Management Of Fistula Research Articles

Conservative management as a viable alternative in the management of paediatric first branchial arch fistula: a case series.

Conservative management as a viable alternative in the management of paediatric first branchial arch fistula: a case series.

Alternative Operative Strategy in the Management of an Atrio-Esophageal Fistula

Alternative Operative Strategy in the Management of an Atrio-Esophageal Fistula

Retrograde endoscopic ultrasound-guided entero-enterostomy for the management of a high-output enterocutaneous fistula and ileal stricture in a complex surgical abdomen.

Retrograde endoscopic ultrasound-guided entero-enterostomy for the management of a high-output enterocutaneous fistula and ileal stricture in a complex surgical abdomen.

Management of Vesico-Vaginal Fistula by Robotic Approach

Management of Vesico-Vaginal Fistula by Robotic Approach

High flow pial arteriovenous fistula with dural sinus malformation of the posterior circulation.

Posterior fossa congenital pial arteriovenous fistulas are rare vascular anomalies associated with high morbidity. These anomalies often present challenges to neurointerventionists due to their complex morphological features. We successfully treated two technically challenging, infratentorial large pial arteriovenous fistulas (AVFs) associated with complete flow steal in the basilar artery. The first case involved an 18-year-old male with a posterior fossa single-hole AVF characterized by dilated venous pouches and retrograde venous reflux. After an unsuccessful initial coiling attempt, this patient was treated using a double microcatheter coiling technique, supported by a large balloon for flow control. The second case involved a 9-month-old infant with a complex two-hole posterior fossa pial AVF and a large venous sac. This patient was treated with coil embolization of the fistula and with balloon protection of the vertebrobasilar junction. Both patients recovered without postoperative complications and showed significant improvement on follow-up. These cases provide valuable insights into the management and characteristics of pial arteriovenous fistulas.

Efficacy and safety of stem cell therapy for fistula management: An overview of existing systematic reviews.

Fistulas, abnormal connections between two anatomical structures, significantly impact the quality of life and can result from a variety of causes, including congenital defects, inflammatory conditions, and surgical complications. Stem cell therapy has emerged as a promising alternative due to its potential for regenerative and immunomodulatory effects. This overview of systematic reviews aimed to assess the safety and efficacy of stem cell therapy in managing fistulas, drawing on the evidence available. This umbrella review was conducted following the Joanna Briggs Institute (JBI) methodology to assess the efficacy and safety of stem cell therapy for treating various types of fistulas. A comprehensive search was performed across multiple electronic databases including PubMed, Embase, Cochrane Register, and Web of Science up to May 5th, 2024. Systematic reviews focusing on stem cell therapy for fistulas were included, with data extracted on study design, stem cell types, administration methods, and outcomes. The quality of the reviews was assessed using the AMSTAR 2 tool, and meta-analyses were conducted using R software version 4.3. Nineteen systematic reviews were included in our umbrella review. The stem cell therapy demonstrated by significant improvements in clinical remission rates, with a relative risk (RR) of 1.299 (95% CI: 1.192 to 1.420). Stem cell therapy enhanced fistula closure rates, both short-term (RR=1.481; 95% CI: 1.036 to 2.116) and long-term (RR=1.422; 95% CI: 1.091 to 1.854). The safety analysis revealed no significant increase in the risk of adverse events with stem cell therapy, showing a pooled RR of 0.972 (95% CI: 0.739 to 1.278) for general adverse events and 1.136 (95% CI: 0.821 to 1.572) for serious adverse events, both of which indicate a safety profile comparable to control treatments. Re-epithelialization rates also improved (RR=1.44; 95% CI: 1.322 to 1.572). Stem cell therapy shows promise as an effective and safe treatment for fistulas, particularly in inducing remission and promoting closure of complex fistulas. The findings advocate for further high-quality research to confirm these benefits and potentially incorporate stem cell therapy into standard clinical practice for fistula management. Future studies should focus on long-term outcomes and refining stem cell treatment protocols to optimize therapeutic efficacy.

Gastrointestinal fistulae: conservative vs surgical management

Background: Gastrointestinal fistulae are abnormal connections between two hollow organs of the gastrointestinal tract or between the hollow organ and the skin. They remain a major clinical problem, especially if complicated by sepsis, bacteraemia or cancer. General Principles of fistula management consist of- Phase of Diagnosis, Stabilization and Management. Methods: The study was conducted in Sir JJ Group of Hospitals, Mumbai. A total of 34 patients with gastrointestinal fistulae were studied between January 2020 to January 2023. The patients were studied on the basis of presenting signs and symptoms, details of initial surgery performed, investigations pertaining to the condition and their management. Results: Out of the 34 cases, 44% of the cases were from the small intestine, 39% cases we]re from the large intestine, and the rest of the cases were from stomach, duodenum, gastrojejunostomy site and appendicular stump following appendicectomy. Conclusions: The database of our retrospective study regarding age and sex incidence, clinicopathological features and therapeutic outcome was comparable to other studies in various literatures.

COMPARATIVE STUDY ON OUTCOME OF OPEN FISTULECTOMY VERSUS LIFT PROCEDURE FOR UNCOMPLICATED PERIANAL FISTULAS

Perianal fistulas, particularly trans sphincteric types, pose a significant challenge in terms of management, often requiring surgical intervention. Traditional open fistulotomy has been a common procedure, but newer techniques like the ligation of the intersphincteric fistula tract (LIFT) procedure are being explored for improved outcomes, particularly in terms of preserving continence. This study aims to compare the outcomes of open fistulotomy versus the LIFT procedure in patients with trans sphincteric perianal fistulas. Objective: To compare the clinical outcomes, healing times, recurrence rates, and continence status between patients undergoing open fistulotomy and those treated with the LIFT procedure for trans sphincteric perianal fistulas. Methods: A prospective comparative study was conducted in the General Surgery Department of Nishtar Medical Hospital, Multan, from May 2024 to August 2024. A total of 150 adult patients with trans sphincteric perianal fistulas were enrolled using consecutive sampling. The patients were randomly divided into two groups: Group A (n = 75) underwent the LIFT procedure, and Group B (n = 75) underwent fistulectomy. Postoperative follow-up was conducted weekly until wound healing and at three months after healing to assess pain scores, recurrence rates, healing time, and continence status. Statistical analysis was conducted using SPSS Version 25, with a significance level set at p < 0.05. Results: Among the participants, 6 patients (8%) in Group A and 8 patients (10.7%) in Group B experienced recurrent fistulas, showing no significant difference between the groups. Postoperative pain scores were similar between both groups. However, the healing time was significantly shorter in Group A (27.2 days) compared to Group B (48.1 days) (p < 0.05). Recurrence rates were higher in Group A (16%) compared to Group B (2.7%) (p < 0.05). Incontinence was observed in 10.7% of patients in Group B, while no incontinence was reported in Group A (p < 0.05). Conclusion: The LIFT procedure offers better outcomes in terms of continence preservation and shorter healing time compared to open fistulotomy in the management of trans sphincteric perianal fistulas. However, open fistulotomy showed lower recurrence rates. These findings suggest that the LIFT procedure may be preferable in patients for whom preserving continence is a priority, while open fistulotomy may be a better option in cases where recurrence prevention is the main concern.

The management of high flow arteriovenous fistula and possible solutions.

The development of a high flow rate arteriovenous fistula (AVF) can expose the patient to development of heart failure due to increased cardiac preload and pulmonary hypertension. AVF flow measurement (Qa) is considered a screening tool for AVF surveillance, aiming to evaluate the access dysfunction and prevent complications, like a non-maturation, suspected stenosis, high-flow AVF, and distal ischemia. In the upper arm AVF, a high Qa may develops, which can expose the patient to the risk of high-output heart failure and ischemia. Although, the exact threshold to define high-flow access is not universally accepted, AVF with a Qa of 1-1.5 L/min or cardio-pulmonary recirculation (Qa/CO) >20% are considered at risk. In our work we describe the treatment performed in three patients with high flow AVF treated with DRIL technique with interposition of a Prosthetic Patch, revascularization procedures such as distal inflow revision or RUDI and with innovative technique a "tench snout," removal the previous anastomosis and reconstruction of the integrity of the radial artery at the terminal in pre and post anastomosis. A PTFE prosthetic segment measuring 5 cm in length and 5 mm in diameter was interposed, terminally anastomosed with the efferent cephalic vein and terminally lateral with the radial artery, reducing the anastomosis to approximately 4 mm. All treated patients showed a clear improvement in the clinical picture in particularly heart failure. The calculation of the post-intervention flow rate approximately 1500 mL/min. The patient on hemodialysis with arteriovenous fistula must be constantly monitored with clinical examination, monitoring during the hemodialysis session and color Doppler ultrasound of the AVF with calculation of the flow rate. The surgical technique used for flow reduction is chosen on the surgical experience of each operator with the main objective of preserving the autologous AVF.

Efficiency and Complications of Esophageal Stenting in the Management of Postoperative Fistulas.

Esophageal anastomotic fistula (AF) is a frequent and severe complication of an esophagectomy due to esophageal or eso-gastric junction cancer, regardless of the selected surgical technique. AF is usually treated by endoscopic stent placement. Objectives: This study aims to examine the efficacy of stents in the treatment of AF, analyzing the healing period and the factors that contribute to its delay. Methods: We collected data from 55 patients who underwent stent implantation for AF, and analyzed multiple variables related to patient healing time and surgical technique with two primary endpoints: post-stenting hospital stay and the time of stent usage until fistula closure. The patients were divided into three groups based on the anastomosis type (eso-gastric anastomosis, eso-gastric cervical anastomosis and eso-jejunal anastomosis) and they were compared using the primary endpoints. Results: Our findings show the differences between the three groups, with a longer hospital stay for eso-gastric anastomosis, and an extended time of fistula closure in the case of eso-gastric cervical anastomosis. We also found a significant correlation between the size of the fistula and the hospital stay (R = 0.4, p < 0.01). Regarding patients' risk factors, our results show an extended post-stenting hospital stay for those patients that underwent preoperative radiotherapy. Conclusions: Our results offer an extended view of the efficiency, hospitalization duration and healing time for esophageal anastomotic fistula, and reveal some of the factors that interfere with its resolution.

Clinical presentation and treatment of a bronchocutaneous fistula with intrathoracic abscessation in a yearling

SummaryThis case report describes the clinical presentation, surgical treatment, post‐operative management and outcome of a bronchocutaneous fistula with intrathoracic abscessation in a yearling horse. The animal was presented with a history of several months of persistent coughing and a cutaneous fistula located over the right ventral hemithorax. The yearling had purulent discharge similar in character from both nares and draining out of the fistula. A bronchocutaneous fistula with intrathoracic abscessation was diagnosed by endoscopic examination of the cutaneous fistula. The treatment initially consisted of cyanoacrylate applied topically to the affected bronchi under endoscopic guidance, which was not successful. The fistula was successfully sealed with a diode laser used to create local inflammation at the site. One week after the second intervention, the patient's clinical signs resolved and the fistula was completely sealed 10 weeks following intervention. Follow‐up at 16 months revealed that the patient was doing well and clinically normal.

Combined local flap placement and negative-pressure wound therapy for the management of critical peritracheostomal pharyngocutaneous fistula

ObjectivePeritracheostomal pharyngocutaneous fistula (PCF), a direct connection between the PCF and tracheal stoma due to a skin defect, is among the most problematic complications after total laryngectomy or pharyngolaryngectomy. Peritracheostomal PCFs can cause lethal complications, including severe pneumonia or carotid blowout, secondary to salivary leakage directly into the tracheal stoma, and their management is challenging without early invasive surgical closure. We aimed to evaluate the utility of our novel and minimally invasive combined local skin flap placement and negative-pressure wound therapy (NPWT) method for the management and conservative closure of peritracheostomal PCFs. MethodsWe retrospectively enrolled patients who developed a peritracheostomal PCF from July 2015 to September 2021 at our institution and affiliated hospitals. Postoperative PCFs were all initially managed with appropriate wound bed preparation. Subsequently, a small local flap of healthy, lower neck skin was elevated and transferred anterior to the PCF to replace the peritracheostomal skin defect. The flap served to provide a sufficient surface for film dressing attachment and facilitated airtight sealing during NPWT. We initiated NPWT after confirming the local skin flap was firmly sutured to the tracheal mucosa. A flexible hydrocolloid dressing was applied to the peritracheostomal skin flap, and a film dressing was placed on the flexible hydrocolloid dressing and surrounding cervical skin. We inserted the NPWT foam shallowly into the fistula tract and applied negative pressure (73.5–125 mmHg). NPWT was continued until the PCF was closed or became so small that salivary leakage was minimal and could be managed by conventional compression dressings. ResultsWe enrolled six patients [male, n = 6; mean age, 66.5 years (range, 57–80 years)]. NPWT was applied for an average of 18.2 days (range, 2–28 days). During NPWT, air leakage occurred once (2 cases), only a few times (2 cases), or not at all (2 cases). In all patients, complete fistula closure was achieved in an average of 28.2 days (range, 15–55 days) after the start of NPWT, and no patient required further surgical intervention. There were no lethal complications (e.g., severe pneumonia) during treatment. ConclusionOur method of combined local flap placement and NPWT enabled effective management of salivary aspiration and accelerated wound healing, which allowed conservative fistula closure in all patients. We believe combined local flap placement and NPWT should be considered a first-line treatment for intractable peritracheostomal PCF.

Reviving the poppy seed test for the diagnosis of colovesical fistula: A case report from a single rural center experience.

The poppy seed test is a valuable, cost-effective, and sensitive initial diagnostic investigation to identify the presence of colovesical fistula, particularly for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support. The poppy seed test therefore may act as a bridge toward the commencement of appropriate referral pathways for the management of colovesical fistula. The diagnosis of colovesical fistula is resource intensive, often requiring a combination of radiological investigation and endoscopy. The poppy seed test is a non-invasive and cost-effective alternative that has been demonstrated to identify presence of colovesical fistula with high sensitivity. There is however a noticeable paucity of recommendations for the poppy seed test in the diagnostic approach to colovesical fistula due to significant advancements in alternative radiologic and endoscopic technologies. Despite this, in resource-challenged areas with lack of specialist support, the poppy seed test is a cost-effective, accessible and safe test that can be performed to confirm the presence of colovesical fistula. We report a case of a 79-year-old man with a past history of colorectal cancer managed surgically with adjuvant chemoradiotherapy who develops noisy micturition, pneumaturia, and fecaluria 22 years after treatment. Given the suspicion of colovesical fistula, computed tomography imaging and cystoscopy were performed which was unable to demonstrate an overt fistula. The poppy seed test was utilized and demonstrated presence of poppy seeds in the urine, confirming the presence of a fistula. The patient was referred to a specialist surgical center for consideration of further management. The poppy seed test is a valuable initial diagnostic investigation for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support in confirming the presence of a colovesical fistula and initiating referral pathways for the management of this condition.

Lymphatic Fistula Treatment: Indocyanine Green Lymphography-guided Microsurgery

Background: Lymphatic fistulas are a common complication from surgery or interventional procedures resulting in persistent lymphatic leakage and delayed wound healing. The management of lymphatic fistula remains a subject of debate, ranging from conservative treatment to surgical lymphatic ligation. The implementation of a novel microsurgical approach involving lymphatic fistula ligation and/or lymphovenous anastomosis (LVA) using indocyanine green (ICG) lymphography is expected to decrease occurrence and complications. In this study, we share our experience in treating lymphatic fistula–guided microsurgical treatment. Methods: A total of 13 patients from our hospital with persistent lymphatic fistula were enrolled in this retrospective study. Lymphatic fistulas and their leakages were identified and ligated by using ICG lymphography and a surgical microscope. In two cases, additional LVA surgery was performed. Results: We were able to precisely identify lymphatic fistulas and treat them in all 13 patients. Lymph ligation was performed in all 13 cases, with additional distal LVA in two cases. In all patients, wound healing occurred following lymphatic ligation, except in one patient due to persistent infection. Patients with a lymphatic fistula were referred to our unit within 3 weeks to 1 year after onset, with an average consultation occurring after 5 months of persistent lymphatic fistula. Conclusions: Targeted lymphatic vessel ligation with or without LVA with ICG-guided surgical microscope represents a promising highly efficacious therapy for persistent lymphatic fistula. This technique may accelerate wound healing and reduce hospitalization duration, thus advocating for its preferential use in managing lymphatic fistulas.

S2394 Endoscopic Management of Complex Colonic Fistula Following Distal Pancreatectomy

S2394 Endoscopic Management of Complex Colonic Fistula Following Distal Pancreatectomy

Novel technique for inguinal lymphatic fistula management using a double U-stitch closure

Novel technique for inguinal lymphatic fistula management using a double U-stitch closure

Symptomatic Pneumorrhachis from Bronchial-Subarachnoid Fistula

Bronchial-subarachnoid fistulas are rare occurrences, which are not well defined in the literature. This uncommon clinical phenomenon may result in symptomatic pneumorrhachis and presents unique clinical challenges. This report details a case of a 53-year-old female whose treatment for recurrent chondrosarcoma of the thoracic spine included multiple surgeries and radiotherapy. Two weeks after her most recent debulking surgery, she experienced a rapid onset of unusual symptoms, including headache, back and neck spasms, bladder incontinence, and confusion. The source of her symptoms was found to be secondary to pneumorrhachis from a pre-existing bronchial-pleural fistula that had fistulized to the subarachnoid space discovered on computed tomography (CT) and confirmed intraoperatively. The patient was treated successfully with high-flow oxygen therapy and bed rest, followed by surgical correction of both a pleural air leak and a dural defect with muscular flaps. The patient was discharged home in stable condition and remained clinically free of recurrent bronchial-subarachnoid fistula six months after surgical repair. This case contributes to the existing literature by providing detailed clinical insights into the diagnosis and successful management of a bronchial-subarachnoid fistula leading to pneumorrhachis, thereby highlighting the importance of early recognition and intervention and underscoring the need for further research in this area.

Outcome of Arteriovenous Fistula Following Renal Transplantation

Background: Renal transplantation is the preferred treatment for end-stage renal disease (ESRD), but the management of arteriovenous fistulas (AVFs) post-transplant remains controversial due to complications like thrombosis.Objective: To determine the outcome of AVFs following renal transplantation, focusing on the incidence and timing of AVF thrombosis.Methods: This ambi-directional cohort study included 155 patients with ESRD who underwent kidney transplantation at the Sindh Institute of Urology and Transplantation, Karachi, in 2021. All included patients had a functional AVF at the time of transplantation. Data were collected from electronic health records, including demographic information, AVF characteristics, and incidence of thrombosis. AVF outcomes were monitored through follow-up assessments until September 2024. Statistical analysis was conducted using SPSS version 25, with significance set at p&lt;0.05.Results: Thrombosis occurred in 71 (45.8%) patients, most frequently within one week (14.8%), within four weeks (21.9%), and within one year (34.2%). Surgical ligation was required in 5 patients (3.22%). No significant associations were found between thrombosis and age, comorbidities, or AVF type (p&gt;0.05).Conclusion: AVF thrombosis is a frequent complication post-transplant, not significantly influenced by patient demographics or AVF type, highlighting the need for continued surveillance.

Management of traumatic scalp arteriovenous fistula: Case report and literature review.

Blunt traumatic arteriovenous fistula (AVF) of scalp, are uncommon and most of them can be secured by simple embolization or surgical ligation of the feeders. Our goal in writing this paper is to show patients with traumatic scalp AVFs how to prevent complications and the likelihood of recurrence. Complete treatment and reduce the recurrence rate of traumatic AVF on the scalp. Traumatic scalp AVF. Transarterial embolization and surgical resection. Complete resection of the AVF and subsequent angiography showed resolution of the contralateral lesion. Combination of endovascular embolization with subsequent surgical removal may reduce intraoperative blood loss compared with surgery alone. In addition, a well-designed scalp flap can be performed based on the angiography findings after embolization.

Pediatric coronary cameral fistula in a structurally normal heart: a case report and review of the literature

IntroductionCoronary cameral fistulas (CCFs) are rare congenital anomalies characterized by abnormal connections between a coronary artery and one of the cardiac chambers. These abnormal connections can lead to significant clinical implications, including heart failure and myocardial ischemia, necessitating timely diagnosis and intervention.Case presentationA 5-year-old Iranian boy was brought to the emergency room at Heart Hospital Center complaining of chest pain and dyspnea on exertion. He had experienced similar episodes over the past 4 months, which had not been evaluated. Physical examination revealed stable vital signs and no remarkable findings. Transthoracic echocardiography demonstrated a dilated left coronary artery with a large aneurysm and a small orifice to the right ventricular body. The left ventricular ejection fraction was 55%. Cardiac computed tomography angiography confirmed the diagnosis. Cardiac angiography showed a dilated left coronary artery and a coronary cameral fistula to the right ventricular . The aneurysm was successfully occluded using two Amplatzer™ devices.ConclusionThis case underscores the critical role of multimodal imaging in diagnosing and managing coronary cameral fistulae. Early detection and appropriate intervention are paramount in preventing the progression of symptoms and potential complications such as heart failure and myocardial ischemia. The successful closure with Amplatzer™ devices highlights the efficacy of minimally invasive techniques in treating complex cardiovascular anomalies. Regular follow-up and careful monitoring are essential to ensure long-term success and to manage any potential recurrences.Clinical key messageTimely identification and management of coronary cameral fistulae are crucial to prevent complications. Advances in imaging techniques and minimally invasive treatments, such as transcatheter closure, offer effective solutions. A multidisciplinary approach and regular follow-up are essential for comprehensive care and successful long-term management.