress, improve quality of life and nursing satisfaction, and achieve better preventive effects.

A nomogram to predict stoma creation in elective surgical resection for penetrating Crohn's disease.

The decision to perform a stoma during surgical resection of penetrating Crohn's disease (CD) is a critical consideration. The objective of this study was to identify factors that influence stoma creation and develop a predictive nomogram model to assist surgeons in making optimal surgical decisions. A retrospective study was conducted at a tertiary center from December 1, 2012, to December 1, 2021, involving consecutive patients with penetrating CD who underwent elective surgical resection. The LASSO regression method was used to select preoperative predictors, and a nomogram was constructed using multivariate logistic regression. The performance of the nomogram was validated in an internal cohort by assessing its discrimination, calibration, and clinical usefulness. The study included 405 cases in the training group and 135 cases in the validation group. Nine risk factors for stoma formation were identified, including disease location, fistula resulted from previous anastomosis, absence of preoperative exclusive enteral nutrition support, albumin levels below 35 g/L, C-reactive protein levels above 10 mg/L, hemoglobin levels below 100 g/L, perianal disease, internal fistula, and surgical approach. These risk factors were selected using the LASSO regression method, and a nomogram was developed based on them. The area under the curve and the coefficient of determination (R2) of the nomogram were 0.821 and 0.394, respectively. And the nomogram demonstrated good performance in the validation cohort. The nomogram exhibited good predictive ability for stoma formation during elective surgical resection for penetrating CD, which can assist surgeons in making informed clinical decisions.

Efficacy of cutting balloon angioplasty versus high-pressure balloon angioplasty for the treatment of arteriovenous fistula stenoses in patients undergoing hemodialysis: Systematic review and meta-analysis.

This systematic review and meta-analysis aimed to assess and compare the therapeutic outcomes of cutting balloon angioplasty and high-pressure balloon angioplasty for arteriovenous fistula stenosis in hemodialysis patients. All studies indexed in PubMed, Embase, and Cochrane Library Web of Science were retrieved. The retrieval deadline was July 15, 2023. Risk of bias 2.0 was used to evaluate the quality of the included studies. Revman 5.4 software was used for data analysis. This review included three studies and 180 patients, with 90 patients in the cutting balloon angioplasty group and 90 patients in the high-pressure balloon angioplasty group. The results of the meta-analysis suggested that compared with high-pressure balloon angioplasty, cutting balloon angioplasty can improve primary lesion patency rates of internal arteriovenous fistulas at 6 months (relative risk, 1.45; 95% confidence interval, 1.08-1.96; P = 0.01). However, there were no significant differences between the technical success rate (relative risk, 0.99; 95% confidence interval, 0.93-1.05; P = 0.72) and clinical success rate (relative risk, 1.01; 95% confidence interval, 0.95-1.07; P = 0.73). Therefore, cutting balloon angioplasty is likely to increase primary lesion patency rates at 6 months. However, more high-quality, large-sample, multicenter, randomized controlled trials are needed for further validation due to the limited number of included studies.

P538 Platelet-rich stroma during surgery for treatment-refractory perianal fistulizing Crohn’s disease: long-term outcomes of a pilot study

Abstract Background Platelet-rich stroma (PRS), a combination of stromal vascular fraction and platelet-rich plasma, proved to be safe and feasible for the treatment of treatment-refractory perianal fistulizing Crohn’s disease (pCD). This study aimed to assess the long-term outcomes in patients with pCD treated with PRS. Methods Long term results from adult patients with pCD, who underwent fistula curettage, closure of the internal fistula opening and PRS injection, included in an earlier conducted pilot study (n=25) were assessed up to October 2023. The primary outcome was complete clinical closure at long-term follow-up (closure of all treated external opening[s]). Secondary outcomes comprised complete radiologic closure (absence of fluid-containing tracts on MRI), partial clinical closure (closure of ≥ 1 treated external opening[s]), recurrence (reopening of the external opening after complete clinical and/or radiological closure) and the need for unplanned re-intervention(s). Results The majority of the patients was female (56.0%)(mean age 34.4 years [SD: 0.9], and mean follow-up 3.7 years [SD: 0.6])(Table 1). 68% of the patients were concomitantly treated with a biological. During follow-up, ≥1 unplanned re-intervention(s) were necessary in 44% of the patients which were minor (e.g. incision and drainage) in the vast majority (83%)(Table 2). Complete clinical closure at long-term follow-up was reached in 88%. Complete radiologic closure was reached in 75% of patients. Partial clinical closure was reached in all patients (100%). Recurrence was reported in 8% of patients, all whom reached (partial/complete) clinical closure, whereas no recurrence was experienced in patients with complete closure on MRI. All patients with complete radiologic closure achieved clinical closure. Vice versa, patients with clinical closure achieved complete radiologic closure in 82% of the cases. Conclusion In this pilot study with treatment-refractory pCD patients treated in a tertiary referral center, all patients had benefit from surgical treatment and an additional injection of PRS. At long-term follow-up, treatment with PRS injection during surgery is promising as complete clinical and radiological closure is achieved in the majority of these patients. In addition, complete radiologic closure seems a valuable prognostic parameter for long-term success for fistula closure. Future (randomized) research is warranted to further assess the effectiveness of PRS in patients with pCD.

DOP77 Mesenchymal stem cell therapy for refractory Crohn’s perianal fistulas: a case series

Abstract Background Nearly one-third of patients with Crohn’s disease will develop one or multiple perianal fistulas within the first two decades after diagnosis, with the majority being complex. Treatment options are limited with high recurrence rates after both medical and surgical approaches. It has been demonstrated that a completely fibrotic tract on Magnetic Resonance Imaging (MRI) with a MAGNIFI-CD &amp;lt;6 is the best predictor for long-term clinical closure. Mesenchymal stem cell treatment (MST) has emerged as a new therapeutic strategy for these fistulas. The aim of the current study was to analyse the effectiveness of MST for complex Crohn’s perianal fistulas based on MRI. Methods Consecutive patients with complex Crohn’s perianal fistulas, previously failing both anti-TNF treatment and surgical closure, that underwent surgical closure of the internal opening with MST between December 2019 and March 2023 were included. All patients underwent a MRI preoperatively and between three to six months after MST. For the current study, MRI’s were read by an senior radiologist. The primary endpoint was radiological remission of the fistula(s) defined as a MAGNIFI-CD &amp;lt;6 on MRI. Secondary endpoints were clinical closure (defined as closure of the external opening(s)), recurrence rate, change of MAGNIFI-CD over time, quality of life based on the perianal disease activity index (PDAI), and serious adverse events (SAE). Results In total, 30 patients (16 females) with 48 fistula tracts were included with a median clinical follow-up of 20 months. Radiological remission was achieved in thirteen patients (43.3%) after a median follow-up of 5.0 months (IQR 3.0-6.0). The median MAGNIFI-CD at baseline was 15.0 (IQR 7.0-20.0) which decreased significantly to 8.0 (IQR 3.0-15.0) after treatment (p= 0.001). Clinical closure of the fistula(s) was achieved in 21 patients (70.0%). Three patients (14.3%) developed a recurrence during long-term FU. All three patients had clinically closed fistula(s), but no radiological remission. The median PDAI decreased significantly from 10.5 (IQR 7.0-14.0) to 4.0 (IQR 0.0-7.3) (p= 0.001). Overall, in this patient group one SAE occurred requiring multiple reinterventions and temporary stoma. Conclusion Closure of the internal fistula opening with MST is a promising treatment strategy for therapy refractory Crohn’s perianal fistulas, resulting in &amp;gt;40% radiological remission and clinical closure in 70%. No recurrences were seen in patients with radiological remission. MST was also associated with a significant increase in quality of life. Further research is needed to gain insight in which patients MST is most likely to induce radiological remission.

A case in which endoscopic ultrasound-guided transrectal drainage was effective for pelvic abscess

The patient, a 33-year-old female, presented to her local doctor with lower abdominal pain. She was referred to our hospital for a plain CT scan, which revealed signs of ileitis. Because acute appendicitis could not be ruled out, the patient was hospitalized. On the third day of hospitalization, she underwent laparoscopic appendicectomy for perforated appendicitis. However, the inflammatory response persisted despite continued antibacterial treatment; we diagnosed this to be due to the formation of a postoperative residual abscess. Since drainage of the abscess was deemed necessary, the patient underwent EUS-guided transrectal drainage on the 26th day of hospitalization. The patient had a favorable postoperative course and was discharged on the 31st day of hospitalization. Along with some literature review, this report details a case in which transrectal drainage under ultrasound endoscopy was effective in treating a pelvic abscess. We report a case of a pelvic abscess that was drained through the rectum under EUS guidance and an internal and external fistula tube was placed. The abscess resolved without complications.

Early surgical intervention in Internal pancreatic fistula with Chronic Pancreatitis: Outcome analysis

Early surgical intervention in Internal pancreatic fistula with Chronic Pancreatitis: Outcome analysis

Anorectal developmental anomalies

Anorectal malformations include a wide range of conditions that can affect both sexes and involve the distal anus and rectum, as well as the urinary and genital tracts. An imperforate anus is a common birth defect that results from defects or delays in the development of the hindgut. The diagnosis of nonperforation of the anus is usually made shortly after birth through a routine medical examination. Patients have the best chance for a good functional outcome if the disease is diagnosed early and effective anatomic repair is started immediately. Most malformations in girls can only be correctly diagnosed on physical examination. An anus visible in the perineum with a normal vagina and urethra suggests a perineal fistula. A rectovestibular fistula occurs when the opening is in the posterior vestibule and beyond the hymen. If only one opening is visible between the labia, it is very likely a cloaca. Rectovaginal fistulae may initially appear as a non-perforating anus without a fistula (a normal-looking vagina and urethra, but no visible anus). Close examination usually reveals the presence of an opening in the back wall of the vagina or inside the hymenal ring. Radiological evaluation of a newborn with non-perforated anus should include abdominal ultrasound, using it to detect urological abnormalities. Sepsis, aspiration, abdominal distention, colonic perforation, respiratory distress, electrolyte imbalance are complications that can result from delayed diagnostic and therapeutic treatment of anorectal malforations. Accurate preoperative identification of an internal fistula between the distal part of the genitourinary tract is very important for optimal surgical treatment and prevention of possible damage to the genitourinary tract. Staged surgery, the most common approach for treating anorectal malformations, consists of three operations: a colostomy at birth, a definitive operation at 2–3 months of age, and closure of the colostomy at approximately 6 months of age.