Fistula Closure Rate Research Articles

Randomized, Placebo-Controlled, Double-Blind Study of the Efficacy of Lanreotide 30 mg PR in the Treatment of Pancreatic and Enterocutaneous Fistulae

Continuous intravenous infusion of somatostatin improves the natural course of digestive fistulae. Lanreotide 30 mg PR is a synthetic analogue of somatostatin with pharmacological activity extending to at least 10 days after intramuscular administration. Its effectiveness was assessed in patients with simple externalized digestive fistulae in a randomized, doubleblind, placebo-controlled study. Patients demonstrating a reduction of at least 50% of fistula output within 72 hours after a first double-blind intramuscular injection of lanreotide or placebo were considered to be responders (primary end point) and continued the double-blind treatment to a maximum of 6 injections at 10-day intervals. Other endpoints included fistula closure rate and time to closure. Blind was lifted for nonresponders, and those initially on placebo were then treated with open-label lanreotide. Following the first double-blind injection, 35 of 54 patients (64.8%) on lanreotide were responders versus 20 of 53 (37.7%) on placebo, ie, a 3.1 times higher response likelihood on lanreotide compared with placebo (P = 0.006). Group mean reduction of fistula output at 72 hours was 45.1% and 8.9%, respectively (P = 0.005). Lanreotide compared with placebo had no effect on closure rate which averaged 77% but median time to fistula closure was shorter on lanreotide, based on Kaplan-Meier analysis, although no statistical significance was achieved. Compared with placebo, intramuscular lanreotide 30 mg PR significantly decreases digestive fistulae output at Day 3 and shortens time to fistula closure by 9 days. ClinicalTrials.gov registration number: NCT00729313.

Treatment of Transsphincteric Anal Fistulas

Treatments for transsphincteric, cryptoglandular anal fistulas pose risks for high recurrence rates and impaired anal continence. Anal fistula plugs have gained popularity because of reports of success without compromising the anal sphincter. To examine the benefit of the anal fistula plug, we compared its success rate with a standard treatment for transsphincteric fistulas with similar indications, the transanal mucosal advancement flap. We examined the outcomes of all patients with transsphincteric fistulas who underwent anal fistula plug repair from July 2005 to December 2006, excluding those with Crohn's disease or less than three months of follow-up. They were compared with a historical control group of patients (2001-2005) with similar transsphincteric fistulas who underwent a transanal mucosal advancement flap procedure because the anal fistula plug was not available. The same surgeons performed both procedures. Outcome was assessed from medical records or telephone follow-up. Twenty-nine patients underwent an anal fistula plug repair, and 26 patients underwent a flap procedure. Fistula closure rates were 34 percent for plugs and 62 percent for flaps (P = 0.045). The groups were similar in all respects except that 3 percent of plug patients and 58 percent of flap patients had postoperative inpatient stays and the median follow-up was longer (279 vs. 819 days) for the flap group. Fistula closure rates were significantly lower with anal fistula plugs than with advancement flaps. Although the low success rates for fistula plugs could be a result of patient selection, more data needs to be accrued before fistula plugs can be recommended as definitive first-line treatment for transsphincteric fistulas.

CR12 ENTEROCUTANEOUS FISTULAE – ARE WE GETTING IT RIGHT?

Purpose Enterocutaneous fistulae (ECF) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients.Methodology A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006. Demographic, management and outcome data was recorded. Factors influencing ECF closure and outcome were assessed with Cox regression analysis.Results Thirty‐three patients (17 male) were identified with ECF (median age 63, range 27–84). The primary aetiology was Crohn’s (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4–72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 hours (SD = 1.8). The median hospital stay for the operative group was 19 days (7–85). Four patients required post‐operative TPN. Fistula closure rate was 97% (operative group 21/21, non‐operative group 11/12). Mean follow up was 37.3 months (0.5–217). Six operative patients (19%) developed fistula recurrence. There were 2 deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis respectively). No factor was predictive of fistula recurrence.Conclusion Patients with enterocutaneous fistula can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. Patients with ECF should be referred to specialist units for management.

How should complex perianal Crohn's disease be treated in the Remicade era?

Perhaps one of the most difficult aspects of treat­ ing Crohn's disease (CD) is the management of complex perianal disease. Perianal fistulas occur in 17%-43% of patients with CD and are more com­ monly associated with colonic CD than small bowel CD. Almost 100% of patients with rectal CD have perianal fistulas at some point. Perianal fistulas in CD can be broken down into two categories: simple or low and complex or high fistulas. The treatment for the two categories is dif­ ferent, and this review will concentrate on complex or high fistulas. This group includes high trans­ sphincteric, suprasphincteric, and extrasphincteric fistulas; multiple fistulas; fistulas with multiple exter­ nal openings; rectovaginal fistulas; and any perianal fistula in the presence of active rectal disease. Remicade is a genetically constructed IgG1 mu­ rine-human chimeric molecule (75% human) that binds both soluble and bound TNFa. In 1999, Pres­ ent et al. I performed a randomized double-blinded placebo controlled trial of Remicade for fistulizing CD. Fifty-five percent of the fistulas (of which 90% were perianal) treated with 5 mg/kg Remicade at 0,2, and 6 weeks were reported as closed. Closure was defined as no drainage despite gentle compres­ sion. The median length of closure was 3 months. Sixty percent of patients reported adverse events, in­ cluding 11 % abscess formation. Based on this study and subsequent studies, the standard dosing regimen of Remicade for perianal fistulas is 5 mg/kg given at 0, 2, and 6 weeks. Maintenance therapy, when indi­ cated is 5 mg/kg every 8 weeks. Premedication with Tylenol, Benadryl, or corticosteroids is given as needed. Subsequent studies have shown a complete peria­ nal fistula closure rate between 25% and 67% and a rectovaginal fistula closure rate of 0%-13%. The Accent II trial randomized patients with fistulizing CD to initial therapy at 0, 2, and 6 weeks with either 5 mg/kg of Remicade or placebo. Sixty-nine percent of patients in the Remicade group responded. Those 69% were then randomized to maintenance therapy with either Remicade at 5 mg/kg or placebo every 8 weeks for 54 weeks. Of those patients on Remicade maintenance, 42% lost the effect of the medication by 54 weeks. Infusion reactions are seen in about 20%-30% of patients, and especially in those patients with subse­ quent doses. The majority of reactions are minor and include low-grade fever, rash, and tachycardia. Symptoms usually resolve with decreasing the infu­ sion rate or cessation of the infusion. Pretreatment with Tylenol and Benadryl, and sometimes cortico­ steroids, usually permits subsequent administration of Remicade. Approximately 2 % of patients have a severe infusion reaction consisting of anaphylaxis, dyspnea, and/or hypotension. In these patients, further treatment with Remicade is contraindicated. Infusion reactions are thought to occur due to the development of human antichimeric antibodies. Infectious complications are not uncommon with Remicade treatment. Abscesses develop in about 10%-35% of patients due to healing of the external opening prior to healing of the fistula tract. This can usually be prevented in perianal fistulas by the place­ ment of setons. Upper respiratory infections, includ­ ing bacterial pneumonia and Pneumocystis carinii, develop in up to 16% of patients. Tuberculosis has been reported in over 70 patients, as have other op­ portunistic infections. Also reported is the possible increased risk of lymphoma and development of lupuslike reactions. Resolution of clinical signs of the fistula such as drainage and closure of the external opening does not mean that the fistula tract has healed. Several studies using endoanal ultrasound and magnetic res­ onance imaging have shown that the fistula tract persists despite cessation of drainage and apparent

Surgical Technique for the Correction of Postpalatoplasty Fistulae of the Hard Palate

Ortak, Turgut M.D.; Kerem, Metin M.D.; Uraloğlu, Muhammet M.D.; Ünlü, Ramazan Erkin M.D.; İnözü, Emre M.D.; Şensöz, Ömer M.D. Author Information

Palatal Fistula Repair Using Acellular Dermal Matrix

Palatal fistulas represent a challenging problem for surgeons caring for patients with cleft palate. The purpose of this study was to examine the rate of fistula closure using conventional surgical techniques (Group 1) versus a newer technique (Group 2) employing the use of acellular dermal matrix (AlloDerm). We reviewed the charts of all patients who underwent palatal fistula repair between July 1994 and February 2005. The surgical techniques in Group 1 varied and were considered a historical control. In the second group, a piece of dermal matrix was interposed between the nasal and oral mucoperiosteum after closure of these layers. The primary fistula closure rate for Group 1 was 83.3% (10/12 patients). Fistula closure was obtained in 100% of the patients in Group 2. There were no complications noted other that the failure of the 2 patients in Group 1. The use of AlloDerm in palatal fistula repair has reduced our failure rate from 16.7% to 0%. The use of AlloDerm during palatal fistula repair is safe, effective over time, and has the potential to reduce palatal fistula recurrence rates.

Use of Endoscopic Ultrasound to Guide Combination Medical and Surgical Therapy for Patients With Crohnʼs Perianal Fistulas

This study was performed to assess if using endoscopic ultrasound (EUS) to assess and guide combination medical and surgical therapy during fistula healing will lead to a high rate of durable fistula closure and a low or absent incidence of perianal abscess formation in patients with Crohn's perianal fistulas. This is a retrospective analysis of 21 patients who presented with a symptomatic Crohn's perianal fistula. Patients were enrolled in a clinical practice protocol of serial EUS exams. All patients underwent a baseline rectal EUS and were placed on maximal medical treatment with 6-mercaptopurine (6-MP) or azathioprine, Cipro, and infliximab (5 mg/kg at 0, 2, and 6 wk and then every 8 wk). Patients were also assessed at baseline by a colorectal surgeon who was aware of the EUS findings. Seton placement and incision and drainage were performed when appropriate. Serial EUS examinations were performed, and the findings were used to guide therapy (i.e., the presence of fistula healing on EUS was used to guide seton removal, discontinuation of infliximab, and Cipro). In the 21 patients enrolled, the median duration of active perianal symptoms was 9 wks (1-36). 10 patients (48%) had previous perianal surgery and 5 (24%) had received infliximab previously. The fistulas treated included 8 trans-sphincteric, 2 superficial, 3 recto-vaginal, and 7 with multiple and horseshoe fistulas. 13 patients (62%) had associated abscesses at presentation. Eighteen of 21 patients (86%) had complete cessation of drainage initially. Median time to cessation of drainage was 10.6 weeks (range, 4-32 wk). Sixteen of 21 patients (76%) maintained long-term cessation of drainage. The median length of follow-up was 68 weeks (range, 35-101 wk). No abscess developed during treatment in any patient. EUS evidence of persistent fistula activity was seen in 10 patients (48%). Of the 11 patients (52%) in whom EUS showed no persistent fistula activity, 7 (64%) have maintained fistula closure off of infliximab and Cipro. Median duration from last infliximab infusion was 47 weeks (range, 20-80 wk). The remaining 4 patients continued infliximab to maintain remission of their luminal disease. Only 1 patient with a horseshoe fistula showed complete healing on EUS. In conclusion, using EUS to guide therapy for Crohn's perianal fistulas with infliximab, an immunosuppressive, and an antibiotic is associated with a high short and long-term fistula response rate. EUS may identify a subset of patients who can discontinue infliximab without recurrence of fistula drainage.

The endoscopic management of pancreatic fistulas

Interest in the use of therapeutic endoscopy for the treatment of pancreatic diseases has been on the increase for several years. Our aim was to assess the efficacy of endoscopic retrograde cholangiopancreaticography (ERCP) in the treatment of pancreatic fistulas. We evaluated the results of therapeutic ERCP in 50 patients with pancreatic fistula treated at the Helsinki University Central Hospital from 1998 to 2003. The success rate of fistula closure after therapeutic ERCP was 82%. Five patients required operative treatment when ERCP was unsuccessful. There was little morbidity and no procedure-related mortality. Four patients died because severe illnesses made them unfit for any further procedures. ERCP is a safe and effective modality and should be considered as first-line therapy in the management of pancreatic fistula.

Surgical Technique for the Correction of Postpalatoplasty Fistulae of the Hard Palate

Postpalatoplasty fistulas of the hard palate remain challenging. The reported recurrence rate after surgical correction ranges between 33 and 37 percent. The authors describe a surgical technique for the correction of postpalatoplasty fistulas by total elevation of the palatal gingivoperiosteum starting at the dental sulcus, excision of the fistula, and watertight separate closure of the nasal and palatal mucosa by means of the transoral approach. This technique has the advantages of providing adequate exposure for closure of the nasal mucosal gap and allowing closure of the palatal defect under minimal tension. Placement of interdental sutures leaves no raw bone surfaces exposed. The authors have used this technique on 60 consecutive patients with fistulas of the primary and secondary hard palate between 1998 and 2003. Their overall success rate of fistula closure was 90 percent. The success rate for previously unoperated postpalatoplasty fistulas was 96.9 percent. All of the failures occurred in patients who had bilateral cleft lip and palate. No complications of tooth loss or gingival recession were observed. A detailed description of the technique with illustrations is provided.

Resource Management In Fistulae Treatment

Background: Gastrointestinal and pancreatic fistulae are characterized as serious complications following abdominal surgery. Fistula formation results to prolonged hospitalization, increased morbidity and mortality and higher treatment costs. Conservative and surgical approaches are both accepted in their management. The purpose of this study was to assess, evaluate and compare the potential clinical benefit of pharmacotherapy and its cost-effectiveness. Both methods involve the use of somatostatin (SMS) and its analogue, octreotide. Patients and methods:Fifty-one patients with gastrointestinal or pancreatic fistulae were randomized, 19 receiving 6000 iu/day of somatostatin intravenously, 17 receiving 100 µG three times daily (tid) of octreotide subcutaneously and 15 receiving only standard medical treatment. Results: The fistula closure rate was 84% for the SMS group, 65% for the octreotide, and only 27% for the control group. Differences between pharmacotherapy and the standard group were of statistical significance (p = 0.007). Overall, the mortality rate was less than 5% and statistically significant differences between the three subgroups could not be established. In regards to cost-effectiveness, this was overall in favor of the SMS and octreotide groups versus the control, and better for SMS than the octreotide group. The average hospital stay was 21.6, 27.0 and 31.5 days for the SMS, the octreotide and the control group, respectively. Conclusions: These data suggest that pharmacotherapy reduces the costs involved in fistulae management (by reducing hospitalization) and also offers an increased, spontaneous closure rate. Further prospective studies focusing on the above parameters are needed in order to demonstrate the clinico-economic benefits.

Analysis of pharyngocutaneous fistula following free jejunal transfer for total laryngopharyngectomy.

The development of a pharyngocutaneous fistula is the most common and troublesome complication in the early postoperative period following free jejunal transfer for total laryngopharyngectomy. However, many aspects of this complication remain unclear. In this study, the authors analyzed their experience with the pharyngocutaneous fistula formation following free jejunal transfers to evaluate its clinical behavior, determine the significance of the anastomotic technique used, and evaluate the role of preoperative radiation therapy on its formation and management. Of 168 patients who underwent free jejunal transfers following total laryngopharyngectomy at the authors' institution between July of 1988 and March of 2000, 23 patients (13.7 percent) with postoperative fistulas were identified. The mean onset of fistula formation was 16 days. Of the 23 fistulas, 13 (56.5 percent) occurred at the proximal and 10 (43.5 percent) at the distal anastomoses. Whereas the majority of the proximal fistulas (69.2 percent) developed near the mesenteric side of the jejunal flap, most of the distal fistulas (90 percent) were located anteriorly. The incidence of proximal fistula formation was higher in patients with a single-layer repair than in patients with a two-layer repair of a proximal anastomosis (80 percent versus 38.5 percent, p = 0.09). The incidence of fistula formation was greater in patients who received preoperative radiation therapy than in those who did not (16.3 percent versus 11.4 percent, p = 0.36). In addition, whereas a majority of fistulas (80 percent) occurred at the proximal anastomosis in patients who did not receive preoperative radiation therapy, most fistulas (61.5 percent) occurred at the distal anastomosis in patients who did receive radiation therapy (p = 0.09). The fistulas closed spontaneously in 15 patients (65 percent). On average, spontaneous closure occurred in 7.4 weeks. Proximal fistulas had a significantly higher rate of spontaneous closure compared with distal fistulas (85 percent versus 40 percent, p = 0.04). The rate of spontaneous fistula closure was higher in patients who had not received preoperative radiation therapy than in those who had (90 percent versus 46 percent, p = 0.07). Surgical closure of the fistula was required in five patients. The fistulas were not repaired in three patients because of recurrent tumor. Twenty patients (87 percent) resumed oral feeding after the closure of the fistula, with 17 (85 percent) of 20 patients tolerating a regular diet and three (15 percent) of 20 a liquid diet only.In conclusion, most fistulas occur at the proximal anastomosis and near the mesenteric side of the jejunal flap, and the use of a two-layer anastomotic technique seems to be associated with a lower incidence of fistula formation at the proximal suture line. Most fistulas close spontaneously, especially ones that occur proximally. Preoperative radiotherapy does seem to increase the risk of fistula formation, especially at the distal anastomotic site and make subsequent resolution of the fistulas more difficult. Most patients are able to resume oral feeding once the fistula is closed.

Effectiveness of endoscopic treatment modalities in complicated hepatic hydatid disease after surgical intervention.

Hepatic hydatid cyst is a common disease in Turkey and the rupture of the cyst into the biliary tract is the most common complication which is difficult to detect and to manage. The aim of this study was to investigate the effectiveness of endoscopic treatment modalities in hydatid cyst patients with biliary complications who had previously undergone surgery. Over the last 8 years, by means of endoscopic retrograde cholangiopancreatography (ERCP), we have examined 87 patients with postoperative biliary symptoms who had previously undergone surgery for hepatic hydatid disease of the liver. Endoscopic treatment modalities were as follows: endoscopic sphincterotomy (ES) and nasobiliary drainage in patients with biliary fistula; balloon and or bougie dilation and stenting in patients with biliary stricture; and ES and balloon extraction in patients with residual hydatid material within the bile duct. Findings from ERCP included biliary fistula in 55 patients (63.2 %), biliary stricture in 16 (18.4 %), and residual hydatid material within the bile duct in 14 (16.1 %). Two patients had normal findings on ERCP. In total, 85 patients were treated by means of endoscopic modalities. The time to closure of fistula was 17.8 +/- 5 days and the rate of fistula closure was 81 %. Biliary stenting was performed in 13 patients with biliary stricture. Endoscopic removal of hydatid material was achieved in 14 patients. The overall success rate of endoscopic treatment was 86 %, and a second surgical intervention was required only in six patients. No serious complication was encountered after endoscopic procedures. Endoscopic treatment modalities are safe and helpful methods for the treatment of biliary complications of hepatic hydatid cyst in the postoperative period.

Fibrin glue for all anal fistulas

The aim of this study was to determine if a new sphincter muscle—sparing technique that uses fibrin glue was effective in closing all types of anal fistulas. All patients with anal fistulas who were seen by a single surgeon over a 2-year period were treated with fibrin glue. Six to 8 weeks after a seton was placed in the fistula tract, either autologous fibrin glue or commercially available fibrin sealant was used to close the fistula tract. Twenty patients were treated with a mean follow-up of 10 months. Etiology of the anal fistulas was as follows: cryptoglandular in 13, Crohn's disease in four, and miscellaneous in three. Fibrin glue closure of the anal fistula was successful initially in 15 patients (75%) and was successful after a second treatment in two additional patients, for an overall fibrin glue fistula closure rate of 85% (17 of 20). Functional results have remained excellent with no patient reporting any change in continence after treatment. Fibrin glue is simple and effective treatment for all anal fistulas with excellent functional results.

Fibrin glue for all anal fistulas

The aim of this study was to determine if a new sphincter muscle-sparing technique that uses fibrin glue was effective in closing all types of anal fistulas. All patients with anal fistulas who were seen by a single surgeon over a 2-year period were treated with fibrin glue. Six to 8 weeks after a seton was placed in the fistula tract, either autologous fibrin glue or commercially available fibrin sealant was used to close the fistula tract. Twenty patients were treated with a mean follow-up of 10 months. Etiology of the anal fistulas was as follows: cryptoglandular in 13, Crohn's disease in four, and miscellaneous in three. Fibrin glue closure of the anal fistula was successful initially in 15 patients (75%) and was successful after a second treatment in two additional patients, for an overall fibrin glue fistula closure rate of 85% (17 of 20). Functional results have remained excellent with no patient reporting any change in continence after treatment. Fibrin glue is simple and effective treatment for all anal fistulas with excellent functional results.

Role of Octreotide and Somatostatin in the Treatment of Intestinal Fistulae

Intestinal fistulae usually arise as a complication of abdominal surgery. Its treatment is complex and intestinal fistula-related morbidity and mortality is high. Fistula closure rates under conservative medical treatment vary between 24 and 72%. Octreotide and somatostatin reduce gastrointestinal, biliary and pancreatic secretion and increase intestinal water and electrolyte absorption. In recent years, octreotide and somatostatin have been associated with conservative medical treatment for patients with intestinal fistulae. Four placebo-controlled studies have been published within the past 6 years. The interpretation of their results is difficult because patient collectives were small and heterogeneous. In one study, somatostatin decreased fistula-related complications when compared to placebo, and in another study, octreotide decreased the healing time of intestinal fistulae and the time patients required total parenteral nutrition when compared to placebo. In contrast, the fistula closure rate, hospitalization time and mortality were not influenced by the use of octreotide or somatostatin in conservative medical treatment. In conclusion, octreotide and somatostatin actually cannot be recommended in the treatment of intestinal fistulae in settings outside of controlled trials.

Endoscopic treatment of postoperative bronchopleural fistula

Abstract Background . The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. Methods . The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. Results . Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas ( Conclusions . Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

Background. The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. Methods. The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. Results. Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment. Conclusions. Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Endoscopic Management of Biliary Fistulas Complicating Liver Transplantation and Other Hepatobiliary Operations

This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations. Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting. During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications. Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%. The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.

Effect of Subconjunctival Daunorubicin on Glaucoma Surgery in Rabbits

ABSTRACT Daunorubicin (DNR), an antibiotic-antimetabolite, was used as an adjunct to standardized partialthickness filtration surgery in 21 rabbits to determine its effects on that surgery. Postoperatively, one of the eyes of each rabbit received subconjunctival injections of DNR 25 µg or 50 µg, while the fellow eyes received only diluent, daily for 2 to 14 days. Bleb survival, fistula patency, the thickness of the subconjunctival connective tissue, and postoperative complications were investigated. The filtration blebs lasted significantly longer (P &lt; .005), the rate of fistula closure was significantly lower (P &lt; .005), and the subepithelial connective tissue was much looser and thicker in the experimental eyes than in the control eyes. Corneal toxicity occurred more frequently in the eyes treated with the higher-dose DNR than in those treated with the lower dose and in the control eyes.

Treatment of Gastrointestinal Fistulas with Sandostatin®

Pharmacological treatment of patients with enterocutaneous fistulas aims at reducing output, increasing the chance of spontaneous closure and reducing the time of fistula closure. Our initial experience with octreotide suggests that this drug effectively reduces output of established enterocutaneous fistulas when compared with a placebo in patients on parenteral nutrition. Output reduction was independent of the basal output. Likewise, this somatostatin analogue was shown to accelerate fistula closure in a series of 27 patients treated with the drug after having received parenteral nutrition for a mean of 25 days. When compared with a historical series, the rate of spontaneous fistula closure was not modified by octreotide.