Small Fistula Research Articles

A Case of Oronasal Fistula Repaired With Inferior Turbinate Rotational Flap

Oronasal fistula is a rare but significant complication that diminishes the quality of life for patients undergoing treatment for cleft palate and head and neck cancer. Various surgical reconstruction methods can be used based on the size and location of the oronasal fistula. The intranasal inferior turbinate rotational flap is a simple and safe method for reconstructing the defect of nasal cavity. In this case report, we experienced a small oronasal fistula of a 50-year-old female caused by osteoradionecrosis after treatment for her malignant melanoma. Successful reconstruction was achieved with inferior turbinate rotational flap alone. For small oronasal fistula in the hard palate, the inferior turbinate flap alone can be a useful option for reconstruction.

A DIFFERENT VIEW OF MINOCA; A RARE CASE OF CORONARY CAMERAL FISTULA

Abstract Coronary cameral fistula (CCF) is defined as an abnormal connection between the coronary artery and the heart chambers. Although rare, most are asymptomatic, usually arising from the right coronary artery and terminating in the right ventricle or right atrium. Often detected incidentally, CCFs may present with symptoms of heart failure or rarely with anginal symptoms. Introduction A coronary cameral fistula is defined as an abnormal connection between the coronary artery and the heart chambers. CCFs are found in less than 1% of the population.[1] The most common coronary artery fistula is that arising from the right coronary artery and spilling into the right ventricle.[2] In particular, CCFs arising from all three epicardial coronary arteries are rare but can be clinically significant. These cases may present with acute coronary syndrome causing steal syndrome. Since there is usually no underlying obstructive lesion, these cases may be diagnosed as myocardial infarction without obstructive coronary arteries (MINOCA)[3] Case; A 51 years old male patient was admitted to the emergency room with a complaint of stabbing chest pain for the last one week. In his anamnesis, he described that the chest pain increased with exertion and radiated to the back. It was learned that he had no known disease and coronary history, was a 20 pack/year smoker, had no family history and was not taking any medication regularly. Vital signs in the emergency room revealed a blood pressure of 120/80 mmHg, pulse rate of 85 per minute and normal saturation. Electrocardiography (ECG) showed sinus rhythm V 1-6 with T negativity 85/min. (Figure 1) Echocardiography revealed no wall motion defect and no major valve pathology. Laboratory findings showed renal function tests within normal range, C-reactive protein within normal range, hemoglobulin level 17.6 gr/dl, HS Troponin-T level 12.9 ng/l (upper limit 14 ng/l). At 3 hours, the control HS Troponin-T level was 69.2 ng/l and the patient was hospitalized in the coronary intensive care unit with a prediagnosis of acute coronary syndrome. Coronary angiography was performed during follow-up. Angiography showed dilatation in the main coronary artery (LMCA), ectasia in the left anterior descending artery (LAD) and circumflex artery (CX), and diffuse tortuosity in the coronaries. CCF formed by the LAD, CX and right coronary artery (RCA) together and spilled into the left ventricle. Opaque filling was observed in the left ventricle. (Figure 2) Although the patient had a low body mass index, dilatation of the coronary arteries was thought to be the effect of steal syndrome caused by multiple fistulas. The patient was admitted to the coronary intensive care unit with medical follow-up. The patient's medical treatment was adjusted as acetylsalicylic acid (ASA) 100 mg pill 1*1, metaprolol 50 mg pill 1*1 and rosuvastatin 20 mg pill 1*1 due to an LDL cholesterol level of 149 mg/dl. In the patient who currently had no signs of heart failure, medical treatment was decided primarily in terms of CCF. The patient was discharged with the recommendation of outpatient follow-up. Discussion and Conclusion; CCFs are rare coronary anomalies.[1] When we look at the etiology, the most common cause of CCFs is abnormal embryogenesis.[4] While the diagnosis can be made at any age, the diagnosis is usually made in early childhood when a heart murmur occurs in an asymptomatic child or in a child with symptoms of heart failure. However, cases of CCF diagnosed at an advanced age with anginal complaints and signs of acute heart failure are seen in the literature. [5]Treatment depends on the anatomical features of the fistula and, of course, the patient's symptoms. While small fistulas may close spontaneously with age, large fistulas may require closure.It may cause anginal symptoms by causing heart failure symptoms and steal syndrome. [6]When we look at the literature, we can see that patients with CCF also present with acute coronary syndrome. [2, 4, 5,] As in the case reported by Alsancak Y et al., CCFs originating from all three coronary arteries cause steal syndrome and are often diagnosed with a prediagnosis of acute coronary syndrome.[7] The absence of an occlusive lesion after angiography in these patients with high troponin levels suggests atherosclerosis at the microvascular level and the diagnosis of MINOCA. [3]Angiography performed with suspicion of stenosis in the coronary arteries and finding a CHF instead of a stenosis may be considered lucky in these patients. The size of the fistula and the possibility that it may lead to heart failure in the follow-up will be the other side of the unlucky coin.

A population-based study of incidence, aetiology, treatment and outcome of enterocutaneous fistula.

The aim of this work was to investigate the incidence of enterocutaneous fistula (ECF), including both small bowel and colonic fistulas, in a defined population of 1.04 million during a 10-year period and to describe aetiology, treatments, care consumption and outcome. A comprehensive search algorithm including diagnostic and procedural codes, enterostomal therapy nurse notes and in-hospital care for >60 days yielded 1970 search hits. After reviewing medical records, 187 patients with ECF were identified. The annual incidence of ECF was 2.3 per 100 000, the incidence of ECF with intestinal failure type II was 0.9 per 100 000. Spontaneous closure of the fistula occurred in 16.0% of patients, while closure was seen in 97.3% of patients who underwent reconstructive surgery with recurrences in 6.7% and 8.3%, respectively. Cumulative ECF-related in-hospital care until closure or end of follow-up was 4 (range 0-61) weeks. Eighty-eight patients (47%) received home-based healthcare including parenteral feeding and/or fistula wound care. The estimated overall mortality at 1, 3 and 5 years was 33.7%, 42.1% and 47.6% respectively. Mortality was mainly in patients without spontaneous closure or reconstructive surgery, and the risk of ECF-related death was 30.2%. This study defines the population-based incidence of ECF and reports a high overall mortality rate. Initial survivors were characterized by either spontaneous closure or eligibility for later reconstructive surgery, but with an eventual mortality rate of approximately 20%. ECF patients are high consumers of care: 55.1% needed ≥4 weeks in hospital and many received home-based healthcare.

Nomogram for predicting intolerable postoperative early enteral nutrition following definitive surgery for small intestinal fistula: a cohort study.

This study was designed to develop and validate a nomogram for predicting intolerable early enteral nutrition (EEN) following definitive surgery (DS) for small intestinal fistula. A total of 377 patients, recruited from January 2016 to September 2023, was randomly allocated into development ( n =251) and validation ( n =126) groups in a 2:1 ratio. Risk factors were identified using the nomogram. Its performance was assessed based on calibration, discrimination, and clinical utility, with validation confirming its effectiveness. Of the 377 patients, 87 (23.1%) were intolerant to EEN, including 59 (23.1%) in the development cohort and 28 (22.1%) in the validation cohort ( P =0.84). Four factors were identified as predictive of intolerable EEN: severe abdominal adhesion, deciliter of blood loss during DS, human serum albumin (Alb) input >40g during and within 48h post-DS, and the visceral fat area (VFA)/total abdominal muscle area index (TAMAI) ratio. The model demonstrated excellent discrimination, with a C-index of 0.79 (95% CI: 0.74-0.87, including internal validation) and robust calibration. In the validation cohort, the nomogram showed strong discrimination (C-index=0.77; 95% CI: 0.64-0.87) and solid calibration. Decision curve analysis affirmed the nomogram's clinical utility. This research introduces a nomogram that enables the individualized prediction of intolerable EEN following DS for small intestinal fistula, demonstrating a possible clinical utility.

Popliteal access for iliofemoral occlusive disease in the office-based catheter laboratory

ObjectivePopliteal access as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study was to evaluate the safety and efficacy of popliteal access for the endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. MethodsFrom October 2018 to October 2023, a total of 1408 interventions for peripheral artery disease were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micropuncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent grafts, aortobifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured perioperatively and at 90 days. Patency was determined clinically, by arterial duplex examination, and by need for reintervention for ≤2 years. ResultsWe performed 27 popliteal access procedures in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in nine. Indications for popliteal access were existing aortoiliac stent graft in 11, aortobifemiliac bypass in 4, noncrossable iliac occlusions in 3, failed antegrade femoral access in 4, flush superficial femoral artery occlusion in 3, and bilateral common femoral artery disease precluding access in 2. Trans-Atlantic Inter-Society Consensus classification preoperatively was B, 4; C, 4; and D, 19. Treatments included atherectomy/balloon angioplasty and stent in 12, balloon angioplasty and stenting in 4, atherectomy/balloon angioplasty in 5, and balloon angioplasty alone in 6. Successful opening of occlusions occurred in 25 of 27 patients (92.5%). No complications or major adverse cardiac events occurred, except one asymptomatic small popliteal arteriovenous fistula. Of the 25 successful procedures, the duplex patency at 3, 6, and 12 months was 19/20 (95%), 11/15 (69.3%), and 11/13 (61%). Rutherford Classification improved from a preoperative value of >4 in 24 of 27 (89%) to a postoperative value of <2 at 1 month in 23 of 23 (100%), at 3 months in 19 of 20 (95%), at 6 months in 11 of 15 (69.3%), and at 12 months in 11 of 13 (61%). Freedom from reintervention at 3 months occurred in 19 of 20 (95%), at 6 months in 13 of 15 (86%), and at 12 months in 12 of 13 (79%). ConclusionsPopliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.

Single Center Retrospective Evaluation of Coronary Artery Fistula Outcomes.

There is a paucity of literature describing long-term outcomes of patients with coronary artery fistula with most manuscripts focusing on those requiring interventions. We describe single-center outcomes of coronary artery fistulas including those not requiring intervention. We performed a retrospective review of the electronic medical record and identified all patients with a diagnosis of coronary artery fistula over the last 10years. 158 patients were identified with a coronary artery fistula. The mean age at diagnosis was 5.8years (SD ± 5.9). There was a male (55%, n = 87) predominance. Concomitant congenital heart lesion was present in 49% (n = 77) and a genetic anomaly was found in 18% (n = 29). No ischemic changes on electrocardiogram or ECG-stress test were observed. The mean follow-up was 5.0 (SD ± 3.8) years. Most patients (94%, n = 149) did not undergo an intervention. Of those 63% (n = 94) had at least one follow-up echocardiogram. There was spontaneous coronary artery fistula closure in 44% (n = 41), 8% (n = 8) decreased in size, and 48% (n = 45) were unchanged. No patient had enlargement of the coronary artery fistula over time. Additionally, tiny and small coronary artery fistulas showed no significant clinical changes in coronary artery dimensions, left ventricle dimensions and function over time. Seven patients required intervention; two patients underwent surgical ligation and five underwent catheter-based intervention. Most patients with coronary artery fistula in our cohort did not require intervention and over half either closed spontaneously or decreased in size with routine follow-up.

Efficacy and Safety of Platelet-Rich Plasma on Bronchopleural Fistula: A Pilot Prospective Cohort Study

IntroductionBronchopleural fistula (BPF) is associated with high morbidity and mortality rates in patients undergoing pulmonary resections. Surgery, bronchoscopy, and conservative management have their limitations for small fistulas. Platelet-rich plasma (PRP) has regenerative properties, which might be efficient in enhancing tissue recovery and repairing small BPF. This study aimed to investigate efficacy and safety of PRP on BPF. MethodsThis is a pilot prospective cohort study. Patients whose fistulas smaller than 4mm were enrolled in this study, treated with PRP under bronchoscopy and followed up at 2 weeks and 4–6 weeks after the last PRP treatment. The cure rate, improvement rate and ineffectiveness rate were investigated. The severity of respiratory symptoms was evaluated by modified Medical Research Council dyspnea scale (mMRC) and COPD Assessment Test (CAT). The recurrence of fistula, new infection and mortality rate were examined. Adverse events were documented to explore the safety profile of PRP therapy. ResultsA total of 16 patients (mean age, 50.1 years) met the eligibility criteria. The median time from the first PRP treatment to the closure of the fistula was 12.0 (IQR 6.0, 21.5) days. Our findings indicate an effectiveness rate of 87.6%, with 68.8% of cure and 18.8% of improvement, along with significant improvement of respiratory symptoms evaluated by mMRC (P<0.001) and CAT (P<0.001). No recurrent of fistulas, newly developed infection, or death was observed. Adverse events of the procedure were most mild (82.6%) and temporary. ConclusionsPRP is a potential treatment for small BPF and is well tolerated.

Vacuum assisted closure therapy in children with complicated abdominal wounds, with or without viscero-cutaneous fistulae

BackgroundManagement of complicated abdominal wounds is challenging in children. Vacuum-assisted closure proved to be beneficial. We aimed to report the outcome of VAC over 5 years’ practice in complicated abdominal wounds with or without viscero-cutaneous fistulae. MethodsRetrospective review of children managed by VAC over 5 years, from January 2017 to December 2022. Included patients had complicated abdominal wounds. Customized VAC devices with continuous negative pressure were used for all patients. The applied pressure was tailored according to the patient's age and the wound condition. ResultsNineteen patients were included, their ages ranged from 3 months to 15 years. Peritonitis was the main pathology in 12 patients, abdominal wall infection in 4, and a combination of both in 3. VAC was applied over closed wounds in 10 patients and over open wounds in 9; 6 of them had cutaneous fistulae. The median duration of VAC application over closed wounds was 7.5 days, while it was 10 days in open wounds. VAC promoted healing in closed and narrow-gapped wounds, while it was successfully used as a bridging therapy in 4 patients with wide-gapped wounds. Patients with viscero-cutaneous fistulae were successfully managed without further surgical intervention. VAC was complicated by fascial dehiscence with evisceration and incisional hernia in two patients. ConclusionVAC could be beneficial to complicated abdominal wounds in pediatric age. It was helpful in managing small viscero-cutaneous fistulae.

Characteristics and management of post-circumcision Urethrocutaneous Fistula: a retrospective study in surgical units in Cameroon.

Urethrocutaneous fistula (UCF) is one of the major complications of circumcision. The risk factors associated with UCF are not clear-cut but its repair remains a challenge for urological surgeons. The aim of this study was to highlight the epidemiological, and clinical features and outcomes obtained from the management of UCF in the context of a country with limited medical resources where ritual circumcision is widely practiced. From February 2010 to December 2022, 35 patients underwent surgical repair for post-circumcision UCF in two tertiary hospitals in Yaounde, Cameroon. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu techniques were performed. The mean age of patients was 7.4 ± 4.1 years with a range of 2 to 21 years; the median age at circumcision was 24 months (12; 48). Most (95%) of circumcisions were performed by paramedical staff. The majority of patients (n = 26) consulted for a bifid stream, Three-quarters of fistulae were located at the corona. Small fistulae represented 74.28% (n = 26) of cases as opposed to large fistulae (25.71%). More than 70% of patients underwent a simple closure. The therapeutic results were satisfactory in 91.4% of cases (n = 32) after an average follow-up of 91.85 ± 51.92 months. There were no statistically significant differences between the patients with coronal fistula and patients with distal penile fistula concerning demographic, clinical and surgical characteristics. Urethrocutaneous fistula is a major and frequent complication of circumcision mostly practiced by non-qualified personnel on children aged 24 months. The usual presentation is micturition with a bifid stream occurring on average 3 months after circumcision. Coronal fistulas are the commoner location. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu technique appear to be safe with the advantages of low recurrence rate. An accurate diagnosis with a timeframe respecting the principles of fistula surgery combined with regular follow-up is mandatory for good long-term results with a low recurrence rate. Further prospective studies on the factors affecting the formation of urethrocutaneous fistula should be performed to prevent this complication of circumcision.

Cystitis glandularis with concomitant Crohn’s disease leading to a paroxysm of Crohn’s disease with ulcerated external iliac vessels

•we report the case of a 36-year-old female patient who presented to our hospital with a diagnosis of cystitis glandularis manifesting as a vesicovaginal fistula. She underwent cystoscopic biopsy at a local hospital, but anti-inflammatory treatment was ineffective, and the patient was experiencing low urination frequency and urgency, as well as pain. The patient underwent laparoscopic repair of a cystoscopy-confirmed vesicovaginal fistula. After surgery, the patient experienced a paroxysm of Crohn’s disease with multiple small bowel fistulas and erosion of the external iliac vessels that ruptured to form an external iliac vessel small bowel fistula. The fistula was confirmed by surgical exploration, and the patient eventually died.

A method for treatment of deep and superficial enteroatmospheric fistulas in an open abdomen, ChimneyVAC: Ten years experience.

Leakage of intestinal fluid is a challenging event when it appears in an open abdomen (OA) and surgical deviation does not seem possible. Intestinal contents in the abdominal cavity maintain inflammation and drainage is there for essential. We have developed a method, ChimneyVAC, to treat both deep and superficial enteroatmospheric fistulas (EAF) AIMS: To describe this innovative surgical technique and our 10-year experience. This single-center observational cohort study included all 16 consecutive patients treated with ChimneyVAC. Seven women and 9 men; median age: 47; (interquartile range [IQR]:39-63) years, 15 with a small bowel fistula and 1 with a large bowel fistula. All except of the colonic fistula were classified as a high output fistula; 14 were deep and 2 superficial. In this technique, a negative-pressure source is applied directly above the fistula opening, in addition to negative pressure wound therapy for the OA. This controls the leakage of intestinal fluid by direct drainage into a vacuum system, thereby avoiding contamination of the abdomen. A controlled enterocutaneous fistula (ECF) then forms as the traction from the ChimneyVAC brings the fistula opening to skin level. In 14 patients, an ECF formed after a median of 42 (IQR:28-55) days and 12 (IQR:7-16) dressing changes. The median length of hospitalization was 103 (IQR:58-143) days. Two patients died of multiorgan failure and 14 initially survived. This study showed that 14 out of 16 patients survived the initial treatment for enteric leakage with the ChimneyVAC method. The outcome of ChimneyVAC treatment is a controlled ECF, which was then corrected after a median of six months. However, hospitalization is lengthy, the patients undergo several dressing changes and many needs additional parenteral nutrition until intestinal continuity is reestablished. ChimneyVAC is a feasible method for treatment of EAF in an OA, with favorable survival.

Thoracoscopic Management of Chylothorax by Application of a Fibrin Sealant Patch

Thoracic duct ligation is a demanding procedure when the chyle leak and/or the duct itself are not identified. This report describes a new procedure using thoracoscopic closure of the chyle leak by application of a fibrin sealant patch. This strategy was successfully applied for closing (i) a small fistula due to a postoperative lesion of the lymphatic tributary vessels in one case, and (ii) a large fistula due to idiopathic rupture of the thoracic duct in another case.

A313 DISCONNECTED PANCREATIC DUCT SYNDROME: A RETROSPECTIVE OBSERVATIONAL STUDY REVIEWING AN IMPORTANT BUT OVERLOOKED COMPLICATION OF NECROTIZING PANCREATITIS

Abstract Background Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis (ANP) characterized by a complete disruption of the main pancreatic duct, leading to the loss of continuity between the pancreatic duct and the gastrointestinal tract (figure 1). Due to unopposed leakage of residual pancreatic fluid, patients with DPDS often experience a prolonged disease course with significant morbidity, including complications such as pancreatic fistulas. However, information about the epidemiology, clinical characteristics, and outcomes of DPDS remains scarce. Aims To assess clinical outcomes, diagnostic delay, burden of endoscopic and surgical interventions, and complications related to DPDS. Methods A retrospective review was conducted for all patients diagnosed with DPDS who underwent either endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) at our tertiary center between January 2010 and December 2022. Results Fifteen patients with DPDS following ANP were identified. The median age of patients at DPDS diagnosis was 56 years (range 33-86 years), with 47% being female. The most common etiology of ANP was biliary (40%), followed by idiopathic (33%) and alcoholic (27%). The median time between ANP diagnosis and DPDS diagnosis was 265 days (range 86-2023 days). Patients underwent a median of 3 (1-9) endoscopic interventions and 1 (0-5) surgical intervention between the initial ANP episode and DPDS diagnosis. 40% of patients experienced intra-abdominal sepsis secondary to infected pancreatic fluid collections. 20% developed pancreatic fistulas (two small bowel fistulas and one cutaneous fistula). 20% developed new-onset diabetes, and 13% had significant worsening of pre-existing diabetes. No mortalities were reported. Conclusions There is a significant delay in diagnosing DPDS following ANP, and a substantial burden of endoscopic interventions is required. Frequent complications of DPDS were pancreatic fistulas, recurrent pancreatic fluid collections, and pancreatogenic diabetes. Developing a predictive model for assessing the risk of DPDS development following ANP could aid in earlier diagnosis and potentially reduce morbidity and complications associated with DPDS. Figure 1. Contrast enhanced CT demonstrating typical finding in DPDS in coronal (A) and axial (B) views. CT demonstrates 3cm area of necrosis involving pancreatic neck/body (asterisk) with viable upstream parenchyma in the remainder of the body and tail (white arrow). Pancreatic head/uncinate parenchyma and main duct appear intact (black arrow). B, the distal pancreatic duct is not dilated. DPDS, disconnected pancreatic duct syndrome. Funding Agencies None

Drainage methods in patients with unformed intestinal fistulas during the preparation to the surgical treatment

The aim of the study is to analyze the data of the modern foreign and domestic literature on intestinal fistulas, including high unformed small intestinal fistulas, their classification, treatment methods, drainage methods, their types and effectiveness. Research method: the search in the elibrary, CyberLeninka, PubMed and SpringerLink databases. Intestinal fistulas, often found in the surgical practice, appear due to a number of reasons (errors in the surgical technique and conservative treatment, tactical errors, the presence of severe concomitant diseases, etc.) and present a high-risk factor for death. Clinically, intestinal fistulas can differ depending on their localization, etiology, morphology, function, complications, etc., that causes certain difficulties in choosing the treatment method and reduces its success. Special attention is paid to high unformed small intestinal fistulas, which are accompanied by pronounced impairment of the body's homeostasis system, on the one hand, and the need for a multi-stage treatment, on the other hand. The treatment regimen for high unformed small intestinal fistulas includes both conservative and surgical approaches. The conservative method of treatment includes an intensive infusion therapy, control of the source of infectious complications, reduction of irretrievable losses, nutritional therapy, and a local treatment, which consists in protecting the tissues from the aggressive intestinal content and various methods of adequate drainage of the wound. The drainage methods used for intestinal fistulas differ depending on the principle of their operation, the surgical drain material, the configuration of the wound, the fistula morphology, the number of fistulas, etc. Active and vacuum methods seem to be used most frequently and efficiently in the local treatment of high unformed small intestinal fistulas. So far, according to the (very limited) modern literature, there has been a diversity in the effectiveness of the drainage treatment approaches in patients with high unformed small intestinal fistulas, thus, further studies are needed to study and evaluate their pathogenetic role and effectiveness.

Circumflex to Left Atrial Appendage Fistula Associated With Watchman FLX Closure Device

An 82-year-old man who had undergone Watchman FLX (Boston Scientific) device implantation presented with dyspnea. Multimodality evaluation demonstrated a small fistula from the proximal circumflex artery to the left atrial appendage. Anatomically, the left circumflex artery is close to the atrial appendage; therefore, it is plausible that fistula formation could be a late complication of implantation of the device.

Ruptured Pulmonary Hydatid Cyst with Multiple Small Bronchopleural Fistula Formations: A Case Report

Hydatid disease is a zoonosis caused by Echinococcus granulosus. It manifests as cystic lesions, most commonly found in the liver and lungs, and rarely in other parts of the body. The disease occurs when a human host accidentally ingests contaminated food containing eggs from canine waste products. Since the clinical characteristics of this disease are nonspecific, radiological investigations play a crucial role in diagnosis. Diagnostic challenges arise due to atypical imaging features of complicated hydatid cysts. A 40-year-old female patient presented with fever, breathlessness, chest pain, and an unproductive cough persisting for eight days. Upon examination, she was in hypovolaemic shock, and an intercostal drainage tube had been inserted in the left sixth intercostal space. The chest radiograph revealed a dense, homogeneous opacity in the left hemithorax, partially compressing the left lung medially. An High-resolution Computed Tomography (HRCT) thorax showed a thick-walled cavity with an air-fluid level and layered membranes in the dependent part of the cavity, indicating a water lily sign in the left lower lobe of the lung, suggesting a ruptured hydatid cyst. The patient underwent cystectomy with suturing of a small bronchopleural fistula. Computed Tomography (CT) is the preferred imaging modality, especially for assessing associated complications and ruling out differentials in cases of ruptured pulmonary hydatid cysts.

Patient Satisfaction After Using a Reverse Flow Based Facial Artery Musculomucosal Flap (FAMM) versus a Palatal Pedicled Flap for Closure of Recurrent Small and Medium-Sized Oronasal Fistula: A Randomized Clinical Trial

Patient Satisfaction After Using a Reverse Flow Based Facial Artery Musculomucosal Flap (FAMM) versus a Palatal Pedicled Flap for Closure of Recurrent Small and Medium-Sized Oronasal Fistula: A Randomized Clinical Trial

Decellularized small intestine scaffolds: a potential xenograft for restoration of intestinal perforation

ABSTRACTSmall intestine perforation is a serious medical condition that requires immediate medical attention. The traditional course of treatment entails resection followed by anastomosis; however, it has complications such as small bowel syndrome (SBS), anastomotic leakage, and fistula formation. Here, a novel strategy is demonstrated, that utilizes the xenogeneic, decellularized goat small intestine as a patch for small intestine regeneration in cases of intestinal perforation. The goat small intestine scaffold underwent sodium dodecyl sulfate decellularization, which revealed consistent, quick, and effective decellularization. Decellularization contributed the least amount of extracellular matrix degradation while maintaining the intestinal architecture. By implanting the decellularized goat small intestine scaffolds (DGSIS) on the chorioallantoic membrane (CAM), no discernible loss of angiogenesis was seen in the CAM region, and this enabled the DGSIS to be evaluated for biocompatibility in ovo. The DGSIS was then xeno-transplanted as a patch on a small intestine perforation rat model. After 30 days post transplant, barium salt used as contrast gastrointestinal X-ray imaging revealed no leakage or obstruction in the small intestine. Histology, scanning electron microscopy, and immunohistochemistry assisted in analyzing the engraftment of host cells into the xeno patch. The xeno-patch expressed high levels of E-cadherin, α-smooth muscle actin (α-SMA), Occludin, Zonnula occluden (ZO-1), Ki 67, and Na+/K+-ATPase. The xeno-patch was consequently recellularized and incorporated into the host without causing an inflammatory reaction. As an outcome, decellularized goat small intestine was employed as a xenograft and could be suitable for regeneration of the perforated small intestine.

Small Arteriovenous Anastomosis in Fistula Creation: Establishing a Functional Vascular Access while Minimizing Steal Syndrome

ObjectivesThe size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis, but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends an 7-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula (AVF) creation. MethodsWe conducted a comparative retrospective analysis of patients who underwent fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between March 2019 and October 2020 at our institution. Anatomic sites included radiocephalic, brachiocephalic and brachiobasilic. All arteriovenous anastomoses were measured intra-operatively to be 5-6 mm in diameter for the small size groups and 8-10mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency and secondary patency. ResultsOut of 110 patients who underwent an AVF creation, 59.1% received a 5-6 mm anastomosis with a median follow-up time of 10±6 months. Patients’ demographics and comorbidities were relatively similar between the two groups except for a higher rate of hyperlipidemia (55.4% vs. 28.9%, P=0.008) in the small size group. Patients in the small size group were more likely to undergo a radiocephalic fistula (40% vs. 4.5%, P<0.001) and to have a smaller mean vein diameter on preoperative duplex ultrasound (3.2±1mm vs. 3.9±1mm, P=0.0016) when compared to their regular size counterparts. During follow-up, none of the patients in the small group developed steal syndrome (0% vs. 9%, P=0.015). At 1 year, patients in the regular size group achieved higher rates of primary patency (67.9% vs. 46.9%, P=0.02); however, no difference was seen in 1-year primary-assisted patency (84.9% vs. 73.6%, P=0.3), secondary patency (89.6% vs. 79.5%, P=0.3) nor in functional patency (87.7% vs. 82.2%, P=0.64) between the small and regular size groups, respectively. ConclusionsThe use of a 5-6 mm anastomosis in the creation of new arteriovenous fistulas of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. Additionally, even with smaller vein sizes pre-operative, adequate dialysis access can be created via a small sized anastomosis, including distal arm access. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.

THU200 Three Cases Of Prepubertal Vaginal Bleeding

Abstract Disclosure: H. Doi: None. M. Igarashi: None. T. Kashima: None. N. Ujita: None. H. Konno: None. A. Fujioka: None. H. Miyagi: None. K. Yoshii: None. Y. Naiki: None. R. Horikawa: None. Introduction: Children with prepubertal vaginal bleeding (PVB) are usually referred to pediatric endocrinologists, because precocious puberty is one of the important causes of PVB. However, the diagnosis remains challenging due to a wide variety of causative diseases beyond endocrinological disorders. We present three illustrative cases of children with PVB in our institution. Case presentations: Case 1. A 2-year-old girl had suppressed serum LH and FSH levels and elevated estradiol level. She had café-au-lait spots with jagged “coast of Maine” borders on her left chest and back. Her bone X ray showed multiple fibrous dysplasia. The diagnosis of McCune-Albright syndrome was made by a triad of skin, bone and hyperfunctioning endocrinopathy. Case 2. A 5-year-old girl had low serum LH, FSH, and estradiol levels. Her pelvic MRI showed a mass in her vagina and contrast enhancement of the vaginal membrane. Although some malignant tumor had been suspected, vaginal observation using cystoscopy revealed a foreign body of a sponge that seemed to be part of a toy. Her vaginal bleeding disappeared after removal. Our multidisciplinary team concluded that this case was not child abuse. Case 3. A 4-year-old girl had been misdiagnosed as central precocious puberty due to slightly elevated gonadotropin levels. She was referred to our hospital because gonadal suppression therapy with leuprorelin didn’t stop her PVB. Although the observation of her urethra, bladder, vagina, and uterus using cystoscopy revealed no abnormal findings, a small fistula on the membrane of her vaginal opening was noted. Finally, the diagnosis of von Willebrand’s disease type I was made by low level of von Willebrand factor. We speculated that her repeated bleeding was triggered by minor trauma with the background of bleeding tendency. When severe bleeding occurs or is expected to occur, factor VIII containing von Willebrand factor should be administered. Discussion: There are various etiologies of PVB. Detailed history taking and physical examination are quite important, but might be difficult for young pediatric patients. Neoplasms and sexual abuse must be ruled out. In case of suspicion of abuse, the patient’s safety should be guaranteed. Inspection using cystoscopy under general anesthesia is a useful option in recurrent PVB cases. It is critical to make the correct diagnosis because the treatments can be totally different. Conclusion: In PVB cases we need to perform detailed assessments including careful history taking, physical examination and necessary testing considering a broad range of possible diseases. Presentation: Thursday, June 15, 2023