Previous Fistula Research Articles

Risk factors for developing residual stress urinary incontinence after vesico-vaginal fistula repair: a retrospective cohort study

Background : Previous studies have identified predictors for residual urinary incontinence after successful closure of fistula. However, these findings remain uncertain because the predictors vary from one study to another. The present study aimed to examine the risk of residual stress urinary incontinence after successful closure of vesico-vaginal fistula (VVF).Materials and Methods : We conducted a multicenter retrospective cohort study over 07-years period, from 1st January, 2010 to 31 December, 2016. We included women who underwent VVF repair in one of the seven fistula centers. At three months postoperatively, a cough test was performed among patients who had their fistula successfully closed. The predicted outcome was the urinary continence status after sussessful closure of the fistula and was categorized as (Residual stress urinary incontinence and No Residual stress urinary incontinence). Multivariable binary logistic regression model was performed to analyze association between outcome and predictors.Results : Overall fistula closure rate at 3 months was 88.6% (404/456). Of the patients who had their fistula successfully closed, 16.3% (66/404) experienced a residual stress urinary incontinence. Risk factors for residual stress urinary incontinence in univariate analysis were : urethro-vesical junction involvement, circumferential fistula, Goh type 3, fistula size greater than 3cm, previous fistula repair, urethra involvement. Three independent predictors have been identified : urethro-vesical junction involvement, previous fistula repair and type 3 of Goh’s classification.Conclusion : This study showed that the rate of residual stress urinary incontinence is high in our setting. The involvement of sphincteric mechanism is the main predictor.

Is there an association between arteriovenous fistulas and axillary artery aneurysms? A report of two cases

IntroductionAxillary artery aneurysms are rare vascular conditions that can present with various clinical manifestations, including neurological deficits and vascular compromise. While the underlying pathophysiology remains complex and multifactorial, potential associations with trauma, arteriovenous fistula formation, and atherosclerosis have been reported.Presentation Of Case.Two male patients, aged 33 and 38, with a history of kidney transplantation and previous arteriovenous fistula (AVF) presented with symptoms of upper limb ischemia and neurological compromise. Imaging revealed large axillary artery aneurysms. Open surgical repair was performed for both cases. Two weeks after discharge, one patient showed good pronation and supination with mildly limited extension. The other patient's wrist drop gradually improved with physiotherapy. DiscussionMultifactorial pathophysiology encompassed altered blood flow dynamics, inflammation, and the underlying vascular pathology. Chief complaints and prior vascular interventions contributed. Open surgical repair was preferred to endovascular approaches, achieving favorable outcomes. ConclusionAxillary artery aneurysms in patients with a history of AVF are rare but potentially serious complications. The cases highlight the complexity of axillary artery aneurysms and the need for careful evaluation and surgical intervention This strategy is crucial to prevent potential complications and optimize patient outcomes. Further research is needed to elucidate the precise pathophysiology and the potential association between AVF and the subsequent development of axillary artery aneurysms. Increasing awareness among surgeons could enable earlier detection of aneurysms, thereby reducing the risk of complications.

Predictive Factors for Recurrence of Fistula-in-Ano After Surgery: A 10-year Experience in a Single Center Study

OBJECTIVE This study aimed to evaluate the recurrence rate of fistula- in-ano treatment and factors associated with recurrence. METHODS A retrospective cohort study was performed of cryptoglandular-cause fistula-in-ano patients who underwent surgery between January 2010 and June 2020. Cox’s regression analysis was used to identify predictive factors for recurrence FIA. RESULTS The study included 282 patients of whom 233 (82.6%) were male, 76 (27.0%) had previous anal fistula surgery, 77 (27.3%) had a complex type of fistula, 72 (25.5%) were high transphincteric, 3 (1.0%) were suprasphincteric, and 2 (0.7%) were extrasphincteric. Five types of operations were performed: 106 (37.6%) fistulotomies, 43 (15.2%) fistulectomies, five (1.8%) setons, six (2.1%) endorectal advancement flaps (ERAF), and 122 (43.3%) ligations of the intersphincteric fistula tract (LIFT). The recurrence rate was 20.1% (57 patients) among whom 54 (94.0%) were detected at follow- up within 12 months, 2 patients were detected in the second year, and 1 patient was detected in the third year. Four independent factors associated with the recurrence of FIA after surgery were identified: female gender (HR 2.67; 95% CI 1.34-5.34), BMI >25 kg/m2 (HR 2.47; 95% CI 1.38-4.44), complex type of fistula (HR 2.02; 95% CI 1.02-3.97), and anterior opening (HR 2.14; 95% CI 1.12-4.10). Compared to the LIFT procedure, fistulotomy was the protective factor (HR 0.12; 95% CI 0.03-0.46) while ERAF had a higher rate of recurrence (HR 6.12; 95% CI 1.87-20.03). CONCLUSIONS Patients with high BMI and female patients should be advised of the higher chance of recurrence after anal fistula surgery. More complex fistula-in-ano and sphincter-preserving surgery was also associated with a higher recurrence rate. The complete healing of the surgery should be monitored for two years after surgery. KEYWORDS predictive factors, recurrence, fistula-in-ano, anal fistula

Chronic schistosomiasis infection and obstetric fistula repair outcomes in Lubango, Angola: A retrospective chart review

AbstractObjectiveTo assess the association between chronic schistosomiasis infection, determined by bladder biopsies, and vesicovaginal (VVF) repair outcomes at an urban hospital in Angola. Other objectives were to quantify the prevalence of chronic schistosomiasis among patients with VVF and to assess agreement between pelvic X‐rays and bladder biopsies for chronic schistosomiasis diagnosis.MethodsIn this retrospective chart review, data were collected on patients who underwent VVF repair between 1 June 2022 and 30 November 2022 including: age, number of previous fistula repairs, Goh classification of fistula, X‐ray and biopsy results, fistula repair outcome, perioperative complications and postoperative incontinence. Age and number of previous repairs were described using means with standard deviations. Goh classification, X‐ray and biopsy results, fistula repair outcome, perioperative complications, and postoperative incontinence were described using frequencies. Parametric and nonparametric tests and Cohen's κ were calculated using R software and Excel.ResultsOf the 76 charts retrieved, 60 met inclusion criteria. The overall fistula repair failure rate was 26.7% (n = 16). There was no difference in the fistula repair failure rate between those with (26.9%) and without (26.5%) evidence of chronic schistosomiasis infection (χ2 = 2.33 e‐31, 95% confidence interval [CI]: −0.30, 0.28). The prevalence of chronic schistosomiasis was 43.3%. There was no agreement between X‐ray and biopsy in diagnosing chronic schistosomiasis infection (Cohen's κ = 0.23, 95% CI: −0.001, 0.47).ConclusionThere was no difference in the chance of fistula repair failure between those with evidence of chronic schistosomiasis infection and those without.

#2143 Unveiling key factors on arteriovenous fistulas maturation—a prospective observational study

Abstract Background and Aims The incidence of patients starting haemodialysis is increasing. While Arteriovenous Fistula (AVF) stands as the preferred vascular access method, a significant proportion of AVFs experience primary failure, with rates ranging from 20% to 65%. Moreover, around 50% require reintervention due to delayed maturation, resulting in increased costs and patient morbidity. Understanding the factors involved and their influence on AVF development is paramount. This analysis aims to improve the preoperative decision-making process, advocating for a personalized patient approach, thereby increasing the likelihood of success. Method A prospective observational cohort study that included patients with chronic kidney disease either on dialysis or in the pre-dialysis stage. The study enrolled a total of 140 patients attending a multidisciplinary team appointment (including a vascular surgeon and a nephrologist) at a Tertiary Hospital Centre during the first semester of 2023, of whom 98 patients were included. Demographic characteristics, comorbidities, and vascular parameters observed through ultrasound underwent a comprehensive analysis. The newly formed fistulas were then thoroughly reassessed for maturation using both physical and ultrasound examinations. Results The cohort comprised 56.1% male, with a mean age of 71.06 ± 12.51 years. Among the newly formed fistulas, there were 35.7% (n = 35) radiocephalic fistulas, 46.9% (n = 46) brachiocephalic fistulas, and 17.3% (n = 17) brachiobasilic fistulas. Out of the total 98 AVFs, 59.2% (n = 58) AVFs were maturate and 11.22% (n = 11) AVFs had delayed maturation and were proposed for surgery or angiography procedure. Primary failure occurred in 29.6% (n = 29) AVF, with 42.9% (n = 15) occurring in the forearm, and 22.2% (n = 14) in the upper arm. The major cause of primary failure was thrombosis, accounting for 93.1% (n = 27) of cases. The analysis unveiled that the absence of immediate post-operative thrill, forearm AVFs and previous fistula failure were associated with a higher likelihood of AVF primary failure and non-maturation. Conversely, a larger vein diameter was linked with a reduced likelihood of AVF primary failure, with a Youden Index-derived cut-off of 4.25 mm, with 40.9% sensitivity and 86.2% specificity (p < 0.05). No other clinical or ultrasound factors exhibited a statistically significant impact. Conclusion This study sheds light on the challenges faced in AVF maturation due to a high incidence of primary fistula failure and a maturation rate that only slightly surpasses 50%. A larger vein diameter emerges as a significant predictor of AVF maturation. Although the cut-off point for vein diameter is frequently cited as 2 mm, this value often varies in the literature. This study underscores the importance of considering higher vein diameters, but, more importantly, it suggests that establishing a rigid and uniform cut-off for all centres may not be beneficial. It is crucial to recognize that the optimal vascular characteristics may vary based on the unique circumstances of each centre and the specific needs and features of each patient. The lack of association between demographic parameters and comorbidities with primary failure, juxtaposed with the evidence of more susceptible patients to consecutive primary failure, underscores the need for further studies to explore the unique individual circumstances that may account for this phenomenon.

Genitourinary Fistula: 5 Years' Experience of Five Referral Centers in Iran.

Genitourinary fistula is a devastating ailment that has an impact on women's physical health, mental health, emotional health, and financial security. The management of genitourinary fistula depends on the type, size, and duration of fistula formation. The purpose of this study is to report the features of genitourinary fistula in Iranian women and our experience in the management of fistula. Retrospective chart reviews of 283 patients were performed to determine the cause of the fistula, prior repairs, tissue interposition, and the success rate. The operation was considered successful if the patient did not have any urine leakage during the observation time. The mean (SD) age of women was 49.51 (19.39; range: 21-70) years, Of these, 137 (52.9%) had a history of previous genitourinary fistula surgery. The average fistula was 1.53 (0.041) cm in size. The median (interquartile range) operation lasted 70 (15) min. The success rate after fistula repair was 91.5%. The typical follow-up period lasted 13.26 (range: 1-88) months. Forty-three (15.2%) patients had a big fistula (>2.5cm) and 4 patients (1.4%) had a history of pelvic radiation therapy, among other reasons for failure. After a second repair, all patients' initial failures were resolved. There were no significant complications, as classified by Clavien-Dindo class 2 or greater. Additionally, there were no bowel, ureteral, or nerve injuries. Our patients with genitourinary fistula had a successful outcome following repair techniques, without any significant morbidity or mortality.

Factors Affecting the Early Maturation of Arteriovenous Fistulae Created at a Tertiary Centre in Oman.

This study aimed to determine the risk factors associated with the failure of arteriovenous fistulae (AVF) maturation. This retrospective cohort study was conducted from January 2014 to December 2018 in Sultan Qaboos University Hospital, Muscat, Oman. Patients were followed-up 3 months after surgery, and their electronic medical records were accessed for demographic and clinical data. Univariate analysis was used to determine the risk factors associated with early AVF maturation and multivariant analysis was used to determine the predictive factors for AVF failure. A total of 269 patients were included. Female gender was a significant factor affecting AVF maturity (P = 0.049), while age (P = 0.626), diabetes (P = 0.954), hypertension (P = 0.378), dyslipidaemia (P = 0.907), coronary artery disease (P = 0.576), cerebrovascular accident (P = 0.864), congestive heart failure (P = 0.685), previous central venous catheterisation (P = 0.05), fistula type (P = 0.863) and fistula site (P = 0.861) did not affect AVF maturation. Binary logistic regression showed that all the risk factors were insignificant. Failure of early AVF maturation affected 11.5% in the cohort. This study found that the proportion of early AVF maturation at our hospital is at par with that in the international literature. Failure of AVF maturation was significantly associated with the female gender. These findings can help nephrologists and vascular surgeons prognosticate AVF maturation rates. However, a larger study is needed for definitive conclusions.

Pedicled pericardial patch in tracheal reconstruction in children – Novel technique to provide vascularized tissue for salvaging difficult airways

BackgroundManagement of large central airway defects are often complex. Children who present with these defects have multiple co-morbidities or have had previous surgeries. Surgical options include various tissue cover for these defects without longer term benefits. Vascularized autologous pericardial patch offers a better solution to these defects by providing vascularity and potential for remodelling in future. Methods41 children (M:F of 24:17) were operated for large trachea-bronchial defects between January 2015 and August 2022. The median age of was 12 months with median weight of 8.9 kg (IQR 3.3 kg–17.7 kg) Causes leading to the central tracheal defect include failed repair of previous trachea-oesophageal fistula (TOF) (n = 21) and acquired fistula due to button battery injury (n = 11). Surgical repair consisted of autologous pedicled pericardial patch repair for the airway defect under cardiopulmonary bypass. ResultsThere were two operative deaths related to extensive sepsis and necrosis of reconstructed trachea. Four children had further reoperation with additional patch. Bronchoscopy was used as surveillance in all these children, with use of airway stents (biodegradable stent) in 9 children. The median ventilation time was 8 days, with tracheostomy being needed in 5 for long term support. ConclusionsAutologous pericardial patch is a versatile technique and can be used to salvage large tracheal defects when other method have failed or not feasible. Tracheomalacia at the site of repair could be managed with biodegradable stents. Vascularity and ciliary function of the patch still needs to be evaluated.

Obstetric fistula repair failure and its associated factors among women who underwent repair in sub-Saharan Africa. A systematic review and meta-analysis.

Obstetric fistula repair failure can result in increased depression, social isolation, financial burden for the woman, and fistula care programs. However, there is limited, comprehensive evidence on obstetric fistula repair failure in Sub-Saharan African countries. This systematic review and meta-analysis aimed to determine the pooled prevalence of obstetric fistula repair failure and associated factors among women who underwent surgical repair in Sub-Saharan African countries. To identify potential articles, a systematic search was done utilizing online databases (PubMed, Hinari, and Google Scholar). The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guideline was used to report the review's findings. I2 test statistics were employed to examine study heterogeneity. A random-effects model was used to assess the pooled prevalence of obstetric fistula repair failure, and the association was determined using the log odds ratio. Publication bias was investigated using the funnel plot and Egger's statistical test at the 5% level of significance. Meta-regression and subgroup analysis were done to identify potential sources of heterogeneity. The data were analyzed using STATA version 17 statistical software. A total of 24 articles with 9866 study participants from 13 Sub-Saharan African countries were included in this meta-analysis. The pooled prevalence of obstetric fistula repair failure in sub-Saharan Africa was 24.92% [95% CI: 20.34-29.50%]. The sub-group analysis by country revealed that the highest prevalence was in Angola (58%, 95% CI: 53.20-62.80%) and the lowest in Rwanda (13.9, 95% CI: 9.79-18.01%). Total urethral damage [OR = 3.50, 95% CI: 2.09, 4.91], large fistula [OR = 3.09, 95% CI: (2.00, 4.10)], duration of labor [OR = 0.45, 95% CI: 0.27, 0.76], and previous fistula repair [OR = 2.70, 95% CI: 1.94, 3.45] were factors associated with obstetric fistula repair failure. Women who received surgical treatment for obstetric fistulas in Sub-Saharan African countries experienced more repair failures than the WHO standards. Obstetric fistula repair failure was affected by urethral damage, fistula size, duration of labor, types of fistula, and history of previous repairs. Therefore, we suggest policy measures specific to each country to provide special attention to the prevention of all risk factors, including poor nutrition, multiparty, obstructed labor, and maternal age, which can result in conditions like large fistulas, urethral damage, and repeat repair, in order to reduce obstetric fistula repair failure.

¿Es posible alcanzar el objetivo de catéteres propuesto por las guías? Razones que determinan el uso de catéter en pacientes prevalentes en hemodiálisis

IntroductionDespite the recommendations of the clinical guidelines, the percentage of central venous catheters (CVC) continues to be above the recommended standards. We do not know whether the increasing use of catheters is due to unavoidable or avoidable factors and, in the latter case, it would be in our power to modify these results.The aim of this study was to analyze the causes that condition the use of CVC in a prevalent hemodialysis (HD) population in order to identify those modifiable factors on which to act in order to achieve the objectives of the guidelines. MethodsRetrospective, descriptive and observational study in all prevalent patients on chronic hemodialysis belonging to seven hemodialysis centers in Madrid, Castilla y León and Galicia in a cross-sectional study carried out in June 2021 (637 patients). The following were analyzed: age, sex, nationality, etiology of CKD, the vascular access with which they started hemodialysis, the number of previous failed arteriovenous fistulas (AVF), time since the start of HD, time since the placement of the CVC for the first time, the situation with respect to surgery and the causes of being a CVC carrier. In patients whose cause was refusal to undergo AVF, patients were asked about the cause of the refusal by directed questioning. ResultsOf the 637 patients studied, 255 (40%) had a CVC, 346 had an AVF (54.3%) and 36 (5.7%) had a prosthesis. Of the 255 patients with CVC, 20.4% (52 patients) were awaiting vascular access (AVF/prosthesis), 10.2% (26 patients) had an AVF but could not be used and 69.4% (177 patients) were not considered candidates for surgery (due to vascular surgery (16.9%; 43 patients), nephrology (16.5%, 42 patients) and patient refusal (36%; 92 patients). The most frequent cause for refusal of AVF was fear and patient preference. One of the most important factors associated with CVC use in prevalent patients was having started hemodialysis with a CVC. The greatest use of CVC at the start of HD was significantly associated with having more than one AVF performed or starting HD urgently and not having been followed up and evaluated in the ACKD consultation. ConclusionsThere is a high percentage of patients with a central venous catheter due to modifiable causes, which makes it necessary to systematically evaluate the process of creating AVF in order to enhance the planning, creation and maintenance of vascular access from the ACKD clinic, and to achieve the objective of the guidelines.

Outcomes of Arterio-venous Fistula Reconstruction in Chronic Kidney Disease Patients Presenting in Tertiary Care Hospital in Eastern Nepal

Introduction: Renal Replacement Therapy is the treatment modality for the chronic kidney disease (CKD) which ranges from hemodialysis, peritoneal dialysis to the renal transplantation, the latter being the best form of treatment. But, renal transplantation is available at limited centers only so hemodialysis is the most commonly used treatment modality of chronic kidney disease which requires a vascular access. But there are limited vascular surgeons in the region so most of the arterio-venous (AV) fistulas are reconstructed by Urologist/Surgeons exposed to vascular surgery during their residency/training period. Objectives: To know the factors influencing the site selection, to assess the success rate and to document the complications of AV fistula reconstruction. Methodology: This is a hospital based prospective observational study conducted in the Birat Medical College – Teaching Hospital, Morang, Nepal from June 2021 to May 2022. We included the CKD patients requiring vascular access for hemodialysis with Color Doppler available for vascular mapping. Patients with brachial sites previously used and without Color Doppler were excluded from the study. AVF was reconstructed under local anesthesia and outcomes were recorded. Results: Thirty one patients of CKD underwent AVF reconstruction over the study period. Male and female ratio was 1.33 (57% and 43%). The mean age was 42.14 ± 11.34 years (Range 26-65 years). The mean diameter of radial artery (RA) and cephalic vein (CV) at wrist were 1.92 ± 0.56mm and 1.91 ± 0.20 mm respectively. Similarly, the mean diameter of brachial artery (BA) and CV at elbow were 3.66 ± 0.87mm and 3.57 ± 0.55 mm respectively. The fistula reconstructed were Lt RC (radio-cephalic) – 50% (14), Lt BC (brachio-cephalic) -35.71% (10) and Lt BB ( brachio-basalic) - 14.29% (4) respectively. Complications occurred in 4 cases (14.28%). Conclusion: Selection of type of AVF creation is influenced by the vessel diameter as well as previous fistula surgery status and AVF access for hemodialysis has adequate patency with acceptable complications.

Predictive Factors Affecting Recurrence of Anal Fistula after LIFT Procedure.

To determine the predictive factors affecting the recurrence or persistence of anal fistula of demographic and technical variables. Descriptive study. Department of General Surgery and Radiology, Private Ortadogu Hospital General, Turkey, between 2014 and 2020. The recurrence, persistence, and complication rates of 176 patients who underwent LIFT were compared with demographic and technical data by multivariate logistic regression analysis. Inclusion criteria were patients with anal fistula cryptoglandular origin. Exclusion criteria included patients with intersphincteric fistula, rectovaginal fistula, abscess, pilonidal sinus fistula, and inflammatory bowel disease. Recurrence was defined as the opening of a fistula that persisted after 3 months. The mean age was 38.6±9.0 years. The mean BMI was 31.9±5.7 Kg/m2. There were no statistically significant differences between the two groups concerning, age, the complexity of fistula tract(s), the surgical technique of suture versus ligation, operation time, and seton placement duration. Twenty-three patients had previous fistula surgery. Twenty-One patients had previously required seton drainage. Higher BMI, being male, having a prior fistula surgery, and having a height IFO >15 were independent risk factors for recurrence (OR =1.28, 5.69, 23.39, and 15.38 respectively). Higher BMI, male gender, having a prior fistula surgery, and having a height IFO >15 were independent risk factors for recurrence. LIFT, Anal fistula, Recurrence, Wexner incontinence score (WIS), Male, Prior fistula surgery, height 1FO.

S2265 A Rare Case of Esophageal Carcinoma After Tracheoesophageal Fistula Repair

Introduction: Tracheoesophageal fistula (TEF) constitutes one of the commonest congenital anomalies with an incidence of roughly 1 in 3500 births with treatment consisting of surgical correction in very early life. Chronic complications can include esophageal stricture, dysphagia, gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal cancer. While rare, these patients do have an increased risk of esophageal carcinoma attributable to chronic GERD leading to ongoing mucosal disruption. Sparce data on esophageal cancer after TEF repair appears to show an increased risk of this event occurring after 40 years of age. Case Description/Methods: The patient is a 32-year-old man with a past medical history of Cystic Fibrosis, GERD, osteoporosis, and tobacco use, and a past surgical history significant for Tracheoesophageal fistula repair. The patient presented to a primary care physician with complaints of dysphagia. He reported dysphagia only to liquids that started 2 months before presentation. The dysphagia was gradually progressed to solids. He was referred to gastroenterology, and an EGD was performed showing a single traversable mass measuring 5 cm in the esophagus (20 cms. from incisors) covering one-quarter of the circumference, and cold forceps biopsy was performed. The EGD also revealed signs of the previous tracheoesophageal fistula repair and mild generalized atrophic mucosa. Biopsies taken from the esophagus and stomach were sent for pathology. Pathology from the esophageal biopsy came back positive for moderately differentiated Squamous cell carcinoma and gastric biopsy revealed chronic gastritis with complete intestinal metaplasia. The patient was referred to oncology and underwent a PET scan which revealed the esophageal malignancy and bilateral pulmonary nodules. The patient was started on chemoradiation therapy and follows up with oncology regularly (Figure). Discussion: This case describes the importance of continuity of care during the transition from pediatrics to adult care in the field of gastroenterology in patients with a history of TEF repair, given the patient’s young age. While it appears esophageal cancer after TEF repair is rare, there should be an investigation into guidelines for adequate screening in this disease process.Figure 1.: Histopathology and endoscopic images.

Detection and analysis of intestinal flora diversity in patients with complex anal fistula

Objective: To explore the possibility that the intestinal flora profile in complex anal fistula patients is different to that of healthy controls. This was assessed by sequencing of 16S rDNA in fecal samples from cohorts representing these populations. Methods: Fecal samples were collected from 30 complex anal fistula patients and 30 matched healthy controls. Patients were included if they met the diagnostic criteria of cryptoglandular anal fistula and had exhibited symptoms for more than 3 months. Complex anal fistula is diagnosed under the following circumstances: if the fistula in question spans 2/3 or more of the diameter of the anal sphincter; if there are more than two external orifices or fistula tracks; or if recurrence is observed after previous anal fistula surgery. Patients were excluded if there were comorbities including inflammatory bowel disease (as assessed by colonoscopy), chronic diarrhea, chronic constipation, diabetes, gastrointestinal malignancies, liver/ kidney dysfunction, or cognitive impairment. Patients whose anal fistulas were caused by Crohn's disease, trauma, special infections (such as actinomycosis and tuberculosis) were also excluded, as were those who had used antibiotics, prebiotics, or probiotics that may affect intestinal microecology in the month prior to the study. Total bacterial genomic DNA was extracted by PCR amplification of the V4 hypervariable region of the 16S rRNA sequences. High-throughput sequencing and data analysis were performed on the Illumina Miseq platform. Finally, operational taxonomic unit (OTU) clustering, alpha diversity and LEfSE data analysis were carried out. The larger the Chao or ACE index is, the higher the species abundance of the microflora is expected to be. Similarly, a smaller value for the Simpson index or a larger value for the Shannon index indicates greater microflora diversity. There was no statistically significant difference in gender, age, body mass index (BMI), drinking history, or smoking history between the two groups (P>0.05), indicating that they were comparable. Results: The α-diversity analysis including ACE, Chao, Shannon and Simpson indexes indicated a richer diversity of intestinal microflora in complex anal fistula patients than in healthy controls. In both patients and controls, OUT cluster analysis demonstrated that 93.4%±32.0% and 87.4%±41.2% of sequences were from Firmicutes and Bacteroidetes spp., respectively. On a genus level, samples from anal fistula patients showed a greater abundance of Prevotella spp. (4.9%±7.4% vs. 0.1%±1.1%, P<0.001), Megamonas (3.9%±8.2% vs. 0.5%±4.2%, P<0.05) and Lachnospira (2.6%±5.7% vs. 0.1%±3.4%, P<0.05), while showing a lesser abundance of Proteobacteria spp. (0.02%±4.2% vs. 9.3%±14.4%, P<0.01), Enterococcus (0.02%±2.3% vs. 9.3%±19.6%, P<0.05), Bacteroides (24.7%±9.9% vs. 29.8%±9.1%, P<0.05) and Klebsiella (0.4%±4.2% vs. 3.9%±7.3%, P<0.05) compared with healthy controls. Intestinal flora diversity in the complex anal fistula group was richer than in controls, as indicated by a higher ACE index (293.30±44.00 vs. 218.75±33.83, t=102.069, P<0.001), a higher Chao index (318.40±41.99 vs. 250.00±46.38, t=77.818, P=0.028), a higher Shannon index (3.36±0.29 vs. 2.43±0.34, t=9.657, P=0.001), and a lower Simpson index (0.103±0.013 vs. 0.131±0.013, t=5.551, P=0.046). LDA effect size analysis suggests that the main strains of Veillonellaceae, Selenemondales and Negativicutes, which all belong to the phylum Firmicutes, have the greatest influence on the above difference (LDA>4). Conclusions: The diversity of intestinal flora in patients with complex anal fistula is greater than in healthy controls, suggesting that these bacteria or their metabolites may be involved in the occurrence and development of anal fistulas.

Initial Experience of A New Technique for Sphincter Preserving Anal Fistula Repair Using a Radial Emitting Laser Probe

Background: Fistula in ano has been a troublesome pathology to both patients and surgeons throughout surgical history. Several techniques have been described for the management of fistula-in-ano but all carry their own risks of recurrence and incontinence. To overcome this problem, a novel technique called distal laser and proximal ligation (DLPL) was developed using a newly invented radial emitting laser probe. This study is aimed to see the outcome in terms of recurrence and incontinence of newly described technique. Materials and methods: This prospective study was conducted in a single private institute in The Dhaka city between January 2018 and July 2019. All patients with fistula in ano of cryptoglandular origin are included in this study and evaluated in outpatient department. Fistulogram done beforehand only those with recurrent fistula tract. Patients having fistula with chron’s disease, abscess cavity, side tract or malignancy were excluded from this study. A total of fifty two (52) male patients were selected. All patients were followed up and Results were evaluated. Results: The median age of the patients was 46 years (range 22-60 years), 39 patients were primary fistula, 9 patients were recurrent fistula with history of previous fistula surgery and 4 patients were bilateral anal fistula. All patients underwent DLPL (distal laser proximal ligation) operation by radial emitting Laser probe. The mean follow up was 11 months (range 6-24 months). Forty three out of 52 fistulas showed primary healing (82.6 %) without any problem of anal incontinence. Only 6 patients developed recurrent fistula (11.53%) within 3 months of Surgery. Conclusion: The use of a diode laser source and a radial emitting laser probe in addition to conventional surgery in treating different types of anal fistula for selected group of patients is a very promising new technique in sphincterpreserving anal fistula repair. J Bangladesh Coll Phys Surg 2022; 40: 153-158

The outcomes of a novel two-stage proximal brachial artery to proximal basilic/brachial vein arteriovenous graft extension for dialysis access.

We describe a technique to mature a basilic/brachial vein in the mid-arm in preparation for a second stage loop proximal brachial artery to basilic/brachial vein arteriovenous graft (BBAVG). This can occur after a failed basilic/brachial vein transposition or a lack of adequate veins in the distal arm. This allows a mature vein to be used in an end-to-end configuration as an outflow to a BBAVG while preserving proximal vessels for the future. This single-center retrospective study was performed from 2015 to 2021, including 104 AVG patients divided into three groups: (1) Patients who failed a basilic vein transposition and had an enlarged vein suitable for an AVG outflow; (2) Patients who had a small caliber basilic/brachial vein after the transposition, requiring a mid-arm brachial artery to brachial/basilic arteriovenous fistula (AVF) creation with a subsequent AVG extension; (3) and lastly, patients who had no distal arm veins available and required a primary brachial artery to basilic/brachial AVF with AVG extension. A survival analysis was performed looking at time to loss of primary and secondary patency, calculated with Kaplan-Meier estimates and Cox regression models adjusted for covariates. The median follow-up time was 11 months (IQ = 11-30 months). The survival analysis showed 28% lost primary patency at a median time of 9 months, and 14% lost secondary patency at a median time of 61 months. Overall secondary patency of the vascular access measured at 12 months was 85.6%. Loss of primary (p = 0.008) and secondary patency (p = 0.017), as well as patency during the first 12 months (p = 0.036), were all significantly associated with increased age when adjusting for covariates. Our results suggest that the graft extension technique using a mature vein from a previous fistula can result in reliable and durable access. This is important for patients with limited access for hemodialysis, as the axillary vein is preserved for future use if needed.

True Brachial Artery Aneurysm in Patients with Previous Arterio-Venous Fistula Ligation and Immunosuppressant Therapy for Renal Transplantation: Case Report and Literature Review.

Background/Objective: Brachial artery aneurysm (BAA) is a serious complication in patients with previous arterio-venous fistula (AVF), renal transplantation (RT), and immunosuppressive regimens. Until now, there has been no standard of care for these patients, especially for patients undergoing chronic dialysis and immunosuppressive treatment. The aim of this study was to investigate data from the literature regarding these patients and to suggest recommendations for the best approach to their treatment. Methods: A review of the literature was performed by searching the PubMed database in the English language. The review was accompanied by two case reports. A total of 24 articles with different variables—demographics, renal transplantation, aneurysm size, and type of surgery—were subjected to the review. In addition, two cases are reported. Conclusion: This review suggests that the best treatment for these patients is open surgery, with aneurysmectomy and graft interposition. Results: All patients had RT. The age of patients ranged from 26–77 yo, with a male predominance. The majority had an AVF ligated after RT. The main clinical symptoms were pain, swelling, and pulsatile mass (66%). All patients, except one, were treated through open surgery. The first option for treatment was reversed saphenous vein graft interposition (36%), followed by ePTFE graft (16%).

Human Amniotic Membrane for the Treatment of Cryptoglandular Anal Fistulas.

Background: Implantation of the amniotic membrane and their derivatives can have a beneficial effect on tissue repair and regeneration. We report for the first time the implant of an amniotic membrane in a patient affected by cryptoglandular anal fistula. Methods: A patch of human amniotic membrane was implanted in a female patient affected by an anterior transphincteric fistula. Following an accurate curettage of the anal fistula, the cryopreserved amniotic membrane was thawed and then washed in the operating room; one side of the membrane was transfixed with a resorbable suture thus creating an implantable fusiform patch. The membrane was subsequently implanted into the fistula tract from the external to the internal opening. The inner and outer parts of the membrane were then sutured to the internal and external fistula openings. Results: No intraoperative or postoperative complications occurred. The patient was discharged one day after the procedure after an uneventful hospitalization. At the 1-week, 1- and 3-month follow-up visits no pain (VAS 0) was referred by the patient and no inflammation was evident at the level of the previous external fistula opening. Conclusions: The implant of human amniotic membrane in a patient affected by cryptoglandular anal fistula was safely and easily performed. Moreover, future studies to assess the efficacy in the long-term follow-up are needed.

Management of anorectal reverse sinus diseases

Background: It is usual to face complexities in perianal abscesses, fistulas and perianal sinus diseases. Perianal sinus indicates to a blind tract in the perianal area with a discharging opening externally. We selected patients with perianal blind tracts with intra-luminal discharging openings (Reverse sinus) without any visible external opening. Treatment policy was altered accordingly.Methods: We excluded sinuses with external discharging openings, fistulas, hemorrhoids, simple fissures and malignant pathologies. Study was conducted in 64 patients at city hospital, sector-8 Chandigarh. Ours is a hospital based descriptive study conducted between January 2020 to June 2021.Results: Patients with reverse sinuses were divided into four groups based on their etiology. Chronic fissures with discharging opening at 6o clock position (18 cases). Primary anorectal abscesses with intraluminal opening and without any external opening (14 cases). Primary operated anorectal abscess with reverse sinus and no external opening (20 cases). Patients having previous fistula surgery presenting with reverse sinus (12 cases). Treatment in general was tricky yet local healing and long-term results were very good.Conclusions: Once the internal opening is located retrograde probing was done. Perianal nick-incision over the tip of the probe helped to convert sinus into fistula. Subsequent fistulotomy was performed. In case of thick Sphincteric chunk loose seton was encircled around the sphincteric muscle. Subsequently the seton was tightened to achieve cutting and healing simultaneously. In cases of failed retrograde probing perianal nick-incision was given to perform usual probing of the fistula made.

Polypropylene suture as a seton in recurrent fistula-in-ano in lower socioeconomic class-a good option

Background: Recurrent anal fistulas after previous fistula surgery are a unique problem that typically necessitates more anal surgical experience to address the cause of recurrence. The present study was planned with the objective to determine the outcomes of the polypropylene suture as a seton placement for the treatment of recurrent anal fistula.Methods: Patients between the ages of 20-80 years with recurrent fistula-in-ano with single external opening and with history of previous surgery. Patients with preoperative incontinence, patients with difficult follow-up and who were not ready to participate in the study, patients with fistulas caused by inflammatory bowel disease, malignancy, tuberculosis, or trauma, patients with a horseshoe or multiple fistulas, patients with recurrent fistula-in-ano with multiple external opening, or recurrent fistula-in-ano with diseases like Crohn’s disease, tuberculosis, actinomycosis, malignancy, or high level fistula-in-ano without internal opening, and patients with synchronous anorectal problems such as haemorrhoids were excluded.Results: Post-operative pain was observed in all patients while discharge, bleeding and inflammation were observed in 27, 10 and 8 patients, respectively on day 0. Majority of post-operative symptoms were resolves in almost all patients except, pain and discharge were observed in 2 and 1 patients, respectively on day 7. At 6 months follow-up, incontinence of flatus was found out in 2 patients while no patient had incontinence of faeces.Conclusions: Polypropylene suture as a seton in recurrent fistula-in-ano, in previously operated patient is safe and most acceptable treatment. Ksharsutra is not easily available but polypropylene suture is easily available.