Previous Fistula Research Articles

INTERESFINCTERIAL LIGATION OF FISTULA TRACT (LIFT) FOR PATIENTS WITH ANAL FISTULAS: A BRAZILIAN BI-INSTITUTIONAL EXPERIENCE.

ABSTRACT Background : The best treatment for anal fistula should extirpate infection and promote healing of the tract, whilst preserving the anal sphincter complex and full continence. Aim: To analyze the success rate after a modified technique for ligation of the intersphincteric fistula tract (LIFT) for patients with anal fistulas. Methods: A prospective (observational cohort study) Brazilian bi-institutional experience with a modified (ligation of the intersphincteric fistula tract without excision) LIFT technique was undertaken. A clinical database was settled for the following variables: age, gender, BMI, comorbidities, distance between external orifice and the anus, previous fistula surgery, type of fistula, operative time, intra- and postoperative complications, duration of follow-up, and success rate. Results: Between November 2015 and January 2017, 38 patients with transsphincteric fistulas were operated on using the modified LIFT procedure. Seventeen (44.7%) were men. Median age was 41 (18-67) years. Median BMI was 26.4 (22-38) kg/m2. Five (13.2%) had undergone previous surgery. The fistula was transsphincteric in all cases. Median follow-up was 32 (range, 14-56) weeks. Success was observed in 30 (79%) patients. Conclusions: The LIFT technique without excision of the fistula tract proved to be safe and effective for transsphincteric anal fistulas.

Two-Stage Basilic Vein Transposition: Second Stage Results.

The increasing survival of hemodialysis patients results in the depletion of superficial venous capital justifying the use of the basilic vein. Many groups still prefer an arteriovenous graft due to transposition complexity and the time needed to achieve maturation. In this work we review the results of our series of basilic vein transpositions (BVT). BVTs were performed in two stages: first, creation of the fistula; second, transposition of the vein using three small incisions in the arm. All patients had to have direct arterialization of the basilic vein, therefore, patients with previous ipsilateral wrist fistulas also followed a two-stage protocol. Data were retrospectively revised from all transposition procedures made between September 2005 and November 2012. Patency and complication rates were the primary outcomes evaluated. A total of 276 basilic veins were transposed. Usage rate was 82.2%. 8% (N=22) of the fistulas were never used due to thrombosis. Secondary patency rates at 1 and 2 years were, respectively, 84% and 66.3%. Complications occurred in 61.6% (N=170) of fistulas and 65.9% (N=112) of which had to undergo surgical or endovascular revision. The most frequent complication was vein stenosis (39.7% of late complications, N=92). Albeit its greater technical complexity, the transposed basilic vein represents a hemodialysis access with good patency rates. Complication rates, although high, are less than those of CVC or prosthetic grafts. These results support the use of the transposed basilic vein as hemodialysis access after the brachiocephalic fistula.

A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT).

Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive technique for the treatment of fistula-in-ano (FIA). This review aimed to search the literature for the outcome of VAAFT regarding the recurrence and complication rates of the technique. A systematic literature search was conducted in compliance with the PRISMA screening guidelines. PubMed/MEDLINE and Scopus were searched for articles reporting the outcomes of VAAFT procedure from inception through April 2017. The main outcomes were patients' characteristics, technical aspects, operation time, recurrence, and complication rates. Eleven studies (n = 788 patients) were included. The mean age of the patients was 39.5years. 66.5% of patients had high or complex FIA and 18.4% underwent previous fistula surgery. The internal opening of the fistula was detected in 85.7% of patients. The mean operation time was 42 ± 14.2min. The weighed mean rate of detection of internal opening was 93.3%. Recurrence occurred in 112 (14.2%) patients after a median follow-up of 9months. Recurrence rates varied according to method of closure of internal opening from 15.3% after using staplers, 17.7% after suturing, to 25% after advancement flap. The weighted mean recurrence rate across the studies was 17.7%. The weighted mean complication rate was 4.8%. VAAFT may be considered an effective diagnostic tool and a safe method for the treatment of complex and high FIA attaining satisfactory outcome and acceptably low complications. Recurrence after VAAFT may be related to previous fistula surgery and the method of closure of the internal opening.

Video-assisted anal fistula treatment: a high volume unit initial experience.

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton

BackgroundThe optimal surgical treatment for high transsphincteric fistula-in-ano (FIA) should attain complete eradication of the fistulous track and, in the same time, not compromising the anal sphincters. The present study aimed to investigate the predictive factors for recurrence of high transsphincteric FIA after placement of draining seton and to evaluate the efficacy and complications of seton treatment for high cryptoglandular anal fistula. Materials and methodsThis is a retrospective case–control study of patients with high transsphincteric FIA who were treated with seton placement. Variables analyzed were the characteristics of FIA, incidence of recurrence, postoperative complications including fecal incontinence (FI), and the predictive factors for recurrence. ResultsA total of 251 patients (232 males) with high transsphincteric FIA were treated with loose seton placement. Patients were followed for a median period of 16 mo. Recurrence of FIA was recorded in 26 of patients (10.3%) after a mean duration of 12.2 ± 3.9 mo of seton removal. Previously recurrent fistula (odds ratio [OR] = 2.81, P = 0.02), supralevator extension (OR = 3.19, P = 0.01) and anterior fistula (OR = 3.36, P = 0.004), and horseshoe fistula (OR = 5.66, P = 0.009) were the most significant predictors of recurrence. FI was detected in eight patients (3.2%). Female gender (OR = 15.2, P = 0.0003) and horseshoe fistula (OR = 8.66, P = 0.01) were the significant risk factors for FI after the procedure. ConclusionsSignificant risk factors for recurrence of FIA were previous fistula surgery, anterior anal fistula, and presence of secondary tracks or branches as supralevator extension, and horseshoe fistula.

The Deepithelialized Dorsal Tongue Flap for Reconstruction of Anterior Palatal Fistulae: Literature Review and Presentation of Our Experience in Egypt.

The purpose of this study was to present our experience with the closure of challenging palatal fistulae using the deepithelialized dorsal anterior tongue flap. We highlight the efficacy of suturing the tip of the tongue flap to the nasal septum for prevention of flap detachment. Prospective analysis of cleft patients with anterior palatal fistulae repaired by deepithelialized dorsal anterior tongue flap. Institutional center. A total of 30 patients with anterior palatal fistulae in the setting of previous cleft palate or fistula repair. Deepithelialized dorsal anterior tongue flap for treatment of anterior palatal fistulae. Patients had repair using deepithelialized dorsal anterior tongue flap between 2011 and 2014. Patients' photographs and clinical records were collected. The technique of flap harvesting and method of securing it in its position are described in this study. Patients were followed up over a mean period of 13.8 months to check flap viability, competent repair, and donor site function and aesthetics. All patients showed uneventful healing without complications. This technique offered a secure method of palatal fistulae reconstruction. Further research is needed to show this technique's advantages and drawbacks.

A Simple Method for Closure of Urethrocutaneous Fistula after Tubularized Incised Plate Repair: Preliminary Results

BackgroundUrethrocutaneous fistula (UCF) is the most prevalent complication after hypospadias repair surgery. Many methods have been developed for UCF correction, and the best technique for UCF repair is determined based on the size, location, and number of fistulas, as well as the status of the surrounding skin.ObjectivesIn this study, we introduced and evaluated a simple method for UCF correction after tubularized incised plate (TIP) repair.MethodsThis clinical study was conducted on children with UCFs ≤ 4 mm that developed after TIP surgery for hypospadias repair. The skin was incised around the fistula and the tract was released from the surrounding tissues and the dartos fascia, then ligated with 5 - 0 polydioxanone (PDS) sutures. The dartos fascia, as the second layer, was covered on the fistula tract with PDS thread (gauge 5 - 0) by the continuous suture method. The skin was closed with 6 - 0 Vicryl sutures. After six months of follow-up, surgical outcomes were evaluated based on fistula relapse and other complications.ResultsAfter six months, relapse occurred in only one patient, a six-year-old boy with a single 4-mm distal opening, who had undergone no previous fistula repairs. Therefore, in 97.5% of the cases, relapse was non-existent. Other complications, such as urethral stenosis, intraurethral obstruction, and epidermal inclusion cysts, were not seen in the other patients during the six-month follow-up period.ConclusionsThis repair method, which is simple, rapid, and easily learned, is highly applicable, with a high success rate for the closure of UCFs measuring up to 4 mm in any location.

PTU-121 Anorectal Dysfunction in Quiescent Inflammatory Bowel Disease: Is There A Role for Biofeedback Therapy?

Introduction Despite optimal disease control and the absence of objective evidence of mucosal inflammation, symptoms of faecal incontinence (FI), increased stool frequency, urgency and tenesmus secondary to anorectal dysfunction can significantly reduce quality of life (QoL) in Inflammatory Bowel Disease (IBD) patients. Biofeedback therapy (BFT) is an established treatment for FI but its role in IBD patients with Anorectal dysfunction has not been explored. Methods In a retrospective study, we reviewed all patients with IBD referred for Anorectal Manometry (ARM) studies and BFT at our institution between 2009–2014 for FI.1 Data confirming IBD quiescence was recorded with endoscopy, histology, radiography and biochemistry from all subjects. Additionally, IBD phenotypes and therapies, surgical and obstetric histories, baseline FI frequency, QoL scores (rated 0–10), ARM data and Endoanal Ultrasonography results (when available) were recorded. Patients were classified as responders or non-responders to BFT based on symptoms at follow-up. Results Nine IBD patients (median age 53, 7/9 female), with quiescent IBD (6/9 Crohn’s Disease (CD) and 3/9 Ulcerative Colitis (UC)), median baseline FI frequency 11.5/week and QoL score 6, completed in our Gastroenterologist-led BFT programme. In the CD cohort; 1/6 had previous anal fistula repair, 2/6 previous right hemicolectomy with ileal resection and 3/6 crohns colitis. In the UC group; 2/3 patients had proctitis/proctosigmoiditis and the other patient had ileo-anal pouch post-panproctocolectomy. Based on ARM findings; All patients had external sphincter weakness 9/9, whilst 6/9 had internal anal sphincter weakness and 2/9 met criteria for co-existing dyssynergic defecation. Following a mean of 3 BFT sessions; 8/9 (89%) patients reported improvement in FI symptoms with statistically significant improvement in FI frequency compared to baseline (Mann-Whitney U = 0.5, P = 0.003) and 5/9 (56%) reporting no FI episodes. Conclusion Our data in a heterogenous cohort of IBD patients with moderate QoL scores and FI despite disease quiescence, highlights the importance of considering referral for ARM studies after excluding active inflammation. BFT appears to be as effective in IBD patients as it is in non-IBD patients with FI and may have a role in improving QoL in these patients. Reference 1 Vasant D, Solanki K, Sharma R, et al. Ptu-180 predicting outcomes of biofeedback therapy for faecal incontinence – where ‘good’ practice makes perfect. Gut 2015;64:A142. Disclosure of Interest None Declared

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound.

Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS). Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula. There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P=0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P=0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%. The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Obstetric fistula management and predictors of successful closure among women attending a public tertiary hospital in Rwanda: a retrospective review of records.

BackgroundGlobally, 50,000–100,000 women develop obstetric fistula annually. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Among women with fistula seeking care at public health facilities in resource-limited settings, there is paucity of data on quality of care received. The aim of this study was to characterize obstetric fistula among Rwandan women managed at a public tertiary hospital and evaluate for predictors of successful fistula closures.MethodsA retrospective review of records for all obstetric fistula women managed at a public referral health facility between 2007 and 2013 was performed. Patient socio-demographics, obstetric characteristics and fistula repair outcomes data were reviewed. A multivariate logistic regression model was used to analyse for predictors of successful fistula repair outcomes.ResultsA total of 272 women aged between 16 to 78 years and with a mean age of 34.6 years were included. Of these, 93 (34.2 %), 48 (17.6 %), 65 (24 %) and 64 (23 %) women had vesico-vaginal fistula, recto-vaginal fistula, urethro-vaginal fistula and vesico-uteral fistula types, respectively. Successful fistula closure was achieved among 86.3 %. Women with fistula who reported being in labour for ≥3 days, having ≥1 previous fistula repair attempt, and having lived with the fistula for >1 year, had significantly lower odds of successful repair outcomes.ConclusionsAmong 272 women with obstetric fistula managed in this study, 69.5 and 26.5 % of their fistula were causally associated with obstructed labour complications and iatrogenic factors, respectively. Successful fistula closure rates of about 89 % among women of index repair attempt were achieved. Conversely, reported histories of ≥3 days in labour, ≥1 previous failed attempts at repair and a fistula duration of >1 year, were significant determinants of failed fistula closures. To effectively mitigate obstetric fistula burden in Rwanda, a comprehensive package of services including quality emergency obstetric care, increased availability of and access to quality fistula repair, active surveillance to identify community-based women with fistula and a strong political will towards effective fistula care, are recommended.

A randomized controlled trial of interrupted versus continuous suturing techniques for radiocephalic fistulas

Continuous suturing techniques have conventionally been used for the end-to-side anastomoses of radiocephalic fistulas (RCFs); however, primary patency rates are poor. Only 50% to 60% of RCFs ever achieve functional patency. We hypothesized that a hybrid interrupted-continuous suturing technique (as used in many microsurgical procedures) may improve outcomes in fistulas constructed from small vessels. A randomized controlled trial comparing hybrid interrupted-continuous (n = 42) with continuous (n = 36) suturing techniques for RCF was undertaken. Patients were excluded if vessels were <1.8 mm in diameter or if previous ipsilateral fistula had been attempted. A priori power calculation indicated that a sample size of 78 patients was required to detect an improvement in patency from 50% to 80% (α = .05, β = .8). The primary end point was primary patency at 6 weeks (assessed by a blinded observer for the presence of thrill and bruit). Secondary end points were immediate patency, functional patency (assessed clinically and by ultrasound) at 6 weeks, and presence of anastomotic stenosis. Groups were comparable for basic patient demographics, operating surgeon, and vessel diameter as measured on preoperative ultrasound (mean age, 58.9 ± 13 years; 68% male). Primary patency at 6 weeks was higher in the hybrid interrupted-continuous suturing technique group (71% vs 47%; P = .01). Immediate patency was also higher in the hybrid interrupted-continuous suturing technique group (93% vs 67%; P < .001). There was no significant difference in functional patency at 6 weeks (52% vs 36%; P = .18). Three patients developed an anastomotic stenosis. All were in the hybrid interrupted-continuous suturing technique group. One patient from the interrupted suturing technique cohort required re-exploration for bleeding. A hybrid interrupted-continuous suturing technique yielded higher immediate and 6-week primary patency rates for RCF. The hybrid interrupted-continuous suturing technique may improve anastomotic compliance and reduce the narrowing and puckering that can occur on suture tightening in small-caliber vessels. Based on these findings, consideration should be given to performing hybrid interrupted-continuous anastomoses for RCFs.

Steal syndrome following an arteriovenous fistula – case report and treatment option

The paper presents the case of a 48 year-old diabetic patient that underwent hemodialysis for a long period of time and presented to our hospital with digital hypoperfusion symptoms following an arteriovenous fistula between the humeral artery and the basilic vein. The anamnesis of the patient reveals prior circulatory problems and in the case of a previous fistula the patient required the amputation of the distal phalanx of the left index finger. The arterial theft syndrome was dealt with in this case by using a simple method based on techniques of flow diminution through the vein, assessing the calibration by means of clinical criteria such as capillary flow, presence of thrill and decrease in pain levels. A 1 year follow-up showed the fistula was still viable and the symptoms diminished to a level that no longer interfered with the lifestyle of the patient.

Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection: Results in 68 cases at a mean 6.63 years’ follow-up

The goal of this study was to assess the results of treatment of mucous cysts by subcutaneous excision and osteophyte resection without an associated skin procedure. From 1993 to 2013, 81 mucous cysts were operated on. In 27 cases, a nail deformity was present. Obvious osteoarthritis was present in 84% of cases. Among them, 67 patients (68 cysts) were subsequently assessed through a phone questionnaire after a mean follow-up of 6.6 years. Patients who reported a recurrence or suspected one were reassessed in consultation. Among the 68 evaluated cases, two developed an infection and one had delayed skin healing; these complications occurred on cysts with a previous fistula. In one case (1.5%), a recurrence was observed four months after excision of a subungual cyst. All nail deformities had resolved; 53 patients felt no discomfort and 65 were very satisfied or satisfied with the procedure and would undergo surgery again. The recurrence rate of 1.5% is consistent with that of other studies where the same procedure was used, without cutaneous grafting, ranging from 0 to 2%. This result is better than in studies where a graft or a flap was performed without systematic joint debridement. Our procedure is sufficient to effectively treat mucous cysts with less morbidity. Complications are rare and occur only in cysts associated with a fistula, justifying their early surgical treatment.

CIRPLAST: Cleft Lip and Palate Missions in Peru.

The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST, a nonprofit volunteer plastic surgery goodwill program that has provided free surgery for patients with cleft lip and palate deformities in remote areas of Peru. Surgical procedures were performed by the author, together with a group of experienced plastic surgeons, under the auspices of the Peruvian Plastic Surgery Society, and local health authorities. CIRPLAST missions are scheduled annually in different locations around Peru. Selected patients for surgery after adequate screening are photographed, and their cleft deformity is recorded. Scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed 1 day after surgery, before discharge. Between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded. Complications that may occur are recorded and treated by the CIRPLAST team as soon as possible. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor, to reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. After cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. A total of 6108 cleft lip and palate repairs, primary and secondary, were performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Between 45% and 70% of the patients operated on a mission have returned for early follow-up and some the following year. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); of isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 patients (38.3%). Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence was present in 58 patients (15.4). Palate fistula formation in 33 patients (8.8%): 24 (6.4%) after primary palate closure, and 9 (2.4%) after previous fistula closure. Infection occurred in 37 cleft lip patients (9.8%). Hypertrophic lip scars were seen in 56 patients (14.9%). Bleeding occurred in the recovery room after palatoplasty in 48 patients (12.7%), and in most cases, it was contained by applying pressure. No blood transfusions were used. Residual deformities of varying degree of the nose and/or lip occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series. During the past 20 years, the CIRPLAST team has offered free surgery with good outcomes and few complications, to more than 6000 cleft lip and/or palate patients in remote areas of Peru.

Treatment of Crohn’s disease-related high perianal fistulas combining the mucosa advancement flap with platelet-rich plasma: a pilot study

BackgroundHealing rates after surgical closure for high perianal fistula in patients with Crohn’s disease are even more disappointing than in patients with cryptoglandular fistulas. The objective was to improve healing rates by combining the well-known mucosal advancement flap with platelet-rich plasma.MethodsA prospective pilot study was conducted in one tertiary referral centre. Consecutive patients with primary or recurrent Crohn’s disease-related high perianal fistulas, defined as involving the middle and/or upper third parts of the anal sphincter complex, were included. A staged procedure was performed with non-cutting seton treatment for 3 months first, followed by a mucosal advancement flap with injection of platelet-rich plasma into the fistula tract.ResultsTen consecutive patients were operated on between 2009 and 2014. Half (50 %) of the patients had undergone previous fistula surgery. Mean follow-up was 23.3 months (SD 13.0). Healing of the fistula was 70 % (95 % confidence interval, 33–89 %) at 1 year. One (10 %) patient had a recurrence, and in two (20 %) patients, the fistula was persistent after treatment. An abscess occurred in one (10 %) patient. The median post-operative Vaizey score was 8.0 (range 0–21), indicating a moderate to severe continence impairment.ConclusionsThe results of combining the mucosal advancement flap with platelet-rich plasma in patients with Crohn’s disease-related high perianal fistulas are moderate with a healing rate of 70 %. Further investigation is needed to determine the benefits and risks on continence status for this technique in this patient population.

Randomized controlled trial comparing primary and staged basilic vein transposition.

It is unclear if brachio-basilic vein fistula should be performed as a primary or staged procedure, particularly for smaller basilic veins. Our aim was to report on a randomized controlled trial comparing these two techniques. Sixteen patients with a basilic vein ≥2.5 mm were randomized into primary transposed brachio-basilic vein (TBBV) fistula (n = 9) and staged TBBV fistula (n = 7). Patients with basilic veins enlarged by previous arteriovenous fistulas were excluded. Baseline characteristics of the two study groups, including vein size, were comparable (median basilic vein diameter 3.5 mm, range 2.8-4.1 mm). The staged group had a brachio-basilic vein fistula performed first followed by the transposition procedure performed at least 6 weeks later to allow the basilic vein to enlarge. TBBV fistula maturation at 10 weeks, primary, assisted-primary, and secondary patency were the primary outcome measures. Early failures were included in the calculation of patency rates. Transposed brachio-basilic vein fistula maturation rate after primary procedures (3/9, 33%) was lower compared to maturation rate after staged procedures (7/7, 100%, P = 0.011, Fisher's exact test), which led to premature termination of the trial. Time to hemodialysis [median (interquartile range)] of primary and staged procedures was 54 (51.5-113.5) days and 97 (93-126) days, respectively (P = 0.16). One-year primary and assisted-primary patency rates of primary and staged procedures were equivalent (44 vs 57%, P = 0.76 and 44 vs 71%, P = 0.29, respectively); however, there was a trend toward a better 1-year secondary patency after staged procedures (86 vs 44% for primary procedures, P = 0.09). Among candidates for TBBV fistula with a small basilic vein, staged transposition achieves higher maturation rates compared to primary procedures, a difference reflected in long-term secondary patency. www.ClinicalTrials.gov, identifier NCT01274117.

Treatment of recurrent anal fistula using an autologous cartilage plug: a pilot study.

The aim of the present study was to assess a novel autologous cartilage plug technique used to treat anal fistula in ten patients. All ten patients had undergone at least two prior operations for recurrent fistulas. The plugs were prepared using the patients' own cartilage, which was obtained from either the nose or the ear, diced into pieces, and wrapped with oxidized regenerated cellulose. During the same session, fistula tracts were curetted using cytology brushes, and then, the cartilage plug was inserted into the tract. Routine postoperative examinations were performed at 2, 4, 8, 12, and 24 weeks after surgery. Magnetic resonance imaging was performed before surgery and at 3 and 6 months postoperatively. Relief of symptoms, radiological healing, recurrence, and continence were evaluated. The ten patients included six males and four females, with a median age of 39 years (range 25-70 years) and a median of three previous fistula operations (range 2-7 operations). Nine patients had cryptoglandular abscess, and one patient had Crohn's disease. The majority of the patients had transsphincteric fistulas with substantial anal sphincter involvement. The cartilage donor site was the nose for one patient and the ear for nine patients. The median follow-up time was 24 months (range 10-32 months). Of the ten patients, nine had fistula treatment without any short-term complications. The fistula failed to heal in one patient. Among the nine patients whose operations were initially successful, two late recurrences were observed. The cartilage plug seems to be a promising alternative for anal fistula treatment.

Previous Hemodialysis Access Improves Functional Outcomes of the Proximal Radial Artery Fistula in Males

The proximal radial artery fistula (PRA) has been established as an early viable surgical option for arteriovenous fistula creation. The overall assisted primary patency reported in the literature approaches 100% at 1 year. We hypothesize that this excellent patency does not represent a functional result when seen in light of successful cannulation and fistula utilization. We retrospectively queried our Veterans Administration Hospital operative database to identify 284 male patients who had 571 access procedures performed by a senior vascular surgeon attending (R.K.D.) from January 1, 2003, to December 31, 2008. Operative details, patient comorbidities, fistula maturation time (time to first cannulation), functional patency (date of access to abandonment, revision to another fistula type, conversion to a prosthetic graft, thrombosis of the fistula, conversion to peritoneal dialysis, renal transplant, or patient death), and total duration (creation of the fistula to the end of its functional patency) were collected and analyzed. A total of 144 PRAs were placed during the study period. In all, 87 patients underwent primary proximal radial artery fistula (P-PRA) placement in a limb without previous access; 57 patients had a secondary proximal radial artery fistula (S-PRA) after a failed previous fistula or graft in the same limb. There were no differences between the 2 groups in terms of age, comorbidities, and operative details. A total of 91 patients (63.2%) were receiving hemodialysis at the time of P-PRA or S-PRA placement. Outcomes of P-PRA and S-PRA populations on hemodialysis were examined. There was increased cannulation success (33% vs. 55%; P = 0.00354, Fisher's exact test), functional patency (755.2 ± 661.2 days vs. 405.4 ± 531.9 days; P = 0.0220, Wilcoxon two-sample test), and total duration (859.5 ± 650.7 days vs. 516.8 ± 547.2 days; P = 0.0361, Wilcoxon two-sample test) of S-PRA over P-PRA. There was no difference in endovascular interventions between the 2 groups (1.6 ± 1.0 interventions per access versus 1.1 ± 0.7 interventions per access; P = 0.2109, Wilcoxon two-sample test). Subgroup analysis (analysis of variance) of the S-PRA group indicated that a patent but failing previous access in the same arm was not superior in terms of successful cannulation, functional patency, or total duration when compared with a thrombosed previous access. The PRA remains a viable first access procedure undertaken at our institution. Compared with the reported 12-month assisted primary patency of this fistula type, we found a small percentage of PRAs actually being accessed for successful hemodialysis treatment. The S-PRA appears to have a significantly higher successful cannulation rate, functional patency, and total duration time when compared with the P-PRA in patients receiving hemodialysis treatments. The mechanism of these improved outcomes is not known; considering patency or thrombosis of a previous access in the S-PRA group did not predict future access success in the same extremity.

Evaluation of Recurrent and/or Persistent Complex Ano-Perianal Abscess after Surgery: The Unique Value of Magnetic Resonance (MR) Imaging

Introduction: Despite proper treatment and apparent healing after surgery, a recurrent ano-perianal abscess may develop in up to 10% of patients, especially if the opening on the skin heals. Factors reported to be associated with recurrence include complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal opening, previous fistula surgery, and the surgeon performing the procedure [1]. Findings on pelvic MRI have been shown to have accuracy up to 90% for mapping the fistula tracts and 80-90% concordance with operative findings. We report the unusual case of an unknown persistent deep perirectal abscess occurring in an asymptomatic man two years after surgery. Case Blog: A forty-year-old male with remote history of surgical incision of his perirectal abscess dating back to the age of four, and two more recent operations aimed at draining a perianal abscess 5 years before, was admitted at the Coloproctology Unit of Parioli Clinic, Rome, Italy in November 2013 because of painful supralevator abscess, which was successfully treated via intersphincteric route (MP). Worthy of notice, just prior the onset of symptoms and the patient had experienced a stressful period of time during troublesome separation from his wife. As known, this psychological event is capable to adversely affect the immune

Cholecystoduodenal Fistula: A Rare Cause of Massive Upper GI Bleeding

Introduction: Upper gastrointestinal bleeding is a common medical problem. While peptic ulcer disease, varices, tears, gastritis, angiectasias, or malignancy are the common etiologies, unusual causes should always be included in the differential diagnosis. We present a case of a cholecystoduodneal fistula that presented with massive upper GI bleeding. Case Report: A 75-year-old female patient with a history of myelodysplastic syndrome, coronary artery disease, GERD, and hypertension presented with weakness and vomiting, fevers, and altered mental status x 1 day. She was febrile to 104°F, BP 94/52, and HR 102. Initial labs were significant for a WBC count of 24,700 and a Hb of 7 gm. On admission, she had an episode of hematemesis and bright red blood per rectum, and became hypotensive with positive orthostatics. After initial resuscitation, upper endoscopy was performed and showed old blood in the fundus with no source for the bleeding. The next day, she had a recurrent episode of massive hematemesis. A repeat EGD showed bubbles emanating from the papilla with normal gastric mucosa. A CT and MRCP showed pneumobilia with air extending to the duodenal bulb and the presence of multiple gallstones. The findings were compatible with persistent cholecystoduodenal fistula and a decompressed gallbladder. Blood cultures confirmed gram-negative sepsis. The patient was treated with broad spectrum IV antibiotics and improved clinically. Cholecystectomy was not performed for reasons unknown. One year later, the patient presented with chronic weakness, decreased appetite, and weight loss. Labs were significant for WBC count of 15,630, an AST of 225 IU/L, ALT of 207 IU/L, and alkaline phosphatase of 697 IU/L. CT scan and MRI of the abdomen and pelvis revealed a 4.7-cm mass with biliary obstruction at the level of the porta hepatis with obliteration of the previous choledocystoduodenal fistula. Biopsies confirmed gallbladder carcinoma, and a subsequent ERCP was performed with successful palliative biliary stent. Discussion: Rare complications of gallbladder disease include fistula formation, which can lead to further complications, including pneumobilia, recurrent cholangitis, Mirizzi’s syndrome, Bouvaret’s syndrome, and gallstone ileus. In cases of unexplained massive upper GI bleeding, careful inspection of the papilla may help rule out hemobilia. In this case, the diagnosis of hemobilia helped lead to the immediate treatment and management of a complicated cholecystoduodenal fistula. Conclusion: Cholecystoduodenal fistula is an uncommon complication of gall stone disease, and due to the rarity and variability in which it manifests, a high degree of suspicion must be present at the start to reduce morbidity and mortality.