Primary Fistula Research Articles

Changing patterns in the management of Colonic Trauma

Recent prospective studies have recommended primary repair for all colonic trauma. We evaluate the changing patterns given these recommendations and assess our results of primary repair. This prospective study was conducted on 63 patients with colonic trauma received over a year from July 2000 to June 2001. Morbidity was defined as failure of a primary repair, abscess, fistula, wound dehiscence, sepsis, and organ failure. Primary repairs were performed in 28 patients and colostomy was done in 35 patients. Prolonged mean hospital stay and more incidences of postoperative complications occurred in colostomy group. It was therefore, concluded that primary repair of colon should be adapted as a standard procedure. Colostomy should be reserved for patients with a prolonged delay to surgery, severe blood loss, and gross faecal contamination or associated with multiple organ injuries.

Quality of life with anal fistula.

Anal fistula affects people of working age. Symptoms include abscess, pain, discharge of pus and blood. Treatment of this benign disease can affect faecal continence, which may, in turn, impair quality of life (QOL). We assessed the QOL of patients with cryptoglandular anal fistula. Newly referred patients with anal fistula completed the St Mark's Incontinence Score, which ranges from 0 (perfect continence) to 24 (totally incontinent), and Short form 36 (SF-36) questionnaire at two institutions with an interest in anal fistula. The data were examined to identify factors affecting QOL. Data were available for 146 patients (47 women), with a median age of 44 years (range 18-82 years) and a median continence score of 0 (range 0-23). Versus population norms, patients had an overall reduction in QOL. While those with recurrent disease had no difference on continence scores, QOL was worse on two of eight SF-36 domains (p<0.05). Patients with secondary extensions had reduced QOL in two domains (p<0.05), while urgency was associated with reduced QOL on five domains (p<0.05). Patients with loose seton had the same QOL as those without seton. No difference in urgency was found between patients with and without loose seton. In primary fistula patients, 19.4% of patients experienced urgency versus 36.3% of those with recurrent fistulas. Patients with anal fistula had a reduced QOL, which was worse in those with recurrent disease, secondary extensions and urgency. Loose seton had no impact on QOL.

Outcomes of primary arteriovenous fistulas in patients older than 70 years

The population of elderly hemodialysis patients is increasing, yet the most suitable approach for providing permanent hemodialysis access remains unclear. Here we report outcomes using an approach aimed predominantly at creating radiocephalic (RC) fistulas. A single-center retrospective cohort study was performed in which access outcomes for primary arteriovenous fistulas created between January 1, 2005, and December 31, 2012, in patients aged 70years or older were compared. During the study period, 204 RC, 1 brachiobasilic, and 9 brachiocephalic (BC) primary fistulas were created initially for patients requiring dialysis. Immediate failure rates for RC fistulas were lower than for BC fistulas but not significantly so (12% vs 22%; Fisher's exact text, P= .319). One-year primary and secondary patency for RC fistulas was54% and 66%, respectively, and similar for those created in patients between 70 and 80years old and in those olderthan 80years. The secondary patency rate at 1year for RC fistulas using cephalic vein of diameter<2.5mm waslower than for fistulas created with cephalic vein >2.5mm (49% vs 72%; log-rank test, P= .005). Creation of a BCfistula was associated with a significantly higher incidence of steal syndrome than with an RC fistula (10% vs 2%; Fisher's exact text, P= .009). RC fistulas formed in the elderly carry a lower risk of steal syndrome than BC fistulas and offer the potential for further revision surgery, such that acceptable secondary patency is achieved for RC fistulas formed using even small (<2.5mm) cephalic veins.

Impact of preoperative ultrasonography findings on the patency rate of vascular access in Japanese hemodialysis patients.

BackgroundAlthough ultrasonography before a vascular access (VA) operation has become popular in recent years, benchmarks for the diameter or blood flow of arteries or veins are not defined in Japan. The objective of the present study is to analyze the relationship between preoperative US findings and the patency rate of VA in Japanese hemodialysis patients.Methods139 patients with end stage kidney disease were enrolled in this study. They had been given primary radiocephalic arteriovenous fistula (AVF) from February 2009 to December 2010 at the Juntendo University Hospital and were followed up over 2 years. We defined the interval from the time of AVF creation until first access thrombosis or any intervention to maintain or restore blood flow as patency time (primary patency). We examined the correlation between the 2-year primary patency rate of VA and the diameter of the radial artery (RA), brachial artery (BA), or cephalic vein at an anastomosis presumptive region by US, the blood flow of RA or BA, as measured by US, age, gender, and primary kidney diseases.ResultsThe average patency term was 448.6 ± 271.3 days, with the 1-year and 2-year patency rate as 64.0 and 51.2 %, respectively. The patency rate was significantly lower in elderly patients over the age of 75 and in patients with diabetes mellitus. US findings of 2.0 mm or less in the RA diameter also resulted in a noticeably low patency rate. A multivariate analysis indicated that those factors were risk factors for early VA failure.ConclusionsPreoperative US findings of the diameter of RA may involve the patency rate of VA, making it appears that an RA of 2.0 mm or more in diameter at an anastomosis region may be more effective for the improvement in the patency rate of VA.

A prospective multicentre observational study of Permacol™ collagen paste for anorectal fistula: preliminary results

Permacol collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. Patients (N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects.

Management of bleeding and infections in the context of visceral surgery

Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence < 1.5 %) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.

Patient-Centered Dialysis Care: Depression, Pain, and Quality of Life.

Remarkable advancements have been made in the provision of chronic dialysis therapy since its inception decades ago. A series of studies inform current dialysis dosing recommendations, while advancements in strategies to treat mineral and bone disease, acid-base and electrolyte disturbances, and anemia have facilitated the management of these well-recognized complications of ESRD. The collective result has been a model of chronic dialysis care focused principally on the achievement of metabolic and dialysis-related targets. In fact, guidelines such as the Kidney Disease Outcomes Quality Initiative put forth by the National Kidney Foundation recommend metrics that characterize successful dialysis care, including the attainment of specific solute clearance targets; maintenance of hemoglobin, calcium, phosphorous, and parathyroid hormone levels within target ranges; and the preferred use of primary arteriovenous fistulae for vascular access. This focus on serologic and dialysis-specific outcomes has helped renal providers manage the biochemical effects related to the loss of kidney function and has reduced ESRD-related morbidity and mortality. Yet, absent from this model of care is an emphasis on the treatment of bothersome symptoms and the impact of such treatment on quality of life (QOL). Among the many symptoms that affect patients on chronic dialysis, depression and pain are particularly common, strongly associated with decrements in QOL, and potentially treatable. This review discusses key research findings and unanswered questions pertaining to the prevalence, significance, and treatment of depression and pain and the effect of such treatment on QOL in patients dependent on chronic dialysis, with the broad goal of incorporating symptom management strategies into a paradigm of patient-centered dialysis care.

Aorto-duodenal fistula: a rare but serious complication of gastrointestinal hemorrhage. A case report.

A primary aortoduodenal fistula (PADF) is a rare cause of gastrointestinal bleeding that is difficult to diagnose (and sometimes not diagnosed until a laparotomy.) A PADF is associated with high mortality if undiagnosed and untreated (the mortality rate of nearly 100% in the absence of a surgical intervention). While this condition is extremely rare with an incidence rate at autopsy of 0.04% to 0.07%, a secondary ADF occurs much more commonly (the post-operative incidence of 0.5% to 2.3%) and is due to prior aortic surgery and/or the placement of a synthetic aortic graft. It should be considered in any elderly patient who presents with upper gastrointestinal bleeding in the context of a known abdominal aortic aneurysm or without it when no identifiable source of bleeding is found. We present an autopsy case of a 59-year-old man with no history of an abdominal aortic aneurysm who presented with intermittent massive gastrointestinal bleeding. The autopsy revealed a pinhole fistula. It was identified between an atherosclerotic abdominal aortic aneurysm and the lower horizontal part of the duodenum. Our case indicates that the aortoenteric fistula can result in fatal gastrointestinal bleeding. This case is unique in that the fistula formed as a result of a complex atherosclerotic abdominal aorta and a localized necrotizing granulomatous aortitis the etiology of which was not clear.

Endovascular Management of Primary Aortoenteric Fistulae

Primary aortoenteric fistula (AEF) is a rare clinical entity which is life-threatening. Early diagnosis and prompt treatment play a crucial role in the management. Minimally invasive approaches such as endovascular treatment are newer options in treatment. We describe three patients with primary AEF successfully managed with endovascular treatment. The presentation of primary AEF may be acute, with an exsanguinating unstable patient who would be unfit to undergo a major laparotomy. In such instances, endovascular treatment can be used as the initial option to control the bleeding. Endovascular treatment is a valuable treatment option to control bleeding when the morbidity of open repair is high.

Impact of a preoperative evaluation on the outcomes of an arteriovenous fistula.

PurposeThe aim of this study was to determine the possible predictors of primary arteriovenous fistula (AVF) failure and examine the impact of a preoperative evaluation on AVF outcomes.MethodsA total of 539 patients who underwent assessment for a suitable site for AVF creation by physical examination alone or additional duplex ultrasound were included in this study. Demographics, patient characteristics, and AVF outcomes were analyzed retrospectively.ResultsAVF creation was proposed in 469 patients (87.0%) according to physical examination alone (351 patients) or additional duplex ultrasound (118 patients); a prosthetic arteriovenous graft was initially placed in the remaining 70 patients (13.0%). Although the primary failure rate was significantly higher in patients assessed by duplex ultrasound (P = 0.001), ultrasound information changed the clinical plan, increasing AVF use for dialysis, in 92 of the 188 patients (48.9%) with an insufficient physical examination. Female sex and diabetes mellitus were risk factors significantly associated with primary AVF failure. Because of different inclusion criteria and a lack of adjustment for baseline differences, Kaplan-Meier survival analysis showed better AVF outcomes in patients assessed by physical examination alone; an insufficient physical examination was the only risk factor significantly associated with AVF outcomes.ConclusionRoutine use of duplex ultrasound is not necessary in chronic kidney disease patients with a satisfactory physical examination. Given that female gender and diabetes mellitus are significantly associated with primary AVF failure, duplex ultrasound could be of particular benefit in these subtypes of patients without a sufficient physical examination.

Willingness to participate in a randomized trial comparing catheters to fistulas for vascular access in incident hemodialysis patients: an international survey of nephrologists.

BackgroundCurrent guidelines favor fistulas over catheters as vascular access. Yet, the observational literature comparing fistulas to catheters has important limitations and biases that may be difficult to overcome in the absence of randomization. However, it is not clear if physicians would be willing to participate in a clinical trial comparing fistulas to catheters.ObjectivesWe also sought to elicit participants’ opinions on willingness to participate in a future trial regarding catheters and fistulas.DesignWe created a three-part survey consisting of 19 questions. We collected demographic information, respondents’ knowledge of the vascular access literature, appropriateness of current guideline recommendations, and their willingness to participate in a future trial.SettingParticipants were recruited from Canada, Europe, Australia, and New Zealand.ParticipantsParticipants include physicians and trainees who are involved in the care of end-stage renal disease patients requiring vascular access.MeasurementsDescriptive statistics were used to describe baseline characteristics of respondents according to geographic location. We used logistic regression to model willingness to participate in a future trial.MethodsWe surveyed nephrologists from Canada, Europe, Australia, and New Zealand to assess their willingness to participate in a randomized trial comparing fistulas to catheters in incident hemodialysis patients.ResultsOur results show that in Canada, 86 % of respondents were willing to participate in a trial (32 % in all patients; 54 % only in patients at high risk of primary failure). In Europe and Australia/New Zealand, the willingness to participate in a trial that included all patients was lower (28 % in Europe; 25 % in Australia/New Zealand), as was a trial that included patients at high risk of primary failure (38 % in Europe; 39 % in Australia/New Zealand). Nephrologists who have been in practice for a few years, saw a larger volume of patients, or self-identified as experts in vascular access literature were more likely to participate in a trial.LimitationsSurvey distribution was limited to vascular access experts in participating European countries and ultimately led to a discrepancy in numbers of European to non-European respondents overall. Canadian views are likely over-represented in the overall outcomes.ConclusionsOur survey results suggest that nephrologists believe there is equipoise surrounding the optimal vascular access strategy and that a randomized controlled study should be undertaken, but restricted to those individuals with a high risk of primary fistula failure.Electronic supplementary materialThe online version of this article (doi:10.1186/s40697-016-0125-6) contains supplementary material, which is available to authorized users.

Prospective Randomized Trial of Simple Drainage vs. Drainage and Initial Fistula Management for Perianal Abscesses

Background and Aims: Perianal abscess is one of the most frequent proctological disorders and needs urgent treatment. Incision and drainage consists the gold standard therapy of this disorder. However, due to high rates of abscess recurrence, few surgeons favor primary fistula treatment at the time of abscess drainage to decrease the risk of recurrence. This clinical study was designed to compare incision and drainage of perianal abscess with or without fistula treatment. Patients and Methods: Two hundred consecutive patients suffering from acute perianal abscess were prospectively randomized into two groups: group A; treatment of abscess with incision and drainage, group B; incision and drainage plus primary fistula treatment. All patients were followed-up for at least 12 months. Primary endpoints of the study were the rates of abscess recurrence and anal incontinence. Secondary end point was abscess recurrence rate during the overall follow-up period.

Diagnosis and Treatment of Biliary Fistulas in the Laparoscopic Era

Biliary fistulas are rare complications of gallstone. They can affect either the biliary or the gastrointestinal tract and are usually classified as primary or secondary. The primary fistulas are related to the biliary lithiasis, while the secondary ones are related to surgical complications. Laparoscopic surgery is a therapeutic option for the treatment of primary biliary fistulas. However, it could be the first responsible for the development of secondary biliary fistulas. An accurate preoperative diagnosis together with an experienced surgeon on the hepatobiliary surgery is necessary to deal with biliary fistulas. Cholecystectomy with a choledocoplasty is the most frequent treatment of primary fistulas, whereas the bile duct drainage or the endoscopic stenting is the best choice in case of minor iatrogenic bile duct injuries. Roux-en-Y hepaticojejunostomy is the extreme therapeutic option for both conditions. The sepsis, the level of the bile duct damage, and the involvement of the gastrointestinal tract increase the complexity of the operation and affect early and late results.

MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences.

Although some studies proved the role of STIR sequences in the evaluation of perianal fistulas in Crohn's Disease (CD), contrast medium is still injected in many institutions since there is not a validated reference MR protocol. Our purpose was to evaluate the role of the STIR sequence in the detection and characterization of perianal fistulae comparing it to the post-contrast T1 sequence and correlating it with rectal examination under anesthesia. We retrospectively reviewed all clinical records of 31 CD patients, suspected of having perianal fistulas, who had been submitted to an MR study before and after contrast medium injection and surgical exploration under anesthesia within the same month. Perianal fistulas were classified according to the Parks' criteria. Finally, comparison between STIR and post-contrast T1-weighted fat saturated sequences was done. 29 fistulas were detected in 25 patients who underwent an MR study. There was no significant difference between MR imaging and exploration under anesthesia. For the detection of perianal fistulas of any type, there was a perfect statistical agreement between gadolinium-enhanced and STIR sequences (kappa value=1). STIR sequences represent a valid alternative to the T1-weighted sequences acquired after the injection of contrast medium, allowing the identification of the primary fistula, any secondary ramification, and complications of the disease.

EFFICACY OF ARGENTUM-QUARTZ SOLUTION IN THE TREATMENT OF PERIANAL FISTULAS: A PRELIMINARY STUDY

Objective: Nowadays, an optimal and effective medical surgery remains the gold standard for perianal fistulas. Hereby we reported preliminary results in favor of using Argentum-quartz solution for both primary and recurrent perianal fistulas. Methods: Three patients with intersphincteric and extrasphincteric fistulas were enrolled. Argentum-quartz solution was administrated twice a week for a period of 4 weeks, followed by a pause of 8 days and then another 4 weeks of treatment, totally 16 administrations. After treatment, all patients were monitored for a 4-month follow-up. Results: Complete closures of 2 extrasphincteric fistulas and a partial closure with absence of inflammation and superative phenomena in the intrasphincteric fistula were both manifested. Conclusion: Selective treatment of perianal fistulas with an argentum-quartz solution is safe and effective, and may represent a reliable alternative.

Case Discussion: Vesicovaginal Fistula Following a Total Abdominal Hysterectomy: The Case for Abdominal Repair

This is an interesting case that is more common than we would wish. This patient has good performance status, good nutrition, few comorbidities, and no previous abdominal surgery. Thus, we suspect that her tissue quality is good, suggesting an optimistic outcome for primary fistula repair. Bilateral retrograde studies showed no residual obstruction of the upper urinary tract, although the fistula is close to the right ureter. The hysterectomy was for benign disease, so no (additional/adjuvant) oncologic treatments are planned.

The reasons for the failure of the primary arteriovenous fistula surgery in patients with end-stage renal disease.

To analyze the reasons for the failure of the primary arteriovenous fistula surgery and explore preventive measures. A total of 819 patients with end-stage renal disease were enrolled in the study. Autologous arteriovenous fistula surgery was performed on all patients. Their clinical data of hemoglobin (HB), albumin (ALB), cholesterol (CHOL), parathyroid hormone (PTH), blood glucose and blood pressure were collected before surgery, while the diameters of the radial artery and cephalic vein were measured by ultrasound. The operations in 742 patients were successful, but failed in 77 cases (accounting for 7.07%). The failure group was significantly older (61.3 ± 13.4 years) than the successful group (45.6 ± 11.2 years). The ratio of diabetes 36 (46.8%) and hypertension 20 (26.0%) was significantly higher in the failure group than in the successful group, respectively 235 (31.7%) and 145 (19.5%). The patients with blood pressure below 120/70 mm Hg had a higher risk of failed surgery (36.4%) than those with blood pressure above 120/70 mm Hg (9.16%). The cephalic vein and radial artery diameter were significantly smaller in the failure group (1.35 ± 0.64 mm, 2.13 ± 0.81 mm) than in the successful group (1.98 ± 0.47 mm, 2.47 ± 0.74 mm); [corrected] the PTH levels in the failure group were significantly higher (782.39 ± 423.85) than in the successful group (378.83 ± 352.21). The autogenous arteriovenous fistula surgery failure highly correlated with the patient's age, blood pressure, the primary disease and the vessel diameter. In addition, the PTH levels had a certain correlation with the failure of the fistula surgery.

Reoperative surgery for persistent anal fistulae

Failure of treatment of a primary anal fistula is rarely life threatening, but the cost to the patient in terms of pain, discomfort, and interruption of daily life is substantial. Complex or recurrent fistulas must be methodically evaluated so a successful treatment strategy can be developed, and therapy completed, ideally without compromising fecal continence. Advanced imaging can be useful in identifying complex tracts and accumulated sepsis but is rarely indicated in the setting of a primary fistula. Multiple methods to repair complex, recurrent fistulas have been described with varying success rates. Diversion of the fecal stream is often employed after repeat repair of a fistula but is not universally beneficial. Treatment must be individualized according to pre-existing patient factors, number of internal openings, and condition of the tissues in and around the anus.

No-touch technique for radiocephalic arteriovenous fistula--surgical technique and preliminary results.

The radiocephalic arteriovenous fistula (RC-AVF) has significant failure rates due to occlusions and failure to mature. The size and quality of the veins are considerable limiting factors for the procedure. The aim of this pilot study was to describe the No-Touch technique (NTT) to create RC-AVF and present the results up to 1 year of follow-up. Thirty-one consecutive patients who were referred for surgery for a RC-AVF were included (17 men, mean age 63 years, range 35-84) and operated by NTT where the vein and artery were dissected with a tissue cushion around it. Twenty-two patients had small veins or arteries (≤2 mm), 12 patients had a small cephalic vein (≤2 mm), and the mean distal cephalic vein diameter was 2.4 mm (range 1.0-4.1 mm). Technical surgical success and immediate patency were obtained in all patients. Clinical success was achieved in 23 of the 27 (85%) patients who required hemodialysis. The proportion of primary patency at 30 days and 6 months was 84% and 64%, respectively. Secondary patency at 30 days and 6 months was 97% and 83%, respectively. At 1-year follow-up, primary patency was 54% and secondary patency was 80%. There was no major difference in patency due to preoperative vein diameter. The results of this study indicate that NTT can be used for primary radio-cephalic fistula surgery with very good results. This method offers the potential to create a RC-AVF in patients who are not usually considered appropriate for a distal arm fistula due to a small cephalic vein.

Use of Plastic Needles for Early Arteriovenous Fistula Cannulation

Background: The native arteriovenous fistula (AVF) needs maturation before it can be used. Needling done before time may result in haematoma formation, miscannulation or even access loss. Methods: This retrospective study included 20 patients with AVFs punctured with fluoroplastic dialysis catheters within 30 days after access creation and 19 historical controls. Results: The time to first puncture was 2-29 days for the study group and 1-26 days for the control group. The incidences of haematoma were 16.7 and 48 per 1,000 dialysis sessions for plastic and metal needles, respectively. Estimated primary functional fistula survival at 3, 6 and 12 months were 95, 90 and 74% for the study group and 79, 67 and 60% for the control group (p = 0.106), respectively. Conclusions: Use of plastic needles enables safe AVF cannulation. If applied judiciously, it can minimize or even avoid catheter use.