Postoperative Fistula Research Articles

COMPLEXITY OF PITUITARY ADENOMA SURGERY

Introduction Pituitary adenomas are the most common intraselllar tumors, representing 16% of all intracranial lesions. Although the symptomatology is very complex, it requires a multimodal treatment plan, in order to cover all corners of this combined pathology. Mostly the treatment is surgical, hormonal or combined. The transnazosphenoidal corridor offers a optimal visualitation of the anatomic location (via microscope or endoscope) but also comes with a variety of morbidities, one of the most important being the cerebrospinalfluid fistula (CSF leak). Objective We effectuated a retrospective cohort study in which we included patients with pituitary adenoma who were operated in the Clinic of Neurosurgery from Targu-Mures Emergency County Hospital between January 2018 and April 2024 with full documentation, including complications (apoplexy, infections, CSF fistula etc.). Results A total of 45 patients passed the inclusion criteria with a predominance of female patients (60%, n=27) with a mean age of 55.77 years. Analizing the clinical and paraclinical data, there were 39 patients with macroadenoma (vs. microadenoma n=6), with the dominant symptomatology being headache (86.66%) and visual disturbances (66.66%). In 32 cases the transnazosphenoidal (TSS) approach was used (1 case endoscopic and 31 cases microscopic), in 10 cases pure transcranian with modified pterional or subfrontal craniotomy and in 3 cases there was a combined approach. Postoperative complications were encountered in 8 cases (17.77%), and death in 1 case. 6 patients presented postoperative CSF fistula. In 16 cases we encountered postoperative Diabetes Insipidus with a significant difference in the tumor volume favoring this manifestation (p=0.0001). There was no significance found between the volume of the tumor and postoperative CSF leak (p=0.665). In 31 cases (68.88%) the TSS approach was used and the closing of the sphenoid sinus and cranial base was effectuated in a classic manner with fat, fascia and muscle; in additional cases specified glues were used. Conclusions Our study wants to reflect on the importance of anterior/middle cranial base closure, taking into account the possible postoperative complications. It is important to be aware of the technique of different nasoseptal flaps in order to prevent CSF fistula and reduce postoperative complications.

Biodegradable Stents: A Breakthrough in the Management of Complex Biliary Tract Injuries: A Case Report

Background and Clinical Significance: Biliary tract injuries are a recognized complication of laparoscopic cholecystectomy. Early diagnosis and prompt management are crucial to minimize complications such as bile leaks, strictures, and fistula formation. This case report highlights the use of a biodegradable biliary stent in managing a complex biliary injury and discusses the impact of delayed diagnosis on treatment outcomes. Case Presentation: We present the case of a 30-year-old male who sustained a Strasberg E2 biliary tract injury during a laparoscopic cholecystectomy. Initially misdiagnosed, the injury was only recognized on the fourth postoperative day. The patient underwent a Roux-en-Y hepaticojejunostomy and subsequently developed a postoperative biliary fistula, which was managed with percutaneous drainage. A biodegradable biliary stent was later placed to address a stricture and minimize the need for future interventions. One year later, the patient presented with symptoms of cholangitis, and radiological findings revealed a narrowing of the biliary lumen. The stricture was resolved and an endoscopic gastrojejunal shunt was placed to prevent further complications. The patient is currently in good condition with no signs of further complications. Conclusions: This case emphasizes the importance of early diagnosis in managing biliary tract injuries and highlights the potential of biodegradable stents to reduce the need for repeat interventions. Despite a delayed diagnosis necessitating complex surgical procedures, the use of a biodegradable stent proved effective in managing postoperative complications. Further studies are needed to evaluate the long-term efficacy of biodegradable stents in similar clinical scenarios.

Comparative Analysis of Fistula Development After Parotid Gland Surgery: Lateral Parotidectomy Versus Extracapsular Dissection Technique.

The primary objective of this study was to explore the potential disparity in postoperative fistula occurrence rates between patients who undergo (partial) lateral parotidectomy and those who undergo the extracapsular dissection technique for the management of benign parotid gland tumours. A consecutive series of 363 patients treated with (partial) lateral parotidectomy and extracapsular dissection technique for benign parotid gland tumours at one tertiary centre between 2018 and 2022 were included. To evaluate the impact of the surgical technique and possible other risk factors (tumour location, tumour size, Body Mass Index, age, smoking, diabetes mellitus, arterial hypertension) for the development of fistulas, multivariate logistic regression analyses using backward lection were applied to estimate odds ratios (ORs) and 95%-confidence intervals (CIs). In 363 patients, 21 patients (5.8%) developed a fistula. Patients who underwent (partial) lateral parotidectomy had three times higher chance of developing a fistula compared to patients who were operated using the extracapsular dissection technique (ORadjusted = 2.6, 4.1% vs. 12.5%, p = 0.044). In the multivariate analyses, no other risk factors for the development of fistulas were statistically significant in this cohort. The incidence of facial nerve paralysis was not significantly different between the extracapsular dissection and lateral parotidectomy group (5/73 = 6.8% vs. 11/290 = 3.8%, p = 0.333). Fistulas occur more often in patients treated by means of a (partial) lateral parotidectomy approach compared to patients treated using the extracapsular dissection technique. Therefore, surgeons should be vigilant about postoperative fistula risks in lateral parotidectomy and consider preventive measures.

Comparative analysis of Roux-en-Y cystojejunostomy versus conservative surgical strategies for giant hepatic hydatid cysts: A retrospective study

BackgroundThis retrospective study addressed the challenge of postoperative biliary fistula, a common complication observed after surgical management of giant hepatic hydatid cysts. The primary objective was to compare the efficacy and safety of conservative surgical techniques versus prophylactic Roux-en-Y cystojejunostomy (R-en-Y CJ) in addressing residual cavity. MethodsRetrospective analysis was conducted on patients who underwent surgical intervention for giant hepatic hydatid cysts with cysto-biliary communication from July 2021 to Jan 2024. Preoperative laboratory tests, imaging studies, surgical procedures, and postoperative outcomes were reviewed from medical records. Results32 patients who underwent surgery for giant hepatic hydatid cysts were included. There were 19 (59.38%) female patients, with a mean age of cohort was 39.13 years. The patients were divided into two groups with respect to the treatment modality: Group A (n = 14), treated with conservative surgical techniques and R-en-Y CJ, and Group B (n = 18), treated with conservative surgical methods. The overall cavity-related complications occurred in 9/18 (50%) in Group B, whereas 2/14 patients (14.29%) in Group A during the follow-up period (p < 0.05). ConclusionR-en-Y CJ is an effective and safe surgical procedure for tackling residual cavities in giant hepatic hydatid cysts with cysto-biliary communication.

Robotic Versus Laparoscopic Versus Open Surgery for Non-Metastatic Pancreatic Neuroendocrine Tumors (pNETs): A Systematic Review and Network Meta-Analysis.

Background: This systematic review, using pairwise and network meta-analyses, aimed to compare the intraoperative, short-term, and long-term postoperative outcomes of minimally invasive surgery (MIS) and open surgery (OS) for the management of pancreatic neuroendocrine tumors (pNETs). Methods: Studies reporting on the effects of robotic, laparoscopic, and open surgery on pNETs published before November 2023 on PubMed, Scopus, and CENTRAL were analyzed. Results: Thirty-two studies with 5379 patients were included in this review, encompassing 2251 patients undergoing MIS (1334 laparoscopic, 508 robotic, and 409 unspecified MIS) and 3128 patients undergoing OS for pNETs management. Pairwise meta-analysis revealed that the MIS group had a significantly shorter length of hospital stay ((a low certainty of evidence), MD of -4.87 (-6.19 to -3.56)); less intraoperative blood loss ((a low certainty of evidence), MD of -108.47 (-177.47 to -39.47)); and decreased tumor recurrence ((a high certainty of evidence), RR of 0.46, 95% CI (0.33 to 0.63)). Subgroup analysis indicated a higher R0 resection rate and prolonged operative time for laparoscopic surgery than for OS. The network meta-analysis ranked the robotic approach as superior in terms of the length of hospital stay, followed by the laparoscopic and OS arms. Furthermore, it favored both MIS approaches over OS in terms of the R0 resection rate. No significant differences were found in severe postoperative complications, postoperative fistula formation, mortality, readmission, reoperation, or conversion rates. Conclusions: This review supports the safety of MIS for the treatment of pNETs. However, the varying certainty of evidence emphasizes the need for higher-quality studies.

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.

Palatal relaxing incisions versus nasopharyngeal relaxing incisions in Palatoplasty.

Bone denudation after conventional relaxing incisions could be a critical factor in inhibiting maxillofacial growth. To address this, alternative relaxing incisions were designed. Thus, this study aimed to compare the effectiveness of palatal relaxing incisions versus nasopharyngeal relaxing incisions in enhancing postoperative outcomes. A retrospective cohort study was conducted, involving a total of 120 patients divided into three groups: 40 patients have received modified Furlow palatoplasty with nasopharyngeal relaxing incisions (M.F + N.P.I palatoplasty), and 40 patients who received modified Furlow palatoplasty with palatal relaxing incisions (M.F + P.R.I palatoplasty). The other 40 patients received original Furlow palatoplasty without relaxing incisions (F palatoplasty). Data collected included gender, cleft type, cleft width, age at repair, velopharyngeal function, presence of palatal fistula, and follow-up. The chi-square test compared frequencies of sex, cleft type, postoperative fistula, and velopharyngeal outcomes across groups. The Mann-Whitney and independent t-tests compared mean values, with statistical significance set at p < 0.05. The mean age at repair was similar across groups, with follow-up periods ranging from 5 to 11 years. No significant differences were found among the M.F + N.P.I and M.F + P.L.I groups regarding gender, cleft type, cleft width, and age at repair. However, the F group had a significantly narrowest cleft width compared to the other groups. Postoperative outcomes showed no significant differences in velopharyngeal function among the three groups, but the F group had a significantly higher rate of palatal fistula (32.5%) compared to the M.F + P.L.I (10%) and M.F + N.P.I (7.5%) groups. A comparison of the two modified Furlow techniques revealed no significant differences in velopharyngeal closure rates or the incidence of velopharyngeal insufficiency and persistent palatal fistula across different Veau classifications. While both incisions showed similar impacts on palatoplasty outcomes, palatal relaxing incisions may expose more bone and pose a higher risk of secondary healing issues. Therefore, nasopharyngeal relaxing incisions are recommended as an effective and potentially preferable technique in palatoplasty whenever feasible. The current study suggests that, whenever feasible, nasopharyngeal relaxing incisions are advised as an effective and potentially superior technique in palatoplasty.

Postoperative rectovaginal fistula: stoma may not be necessary—a French retrospective cohort

BackgroundPostoperative rectovaginal fistula leads to a loss of patients’ quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula.MethodsThis retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure.ResultsA total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107–2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271–997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate.ConclusionThe creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

Patient-Reported Quality of Life for Osteoradionecrosis Reconstruction in the Head and Neck: A Longitudinal Framework and Risk Factors.

Osteoradionecrosis (ORN) is an aggressive sequela of head and neck cancer, treatment of which focuses on functional restoration and quality-of-life (QoL). This study aims to identify risks for poor QoL in ORN reconstruction and build a chronologic, longitudinal framework for QoL. A prospective database of reconstructions performed by the senior author was reviewed from 2015-2023. QoL metrics (University of Washington [UWQoL]v4) were prospectively administered prior to surgery, one year post-operatively, and each yearly follow-up. 56 ORN patients were included (average 58.2years, mean 6,412Gy radiation). Reconstruction commonly was achieved with the fibula(55.4%) and anterolateral-thigh flaps(37.5%). The total complication rate was 23.2%, median 10.7mo post-operatively.Both "health-related QoL in comparison with prior to cancer diagnosis" (62.5 vs 43.5;p=0.030) and "Overall QoL during the past 7-days" (50.5 vs 41.7;p=0.029) were higher post-ORN reconstruction than before. Physical-QoL was higher pre-cancer reconstruction (79.0) than prior to ORN reconstruction (50.6;p<0.001) and following reconstruction (52.5;p=0.001). Social-emotional function was higher following ORN reconstruction compared to pre-reconstruction (68.7 vs 59.6;p=0.010).On multi-variate analysis, both post-operative social-emotional and physical function were impacted by betelnut use (p=0.038;p=0.025). Poor improvement in QoL from pre to post-ORN reconstruction were affected by maxilla involvement (p=0.048), fistula (p=0.004), and hardware issues (p=0.001). Our longitudinal experience trended decline in QoL at ORN diagnosis with gradual improvement following reconstruction, with eventual social-emotional, pain, anxiety, chewing, and global-QoL significantly improved following surgery. Betelnut was a risk factor for poor post-operative QoL. Maxillary involvement, post-op fistula and hardware issues were risks for non-improvement in QoL.

Application of prophylactic flow restriction in brachiocephalic arteriovenous fistulas

To investigate the effects of prophylactic flow restriction for brachiocephalic arteriovenous fistula on postoperative high-flow-related complications and patency rate in patients undergoing hemodialysis. Clinical data of patients with end-stage renal disease who underwent brachiocephalic arteriovenous fistula surgery for hemodialysis from February 2017 to May 2022 in Department of Nephrology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were retrospectively analyzed. During surgery, a 4-5 mm vascular suture loop was placed around the vein near the anastomosis as a flow restriction device in 43 patients (flow restriction group), while 42 patients did not receive the prophylactic flow restriction ring (control group). All patients were followed up for 1 to 5 years. The incidence rates of complications related to the hemodialysis access pathway, including distal ischemia syndrome, the formation of arteriovenous fistula aneurysms, thrombus, high-flow congestive heart failure, anastomosis of the vein within 1 cm of the anastomosis and cephalic arch stenosis, were compared between the two groups. The natural blood flow rate of the arteriovenous fistula, anastomosis size, the internal diameter of the vein near the anastomosis, primary patency rate, assisted primary patency rate, and secondary patency rate of the arteriovenous fistula, were also evaluated and compared between the two groups. Logistic regression analysis was used to investigate the factors affecting arteriovenous fistula patency rates, as well as the impact of the flow-restricting ring on postoperative factors. Ultrasound measurements showed that the internal diameter of the vein at the site of the flow restriction ring in the flow restriction group was (3.7±0.6) mm at three months postoperatively, which was significantly smaller than the internal diameter of the narrowest part of the vein near the anastomosis in the control group [(4.1±1.0) mm, t=－2.416, P<0.01]. The postoperative anastomotic diameter and natural blood flow rate of the arteriovenous fistula in the flow restriction group were both significantly lower than those in the control group (both P<0.05). Furthermore, the incidence rates of various complications in the flow restriction group were significantly lower than those in the control group (all P<0.05). At 6, 12, and 24 months postoperatively, the primary patency rate and assisted primary patency rate in the flow restriction group were significantly higher than those in the control group (both P<0.05), while there was no significant difference in secondary patency rates between the two groups (P>0.05). Binary logistic regression analysis indicated that age, diabetes, and natural blood flow rate of the arteriovenous fistula at 3 months postoperatively were independent risk factors for primary patency rate, while the flow restriction for brachiocephalic arteriovenous fistula was an independent protective factor for primary patency rate (P<0.01 or P<0.05). The application of flow restriction was negatively correlated with anastomotic diameter at 6 and 12 months, natural arteriovenous fistula blood flow, and the incidence rates of cephalic arch stenosis and aneurysm formation (all P<0.05). The prophylactic constriction during brachiocephalic arteriovenous fistula surgery in patients undergoing hemodialysis can limit the size of the anastomosis and postoperative arteriovenous fistula blood flow, reducing complications such as cephalic arch stenosis and high-flow heart failure, and increasing primary patency rates of arteriovenous fistula and delay the reintervention of the fistula.

Achievement of international benchmark outcomes for robotic pancreaticoduodenectomy in a low volume country

BackgroundRecently, there has been an increase in the utilisation of the robotic platform to perform minimally invasive pancreaticoduodenectomy in high volume centres, with the goal of reducing morbidity and improving patient outcomes. This study reports the successful implementation of a robotic pancreaticoduodenectomy (RPD) programme in the relatively low volume setting of Australia, measured against established, internationally accepted benchmarks for low-risk open pancreaticoduodenectomy (OPD). MethodsRetrospective review of a prospectively maintained database for consecutive RPD at two Brisbane hospitals was performed, comparing data to internationally established benchmarks for low-risk OPD. A structured RPD programme was implemented by two surgeons across a study period spanning May 2017 to December 2023. ResultsOver the study period, seventy-two consecutive RPDs were performed, with 79 % for malignancy. Perioperative outcomes for transfusions, conversion rate, postoperative fistula rate, morbidity, mortality and oncological outcomes were all within established benchmark cutoffs for low-risk open pancreaticoduodenectomy (OPD), although operative time exceeded the benchmark value by 0.7hrs. ConclusionA carefully implemented RPD programme in the low volume Australian setting is feasible, with high quality outcomes achievable when compared to established benchmarks for low-risk OPD and to reported RPD series published by high volume pioneering centres.

The establishment and validation of a clinical prediction model for postoperative biliary fistula after pancreaticoduodenectomy.

At present, pancreaticoduodenectomy (PD) is a classic surgical treatment for benign and malignant tumors around ampulla. The operation is complicated and postoperative complications are frequent. Biliary fistula is the most common anastomotic fistula after pancreatic fistula. Our objective is to analyze the risk factors for biliary fistula after PD and to construct a nomogram to predict biliary fistula after PD. The clinical data of a total of 196 patients who underwent PD from March 2014 to March 2024 in Yueyang Hospital Affiliated to Hunan Normal University and The Third Xiangya Hospital of Central South University were retrospectively analyzed. The number of included patients was divided in the ratio of 7:3 using the random split method, with 130 patients in the training set and 66 patients in the validation set. Predictors were screened and a nomogram prediction model was constructed by one-way logistic regression analysis, Lasso regression analysis and multifactorial logistic regression analysis. The discriminative ability, consistency and clinical effectiveness of the models were assessed by area under the curve (AUC) of the working characteristics of the subjects, calibration curve and decision curve analysis (DCA). The results of multifactorial logistic regression analysis showed that diabetes, low albumin, postoperative gastroparesis, abdominal bleeding, abdominal infection, and postoperative pancreatic fistula were the independent risk factors for biliary fistula after PD (P<0.05). The AUC of the column-line graph prediction model constructed from the above factors was 0.807 [95% confidence interval (CI): 0.652-0.962] in the training set and 0.782 (95% CI: 0.517-1.000) in the validation set, suggesting that the diagnostic efficacy of the model was better, and the calibration curves plotted in the training and validation sets were closer to the standard curves, suggesting that the model consistency was better. The plotted DCA curves also indicated a significant positive net gain. The nomogram prediction model constructed by diabetes, albumin, postoperative gastroparesis, abdominal bleeding, abdominal infection, and postoperative pancreatic fistula can well identify high-risk patients with postoperative biliary fistula (POBF) in PD, which has a good clinical application value.

Successful conservative management of localized pyothorax following pleurodesis in a case of completely dissected postoperative bronchopleural fistula: A case report

Successful conservative management of localized pyothorax following pleurodesis in a case of completely dissected postoperative bronchopleural fistula: A case report

Indocyanine green fluorescence in the evaluation of post-resection pancreatic remnant perfusion after a pancreaticoduodenectomy: a clinical study protocol

BackgroundPancreaticoduodenectomy is associated with an incidence of postoperative complications of approximately 41%. One of the most severe complications is a postoperative pancreatic fistula. The exact cause of postoperative fistula development is still unknown, but it appears to be multifactorial. Proper perfusion of pancreatic remnant is essential for the healing of pancreaticojejunostomy. To date, there is no method to reliably evaluate the vascular supply of the remnant. One of the methods for the assessment of organ perfusion is the indocyanine green fluorescence. This study aims to determine if indocyanine green fluorescence is a reliable method to measure the perfusion of the post-resection pancreatic remnant. The secondary outcome is to determine if intraoperative evaluation of the vascular supply of the post-resection remnant may predict the increased risk of postoperative pancreatic fistula development.MethodsThis study is designed as a prospective, observational study. All consecutive patients undergoing open or robotic pancreaticoduodenectomies at our department during the 1st May 2024-31st December 2026 period will be enrolled. The exclusion criteria are an allergy to indocyanine green and refusal by the patient. The adequacy of the vascular supply of the post-resection pancreatic remnant will be intraoperatively evaluated using a fluorescence detector. Patients will be divided into two groups: Those with high risk of pancreatic fistula development and those with low risk. The incidence of pancreatic fistulas in both groups is to be compared. Postoperative data including morbidity, mortality, hospital stay, intensive care unit stay and postoperative fistula development will be collected.DiscussionIf an intraoperative assessment of the perfusion of post-resection pancreatic remnant using indocyanine green is proven to be a suitable method to estimate the increased risk of the pancreatic fistula, the list of the existing known risk factors could be expanded. In the most high-risk patients the modification of the surgical procedure could be considered.Trial registrationNumber: NCT06198400 ClinicalTrials.Gov. Date 08.01.2024.

Challenges in diagnosis and management of aortobronchial fistula: a case report

Abstract Background Aortobronchial fistulas (ABFs) are rare but potentially life-threatening conditions, often presenting with haemoptysis. They can develop following various thoracic aortic conditions or procedures. Case Presentation A 70-year-old patient with a history of descending aorta replacement and ischaemic stroke presented with chest pain and upper gastrointestinal bleeding. Imaging revealed a fistula between the aortic prosthesis and the lung, along with other cardiovascular abnormalities. Despite the indication for anticoagulant therapy, tranexamic acid was initiated due to bleeding risk. The patient showed clinical improvement with tranexamic acid treatment but experienced recurrence of bleeding after discontinuation. Endovascular treatment for the contained rupture at the proximal stent anastomosis was indicated. Discussion Haemoptysis is the primary symptom of ABFs, often recurring until the fistula enlarges. Postoperative aortic fistulas into the airways are uncommon and can occur years after surgery. Thoracic endovascular aortic repair has become the primary treatment for high-risk patients with thoracic aortic disease. Various diagnostic modalities can visualize a fistula tract, but practical visualization is rare. Untreated ABFs invariably lead to death. Conclusion This case highlights the challenges in diagnosing and managing ABFs, emphasizing the need for a multidisciplinary approach and regular follow-up. Patient education and prompt reporting of symptoms are essential. Early intervention upon suspicion of recurrence is crucial for optimizing patient outcomes.

Direct visualization of postoperative aortobronchial fistula on computed tomography.

Postoperative aortobronchial fistula (ABF) is a rare complication that can occur in 0.3%-5.0% of patients over an extended period of time after thoracic aortic surgery. Direct visualization of the fistula via imaging is rare. To investigate the relationship between computed tomography (CT) findings and the clinical signs/symptoms of ABF after thoracic aortic surgery. Six patients (mean age 71 years, including 4 men and 2 women) with suspected ABF on CT (air around the graft) at our hospital were included in this retrospective study between January 2004 and September 2022. Chest CT findings included direct confirmation of ABF, peri-graft fluid, ring enhancement, dirty fat sign, atelectasis, pulmonary hemorrhage, and bronchodilation, and the clinical course were retrospectively reviewed. The proportion of each type of CT finding was calculated. ABF detection after surgery was found to have a mean and median of 14 and 13 years, respectively. Initial signs and symptoms were asymptomatic in 4 patients, bloody sputum was found in 1 patient, and fever was present in 1 patient. The complications of ABF included graft infection in 2 patients and graft infection with hemoptysis in 2 patients. Of the 6 patients, 3 survived, 2 died, and 1 was lost to follow-up. The locations of the ABFs were as follows: 1 in the ascending aorta; 1 in the aortic arch; 2 in the aortic arch leading to the descending aorta; and 2 in the descending aorta. ABFs were directly confirmed by CT in 4/6 (67%) patients. Peri-graft dirty fat (4/6, 67%) and peri-graft ring enhancement (3/6, 50%) were associated with graft infection, endoleaks and pseudoaneurysms were associated with hemoptysis (2/6, 33%). Asymptomatic ABF after thoracic aortic surgery can be confirmed on chest CT. CT is useful for the diagnosis of ABF and its complications.

MFI-11 in Chinese elderly esophageal cancer patients with postoperative adverse outcomes

BackgroundFrailty becomes more pronounced with advancing age, tightly intertwined with adverse clinical outcomes. Across diverse medical disciplines, frailty is now universally recognized as not only a risk factor but also a predictive indicator for unfavorable clinical prognosis.MethodsThis study was a retrospective cohort study that included clinical data from patients (aged ≥ 65 years) with esophageal cancer treated surgically at the First Affiliated Hospital of Anhui Medical University in 2021. For each patient, we calculated their 11-index modified frailty index(mFI-11) scores and categorized the patients into a frailty group (mFI-11hign) and a non-frailty group (mFI-11low) based on the optimal grouping cutoff value of 0.27 from a previous study. The primary study index was the incidence of postoperative pulmonary infection, arrhythmia, anastomotic fistula, chylothorax, and electrolyte disturbance complications. Secondary study indicators included postoperative ICU stay, total hospitalization time, readmission rate within 30 days of discharge, and mortality within 30 days after surgery. We performed univariate and multivariate analyses to assess the association between mFI-11 and adverse outcomes as well as postoperative complications.ResultsFive hundred and fifteen patients were included, including 64.9% (334/515) in the non-frailty group and 35.1% (181/515) in the frailty group. Comparing postoperative complication rates between the two groups revealed lower incidences of postoperative anastomotic fistula (21.5% vs. 4.5%), chylothorax (16.0% vs. 2.1%), cardiac arrhythmia (61.9% vs. 9.9%), pulmonary infections (85.1% vs. 26.6%), and electrolyte disturbance (84.5% vs. 15.0%) in patients of the non-frailty group was lower than that in the frailty group (p < 0.05). mFI-11 showed better prognostic results in predicting postoperative complications. anastomotic fistula (area under the ROC curve AUROC = 0.707), chylothorax (area under the ROC curve AUROC = 0.744), pulmonary infection (area under the ROC curve AUROC = 0.767), arrhythmia (area under the ROC curve AUROC = 0.793), electrolyte disturbance (area under the ROC curve AUROC = 0.832), and admission to ICU (area under the ROC curve AUROC = 0.700).ConclusionPreoperative frail elderly patients with esophageal cancer have a high rate of postoperative complications. mFI-11 can be used as an objective indicator for identifying elderly patients at risk for esophageal cancer.

Rotational Latissimus Dorsi Flap for Lateral Repair of Thoracic Cerebrospinal Fluid-Pleural Fistula: Case Report.

Giant calcified thoracic discs are challenging surgical pathologies that tend to be more centrally located and calcified. This complicates the removal process and potentiates the formation of dural defects, resulting in persistent cerebrospinal fluid (CSF) leaks and the formation of pleural fistulas. The typical intervention for this is CSF diversion through external ventricular drain or lumbar drain placement, followed by direct repair. However, if all these measures fail, subsequent salvage techniques have not been described previously. A 45-year-old man with past medical history of obesity (body mass index: 58), hypertension, and type 2 diabetes mellitus presented to the emergency department with thoracic myelopathy symptoms. MR demonstrated a giant calcified thoracic discs at T7-T8 with severe spinal cord compression. Intraoperatively, the disc was found fused to the dura and removal caused a large ventrolateral dural dehiscence. CSF diversion and direct repair were attempted unsuccessfully, so a salvage procedure with a rotational pedicled latissimus dorsi flap was performed. The patient's latissimus dorsi was exposed and resected from attachments, maintaining thoracodorsal blood supply, while removing thoracodorsal innervation. The flap was then rotated into the previous corpectomy site. The dural defect was repaired with a sealant patch, overlayed with a parietal pleural flap and the latissimus dorsi flap. By the patient's last follow-up, he had full functional independence at home. We present a surgical case highlighting the challenges of managing postoperative CSF-pleural fistula occurring after giant calcified thoracic disc removal and the successful use of a novel rotational latissimus dorsi flap to definitively repair the fistula after unsuccessful primary interventions.

ESGO Quality Indicators for Surgical Management of Cervical Cancer: An Audit of Compliance of a Tertiary Care Center

Objective This article assesses the compliance of surgical management of carcinoma cervix, to the quality indicators for treatment put forth by the European Society of Gynaeacological Oncology (ESGO), at a tertiary care center. Methods This is a retrospective analysis and audit of data collected from electronic medical records of patients with carcinoma cervix who underwent surgical management in the department of gynecologic oncology from June 1, 2017 to May 31, 2020. Results Compliance to all 15 quality indicators under 5 categories was assessed. The first two structural indicators were met. The mean number of parametrectomies was 24 and all were operated by a specialist. With regard to targets addressing overall management, only 46% cases were preoperatively planned in multidisciplinary team meetings and 74% met the target of required preop investigations. There was deficiency in recording pertinent intraoperative details and postoperative pathological information. On assessing the quality of surgical care, there were no postoperative urological fistula, but 18% had involved surgical margins, 16% were upstaged postsurgery, and 15% had recurrence within 2 years. All were counseled about fertility-sparing technique when relevant but only 7% had undergone lymph node staging as per recommendations and 51% had received adjuvant chemoradiation. Conclusion This audit revealed that the department did not meet the ESGO quality standards published in 2020. The department has implemented structural and procedural changes to meet these standards and a plan to continuously assess compliance to the same.

Ten years’ experience of vacuum systems in treatment of complicated postoperative wounds of various etiologies

Objective: increase effectiveness of wounds treatment after various etiology by using VAC.Materials and methods: study included 128 patients with surgical infection. Specter of operations is presented: pilonidal cyst excision — 40 (31.2%), sternomediastinitis — 23 (18%), mesh hernioplasty — 16 (12.5%), laparotomy — 15 (11.7%), emergency laparotomy — 7 (5.5%), traumatology paraimplant complications — 7 (5.5%), abdominoplasty — 7 (5.5%), postoperative esophageal fistulas — 6 (4.7%), decubital ulcers — 4 (3.1%), mammoplasty — 3 (2.3%).Results: duration of VAC-therapy averaged 22.1±0.26 days. Systemic inflammatory reaction noted in 43 (33.6%) patients. Granulation tissue on 8th day of treatment noted in 98 (76.6%) cases. Microscopically, on day 8 of treatment, inflammatory-regenerative cytograms were detected in 104 (81.3%) patients. Over the course of 16 days, wounds decreased by 62.1±2.5% in all observations. In 47 (36.7%) cases, secondary sutures were applied, in 30 (23.4%) — grafting. A month later, healing was noted in 106 (82.8%) patients. Complications (wound bleeding) were noted in 7 (5.5%) patients. Reoperations were performed in 11 (8.5%) patients. Period of complete healing was 29.3±0.4 days.Conclusions: vacuum therapy is an effective way to treat wounds in purulent surgery. Time of complete reparative regeneration of wound and period of expensive inpatient treatment are reduced.