Low-output Fistulas Research Articles

Iatrogenic esophageal perforation with mediastinitis, multidisciplinary management: a case report

Acute mediastinitis is a low incidence pathology, but it is associated with a high mortality rate. Iatrogenic lesions are the most common cause of mediastinitis secondary to esophageal perforation. Early diagnosis and surgical treatment are the most important factors in the treatment of patients with this condition. 83-year-old female patient, with a history of left saphenectomy due to venous insufficiency with difficult intubation two days prior to the emergency consultation. She was admitted to the emergency room due to dyspnea, hemoptysis, chest pain, and right hemifacial edema. A chest tomography was performed with findings suggestive of esophageal perforation or airway injury. Later, in an upper digestive tract study, extravasation of the contrast medium was documented in the right posterolateral wall of the cervical esophagus with a collection in the middle mediastinum. The patient was taken for drainage of mediastinitis by right thoracoscopy and the presence of a perforation in the cervical esophagus was confirmed with an intraoperative endoscopy. Esophageal repair was performed, with drainage of the prevertebral space and the superior mediastinum by a left longitudinal cervicotomy. Postoperatively, she received antibiotic and enteral nutritional support by a nasojejunal tube. Low output fistula of the cervical esophagus, organized by a drain, was documented, which closed after 4 weeks of conservative management. Iatrogenic esophageal perforation with mediastinitis is a very rare entity with a high mortality. Early surgical treatment is the most important prognostic factor in patients with mediastinitis due to esophageal perforation.

The Novel Use of Flexible Endoscopic Techniques in the Management of Pharyngocutaneous Fistulas

AbstractPharyngocutaneous fistula (PCF) is a complication of laryngectomies in 14 to 23% of patients. The rate of spontaneous resolution of small and low-output fistulas has been shown to be 65 to 94% in those who are radiation-naive, with a reduced rate of resolution in patients who were previously radiated as low as 33%. Two patients are presented who underwent total laryngopharyngectomy and anterolateral thigh free flap reconstruction at our institution eventually complicated with PCF. All the pertinent patient data were retrieved through chart review from the records of our institution. The cases presented had a prior history of radiation or chemoradiation complicating the spontaneous resolution of the PCF. Both patients had successful resolution of PCF with the flexible endoscopic techniques presented. This case series highlights the management of small PCFs using flexible endoscopic techniques including over-the-scope clips and Vicryl mesh plugs.

Enterocutaneous fistula; Management Challenges,Areterospective Review of 11 Patients Treated in our Institute

Enterocutaneous fistula is a local pathology and systemic disorder. OBJECTIVES: To analyze postoperative outcomes, morbidity, and mortality in patients treated for enterocutaneous fistula in our institute for past 18 months. DESIGN, SETINGS AND PATIENTS: Reterospective review of records of patients presented to Liaquat national university hospital Karachi, Pakistan between Jan 2010 to June 2011 with diagnosis of EC fistula. RESULTS: A total of eleven patients presented with diagnosis of enterocutaneous fistula in our institute in specified duration. Mean age at presentation was 33 years with amle to female ratio of 3:1.72.7 % had high output fistula and 27.2 % had low output fistula. Small bowel was involved in 72.7%, large bowel in 18.18% and 9.0% had both small and large bowel fistula.45.45% patients had single fistula while 54.55 had multiple fistula. Total length of stay varied between 22-150 days .6/11 (54.54%) had nosocomial infection, 3/11(27.27%) had bed sores.2/11(18.18%) had TPN related complications.Spontaneous closure occurred in 8/11(72.77) patients and definitive surgical closure was performed in one patient. Mortality rate was 18.8 %. CONCLUSION: Enterocutaneous fistula is a devastating outcome for both surgeons and patients, sytemetic timely multidisciplinary approach can save lives.

Outcome of Biliary Fistula After Liver Hydatid Cyst SurgeryHydatid cyst, biliary fistulae, Outcome, surgery.

Background: Biliary fistula after liver hydatid cyst surgery was occur in about 17.8 percent of patients inour center.Objective: To study the outcome of biliary fistula regarding factors related to its causes and management.Patients and Methodology: This is a prospective study of 241cases submitted to liver hydatid surgery inAl-Sader teaching hospital in Al-Najaf city, from October 2015 to April 2019. A total of 43 patients whounderwent surgery complicated with persistent leakage of bile from externaldrain. Prospectively collecteddatabase were gathered from patients medical records,sent for essential investigations, and treated eitherconservatively to give a chance for spontaneous closure, or by intervention with ERCP.Results: Forty three patients who develop postoperative biliary fistula after hydatid cyst surgery from 241patients(17,8 %),230 patients treated with conservative surgery (95,4 %), 2 patients treated with radicalsurgery(0,82 %) and 9 patients treated with percutaneous aspiration injection reaspiration (3.7%).All the 43patients in this search treated with conservative surgery. Size more than 15 cm is a risk factors. Intraoperativerisk factor is mainly presence of cystobiliary communication which occur in 16 patients (37,2%). Treatment;isconservative in about 23 patients(53.4%).Treatment with ERCP in 19 patients (44.1%).Time of interventionis from 9 – 15 days.Conclusion: Most of patient with external biliary fistula after hydatid liver surgery can be treatedconservatively and resolve spontaneously specially low output fistula.

A Neglected Case of Colonic Tuberculosis With Thoracolumbar Enterocutaneous Fecal Fistulae

Although intestinal tuberculosis (ITB) typically affects ileocecal segments, the complication of tubercular enterocutaneous fistula is very rare. As an isolated phenomenon, primary intestinal manifestation without extraintestinal tuberculosis (TB) is exceptional and rarely reported. We present a patient with isolated ITB with six spontaneous thoracolumbar tubercular enterocutaneous fistulae. A 37-year-old Chinese woman was admitted to our institution complaining of escape of fecal matter through several openings in her back over the previous 20 years. She had nonspecific abdominal symptoms (occasional abdominal pain and alteration in bowel habit). External physical examination confirmed the presence of external thoracolumbar fecal fistulae in association with a scoliosis. Abdominal examination was unremarkable. Diagnostic colonoscopy with biopsy did not definitively confirm a diagnosis of TB. Microscopic examination in both microbiology and histopathology labs failed to identify acid-fast bacilli; however, gastrointestinal TB (GITB) was considered high on the differential diagnosis list. It was elected to perform open laparotomy with resection of the left hemi-colon. Postoperatively, she was treated with standard anti-tuberculous treatment for 6 months. The patient had an uneventful postoperative course, during which the fistulae gradually closed over the next year. This case with several low-output fistulas exiting the patient’s back was successfully treated by a combination of surgery and antimicrobial therapy. The aim of this rare case report is to raise the awareness of atypical presentation of tubercular colonic enterocutaneous fistula so that timely diagnosis and intervention can salvage patient quality of life. J Med Cases. 2020;11(5):111-114 doi: https://doi.org/10.14740/jmc3463

Clinical study of enterocutaneous fistula

Background: An enterocutaneous fistulae (ECF) may be challenging to manage due to the large volume of fluid losses, that may result in severe dehydration, electrolyte imbalances, malnutrition and sepsis. It is imperative that this group of patients receive adequate nutrition, as malnutrition and sepsis are the leading cause of death.Methods: This descriptive study was conducted prospectively in the Department of Surgery between September 2004 and August 2010. Patients whom develop ECF after surgery were included in the study while patients with esophageal, biliary, pancreatic, and perianal fistulas were excluded. The description of fistula included cause, anatomical location, fistula output, complications, and outcome. Fistula output was quantified by direct measurement, in the presence of drain or by calculating number of dressing pads soaked per day. To examine the statistical significance of association between attributes, Chi-square test and Fisher's exact test were used. A probability value of less than 5% (P < 0.05) was considered significant.Results: A total of 42 patients were included in the study, of which 23 were males and 19 were females and the male:female ratio was 1.2:1. Most patients with ECF were aged 41-50 (mean age, 44.23±2.72). Of the 42 patients, 9 patients had colonic fistula and the remaining had small intestinal fistula; 16 ileal, 5 duodenal, and 12 jejunal. There were 22 patients with high-output fistula as compared to 20 patients with low output fistula. Mortality was significantly higher in patients with males, age >60 years, high-output fistula, mesenteric ischemia as underlying pathology, serum albumin <2.5g/dl and re-surgery.Conclusions: Early diagnosis and stabilization form key aspects of management of ECF as most patients are managed conservatively. Prompt nutritional supplementation alters the outcome of this disease. High output fistulae required mostly surgical management and had high morbidity and mortality.

Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study.

The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.

Current Management of Enterocutaneous Fistulas

Background: Enterocutaneous fistulas are abnormal communications between the gastro- intestinal tract and the skin. More than 75% of all ECFs arise as a postoperative complication, while about 15-25% of them result from abdominal trauma or occur spontaneously. Fistulas are defined by their sites of origin, communication and flow. Aim of the work: This paper reviews our experience in the treatment of enterocutaneous fistulas to evaluate current management practice and outcome. Patients and methods: This retrospective study was conducted on 40 patients with enterocutaneous fistulas treated at El-Demerdash, Ain - Shams University Specialized hospitals in Cairo, Egypt and Alazhar Hospital in Riyadh, KSA during the period from March 2011 to March 2015. Thirty patients (75 %) were males and 10 patients (25%) were females. Their ages ranged between 30 and 50 years. Results: 95% of fistulas resulted from previous surgery and 5% after trauma. Fifty percent (50%) of the fistulas were high-output, 25% were intermediate-output fistulas and 25% were low-output fistulas. Conservative treatment was successful in 10 patients (25%) and all of them (100%) closed spontaneously while 30 patients (75%) had to be surgically explored and twenty seven patients (90%) were closed after surgery. The overall mortality rate was 10%. Conclusion: It was concluded from this study, that surgical intervention was indicated in high-output fistulas and fistulas which fail to close with conservative management. Low- output fistulas usually require no surgery and mostly close with conservative treatment

Study of outcome of patient with faecal fistula

Background: Approximately 80% gastrointestinal fistulas occur following surgery. Due to the high morbidity and mortality associated with gastrointestinal fistula, effective treatment is important. Therefore, this study was conducted to study the outcome of management of patients of gastrointestinal fistula. Methods: 30 Patients developing the condition following surgery were included. All patients were treated either conservatively or operatively by various means and varying period of time. Treatment was focused on the correction of dehydration, controlling sepsis, management of electrolyte imbalance. Results: Younger patients had better fistula healing rate (85%) than older (70%). A high rate of spontaneous healing was observed (85%) in patients who were managed conservatively. Patients with low output fistula had better fistula closure rate as compared to high output fistula. Ileum was the most common site for fistula formation, account for 43.33% of all fistulas. Spontaneous healing rate was better in fistula involving large bowel and duodenal fistula. Patients having both anemia and hypoproteinemia had poor healing rate (72.73%) as compared to those having only anemia and hypoproteinemia. Conclusions: Conservative management with emphasis on improvement of nutrition, control of sepsis, management of fluid and electrolyte balance and control of fistula output supersedes than operative management. Operative intervention must be done in selected cases after improvement of nutritional status and control of infection.

Chylothorax after esophagectomy for esophageal cancer: risk factors and management.

Chylothorax is an uncommon complication of esophagectomy. It carries significant morbidity and mortality. The predisposing factors are ill-defined. We retrospectively evaluated the data of 45 patients of carcinoma esophagus who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT) from January 2010 to July 2012 in our tertiary health care center. Four patients (8.88 %) had chylothorax. On analysis of perioperative factors, it was found that patients with chylothorax had tumor in middle third of thoracic esophagus (100 %), shown partial response to neoadjuvant chemoradiation (NACRT) (100 %) and were associated with difficult mediastinal dissection (75 %) leading to higher blood loss requiring transfusion unlike those without chylothorax. There was no significant difference in the incidence of chylothorax following transhiatal, 3/35 = 8.57 % or transthoracic esophagectomy 1/10 = 10 % (p = 0.898). Three patients were managed by transabdominal en masse ligation of tissue between aorta and azygos vein while one patient was managed conservatively. Patients were discharged after a mean hospital stay of 15.5 days. The 30-day mortality rates in the two groups were similar (0 % vs. 4.8 %). Difficult mediastinal dissection during esophagectomy in middle esophageal cancer may lead to thoracic duct injury. Complete response to NACRT may reduce the risk of chylothorax. Early transabdominal en masse ligation carries excellent results. Low output fistula following thoracic duct injury can be managed conservatively.

Nutritional management of enterocutaneous fistula: a retrospective study at a Malaysian university medical center.

Enterocutaneous fistula is a challenging clinical condition with serious complications and considerable morbidity and mortality. Early nutritional support has been found to decrease these complications and to improve the clinical outcome. Location of the fistula and physiological status affect the nutrition management plan in terms of feeding route, calories, and protein requirements. This study investigated the nutritional management procedures at the Universiti Kebangsaan Malaysia Medical Center, and attempted to determine factors that affect the clinical outcome. Nutritional management was evaluated retrospectively in 22 patients with enterocutaneous fistula seen over a 5-year period. Medical records were reviewed to obtain data on nutritional status, biochemical indices, and route and tolerance of feeding. Calories and protein requirements are reported and categorized. The results show that surgery was the predominant etiology and low output fistula was the major physiological category; anatomically, the majority were ileocutaneous. The spontaneous healing rate was 14%, the total healing rate was 45%, and the mortality rate was 22%, with 14% due to fistula-associated complications. There was a significant relationship between body mass index/serum albumin levels and fistula healing; these parameters also had a significant relationship with mortality. Glutamine was used in 50% of cases; however, there was no significant relationship with fistula healing or mortality rate. The nutritional status of the patient has an important impact on the clinical outcome. Conservative management that includes nutrition support is very important in order to improve nutritional status before surgical repair of the fistula.

Nutrition therapy in enterocutaneous fistula; from physiology to individualized treatment

Enterocutaneous fistula is the most common of all intestinal fistulas. Is a condition that requires prolonged hospital stay due to complications such as electrolyte imbalance, malnutrition, metabolic disorders and sepsis. Nutritional support is an essential part of the management; it favors intestinal and immune function, promotes wound healing and decreases catabolism. Despite the recognition of the importance of nutrition support, there is no strong evidence on its comprehensive management, which can be limiting when establishing specific strategies. The metabolic imbalance that a fistula causes is unknown. For low-output fistulas, energy needs should be based on resting energy expenditure, and provide 1.0 to 1.5 g/kg/d of protein, while in high-output fistulas energy requirement may increase up to 1.5 times, and provide 1.5 to 2.5 g/kg of protein. It is suggested to provide twice the requirement of vitamins and trace elements, and between 5 and 10 times that of Vitamin C and Zinc, especially for high-output fistulas. A complete nutritional assessment, including type and location of the fistula, are factors to consider when selecting nutrition support, whether is enteral or parenteral nutrition. The enteral route should be preferred whenever possible, and combined with parenteral nutrition when the requirements cannot be met. Nutritional treatment strategies in fistulas may include the use of immunomodulators and even stress management.

Cervical esophagogastric anastomosis with invagination after esophagectomy

To evaluate the incidence of fistula and stenosis of the cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach after subtotal esophagectomy. We studied 54 patients who underwent subtotal esophagectomy, 45 (83.3%) patients with carcinoma and nine (16.6%) with advanced megaesophagus. In all cases the cervical esophagogastric anastomosis was performed with the invagination of the proximal esophageal stump inside the stomach. Three (5.5%) patients had a fistula at the esophagogastric anastomosis, two of whom with minimal leakage of air or saliva and with mild clinical repercussion; the third had a low output fistula that drained into the pleural space, and this patient developed empyema that showed good progress with drainage. Fibrotic stenosis of anastomosis occurred in thirteen (24%) subjects and was treated successfully with endoscopic dilatation. Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula and stenosis, thus becoming an attractive option for the reconstruction of alimentary transit after subtotal esophagectomy.

The surgical anatomy and etiology of gastrointestinal fistulas

Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas. On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital. Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.

Management of lymph fistulas in thyroid surgery

Postoperative lymphatic leakage following thyroid surgery represents a management problem with considerate potential morbidity, psychological, and economical impact. Conservative and surgical management strategies for high- and low-output lymph fistulas are inconsistent. Reliable criteria to predict outcome of conservative versus surgical treatment in clinically evident lymph fistula are lacking. A retrospective single-center chart review of consecutively quality-control-documented thyroid surgeries from January 1998 to December 2009 was performed to identify reported postoperative lymph fistulas. Documentation of surgical procedures, drainage, medical, and nutritional management was analyzed to identify risk factors for occurrence and criteria for management of evident lymph fistulas. There were 29 patients identified with postoperative clinical evidence of lymph fistulas following thyroid surgery; incidence was 0.5%. Indication to surgery comprised benign nodular goiter, recurrent nodular goiter, and thyroid carcinoma or local and lymphonodal carcinoma recurrences. There were 12 (41%) primary and 17 (59%) redo surgeries performed. Surgical procedures performed included thyroidectomy, completion thyroidectomy, and primary and redo central and lateral systematic microdissection of lymphatic compartments. All patients were initially submitted to fasting diet and medical treatment, successfully in 19 (66%), whereas ten (34%) patients underwent surgical intervention for fistula closure after failure of conservative treatment. Complications were one wound infection and fistula recurrence in five (26%) patients in the conservative group and two (20%) in the surgical group. Hospital stay was exceedingly prolonged in both groups with a median of 21 and 11 versus 6 days in patients with regular postoperative course following thyroid surgery. Data of this series support definition of the two categories of high- and low-output fistulas according to drainage collection with >300 versus <200 ml/day. Fasting in low-output fistula facilitates conservative treatment with closed drainage, whereas in high-output fistulas surgical intervention should be sought. Attendant criteria for treatment stratification are equally important, like patient's compliance, nutritional, and general health status as well as evidence for wound infection. Surgical closure of lymph fistula may be demanding when identification of the secreting fistula is limited and even muscle flap fortification may fail. Ultimately, in unsuccessfully reoperated fistula recurrences, open drainage may become necessary. Lymph fistulas cause significantly prolonged hospital stay, possible critical clinical decay, and unfavorable cosmetic and oncologic outcome while the superior management remains to be defined.

A low-output colocutaneous fistula healed by Surgisis® anal plug

A 43-year-old woman with a postoperative low-output colocutaneous fistula in her lower abdomen was successfully treated under endoscopic control, employing the Surgisis anal plug, a cone-shaped medical device that has been formerly designed to be easily positioned into an anal fistula. We describe the technique employed here which to our knowledge, has never been described in medical literature.

GS13 SPOT MARKING FOR LAPAROSCOPIC COLECTOMIES

Purpose: Mechanical Bowel Preparation (MBP) is often used by surgeons for patients undergoing Laparoscopic Colectomy (LC) due to the concern that small lesions normally palpable at open surgery may not be seen at the time of laparoscopic surgery. This study sought to determine whether preoperative marking of the colonic primary at the time of colonoscopy with Spot® could overcome this concern.Methodology: All patients suitable for a LC had Spot® marking performed at their colonoscopy. One millilitre of Spot® marking was injected submucosally in 3 positions around the circumference of the lumen at least 5 cm distal to the lesion. The first 100 LC performed by the surgeon for lesions were audited for the purpose of this study, and MBP was not used while all patients received preoperative immunonutrition.Results: Overall mortality was 0%. The anastomotic leak rate was 2% (1 reoperation, 1 low output fistula). Conversion rate was 23%. Spot® marking was successfully identified at laparoscopy in all 100 cases. No cases were converted as a result of failure to identify the marking, however 1 case required an extension in the final incision due to the fact the Spot® marking had been placed proximal to the lesion. Anastomoses were performed “across” the Spot® marking on 3 occasions with no untoward effect.Conclusion: Spot® marking is a safe and effective way to mark lesions in the colon in order to facilitate LC without the need for MBP.

External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin

Objective External lymphatic fistula or chyloperitoneum after intra-abdominal lymphadenectomy may present challenging problems. In the absence of definite guidelines the choice of treatment is often empirical, with unpredictable effectiveness, and the reporting of new cases may broaden the available experience. Methods We describe two cases. One patient had high-output external fistula (1300 mL/d) after para-aortic lymphadenectomy for metastatic lymph nodes. The fistula became fully evident at postoperative day 4, with resumption of an oral diet, on the basis of a 1300-mL/d output of white milky fluid from an abdominal drainage. Oral feeding was interrupted and total parenteral nutrition was started; this was transiently associated with octreotide administration, subsequently replaced by somatostatin. The second patient had a low-output fistula (350 mL/d) after liver resection and lymphadenectomy for cholangiocarcinoma and underwent treatment with total parenteral nutrition and somatostatin. Results In the first case the lymphatic fistula healed in just less than 3 wk, with the patient constantly remaining in very good condition, without secondary complications. In the second case the low-output fistula healed more rapidly. Conclusion Interruption of oral feeding with total parenteral nutrition and continuous somatostatin infusion was an effective treatment in both patients with an intra-abdominal lymphatic leak.

Use Of Continuous Low Flow Suction In The Conservative Management Of Pharyngocutaneous Fistulas

Pharyngocutaneous fistula after laryngectomy is the most common complication that we see after this procedure and it increases the morbidity, length of hospitalisation and also the possibility of mortality. A fistula is an abnormal communication between two epithelialised surfaces and in our case; these two surfaces are the pharyngeal mucosa and the skin. With a pharyngocutaneous fistula, a salivary leak develops from the pharyngeal closure to the skin, which implies a breakdown of the pharyngeal suture line. This is a low output fistula and there generally are not any metabolic complications from the fistula output. Fistulas usually develop five to fifteen days after the procedure. Wound erythema and oedema are the things to look for. The main risk factors are high dose of radiation, persistent carcinoma, and delayed extension to the posterior pharyngeal wall, systemic disease, foreign body granuloma and post-surgical persistence. INTRODUCTION Pharyngocutaneous fistula is the most common complication of laryngectomy patients.1,2 In many cases standard treatment is prolonged period of conservative management.1,2,3 Surgical repair is usually reserved for more persistent cases.1 Continuous dribbling of saliva from fistula site make patient susceptible to aspiration pneumonia in spite of use of cuffed tracheostomy tube. Dribbling of saliva to the anterior chest wall is very uncomfortable to patients and the area of tracheostomy is difficult to nurse. METHOD We use continuous low flow suction (10-12 mm of Hg) using a pliable suction catheter (size 12) to remove excessive saliva from the fistula. The tip of the catheter is placed at the fistula site (Fig. 1). The catheter is changed 3-4 times a day and attached to the skin using mepore dressing. Figure 1 Figure 1: Photograph showing low flow suction catheter at the pharyngocutaneous fistula opening. CONCLUSION In our experience this method is acceptable to the patients as it helps them to keep clean and dry and do not interfere in their daily routine. Nursing care of the patient is also made easier. This is an effective, simple and inexpensive technique to use in daily practice. Use Of Continuous Low Flow Suction In The Conservative Management Of Pharyngocutaneous Fistulas 2 of 3 CORRESPONDENCE TO Mr Pavel Mukherjee MRCS Ed SHO Basic Surgical Trainee Torbay Hospital Torquay UK TQ2 7AA E-mail: pavelmukherjee@gmail.com

Pancreatico-enterostomy for isolated main pancreatic duct disruption

We present our experiences with isolated main pancreatic duct injuries due to blunt trauma, managed by pancreatico-enterostomies. This is a retrospective study of seven patients, one female and six males who presented between 1997 and 2005, whose ages ranged from 10 to 54 years. Three were due to motor vehicle accidents, two due to blunt assault, one pedestrian vehicle accident and one go-cart accident. Four presented acutely and were managed surgically within 24h; two were delayed by 3 days and one by 14 days. Six had pre-operative CT scans; one had an ERCP confirming ductal transection by contrast extravasation. Five pancreatico-gastrostomies and two pancreatico-jejenostomies were performed. Three patients complicated; one by biliary cutaneous fistula after a left hepatic segmentectomy, one with an amylase-rich low output fistula and one with haematemesis, for which no cause could be identified. All complications were managed conservatively. Post-operative follow-up ranged between 4 and 20 weeks. No deaths occurred. In a stable patient, pancreatico-enterostomy for an isolated main pancreatic duct injury appears to be a viable option and simpler to perform than distal pancreatectomy with splenic preservation. Furthermore, it has the advantage of pancreatic tissue and spleen preservation and a low fistula rate. The authors believe pancreatico-gastrostomy to be the easier to perform.