Suspicion Of Fistula Research Articles

Novel Hybrid Treatment Approach for Dural Arteriovenous Fistula with Isolated Sinus and Absent Direct Dural Feeders

Introduction: Dural arteriovenous fistula (AVF) may present with varied imaging presentation. Hybrid treatment approches which include surery and endovascular techniques are beneficial for isoloated sinus in dural AVF. Methods: We present two case scenarios of complex cerebral dural AVFs. Both the patients had similar appearances on imaging which mimicked hemorrhage and tumor. With likely suspicion of fistula, digital subtraction angiography was initially performed, which confirmed the diagnosis. We chose to adopt a hybrid technique to treat them using the neurosurgical suite. Burr-hole craniotomy procedure followed by the direct embolization of the fistula was offered to both patients. Results: Fistulae were completely cured with the minimal duration of hospital stay. Follow-up showed the complete resolution of their symptoms. Conclusion: Treating complex cerebral dural AVFs is as challenging as diagnosing them on cross-sectional imaging and may require a combined approach.

V-037 PARASTOMAL MESH INFECTIONS WITH INTESTINAL FISTULA: 2 RARE SURGICAL CASES AND HOW WE FIXED THEM

Abstract Parastomal hernias (PSH) occur in 50–80% after stoma formation and its treatment is considered a real challenge. According to the recent literature, the use of prophylactic mesh at the time of primary stoma should decrease the odds of hernia formation. The most common occurrences after PSH surgery are: recurrence, seroma and wound complications. In this video, we report 2 cases of mesh infection with fistula necessitated removal after 10 and 4 years of mesh placement. The first patient was a 66 years-old male. In 2007 he underwent radical prostatectomy and pelvic lymphadenectomy following radiotherapy. He underwent a radical cystectomy and Bricker's cutaneous uretero-ileostomy for stenosis of the vesicourethral anastomosis. In 2012 for PSH he underwent laparo-alloplasty with a placement of an intraperitoneal mesh. In February 2022, with fever and dyspnoea, at the CT-scan of the abdomen we found air bubbles near the mesh and a suspected sigmoid-to-mesh fistula. The second patient was a 66 years old male. In 2018 the patient underwent neoadjuvant radiotherapy, then Miles’ procedure and prophylactic 3D intraperitoneal mesh, subsequent adjuvant therapy. During the oncological follow-up an abdominal CT-scan showed air bubbles around the stoma and suspicion of fistula on the adjacent intestinal loops. In both cases there was an infection of the area around the stoma due to a fistula between the mesh and the intestine. We proceeded, in laparoscopy, to remove the infected mesh. We converted in open surgery with the resection of the fistulized intestine tract and we did a new ostomy.

IMAGE-Guided Brachytherapy for Primary Vaginal Cancers

To evaluate disease control and toxicities of primary vaginal cancer treated with image-guided brachytherapy. A retrospective study was performed on 26 consecutive patients treated for vaginal cancer with brachytherapy (BT) between 2010 and 2018, all treated after the introduction of ultrasound-based catheter guidance and modified dose optimization to reduce vaginal toxicities. External beam radiation therapy (EBRT) was used in 25/26 patients, with a median dose of 45 Gy in 25 fractions. 16/25 patients had concomitant chemotherapy with EBRT. Endocavitary BT alone was used in 3/26 patients. Interstitial BT was used in 23/26 patients. Standard procedure involved the use of a cylinder and interstitial catheters. They were usually inserted under Transrectal Ultrasound (TRUS) and/or TransVaginal Ultrasound (TVUS) guidance. Inverse Planning Simulated Annealing (IPSA) was used for dose optimization and a class solution was developed to reduce high-dose points in the vaginal mucosa by keeping most of the high dose inside the cylinder. Acute (<6 months) and late genitourinary (GU), gastrointestinal (GI), and vaginal toxicities were reported using the Common Terminology Criteria for Adverse Events version 5 (CTCAE v5). Local control (LC), metastatic disease-free survival (mDFS) and overall survival (OS) were evaluated using Kaplan-Meier survival curves. Mean age was 69,7 years old. Median follow-up was 35,5 months (range 0-85months). 18/26 patients had Squamous Cell Carcinoma (SCC), 5/26 Adenocarcinoma, 1/26 Clear Cell Carcinoma, 1/26 Melanoma and 1/26 Squamous Transitional Carcinoma. 13%, 71%, 8%, and 8% of patients had FIGO stages I, II, III, and IV respectively. LC of 83% and 83%, mDFS of 91 % and 91%, and OS of 80% and 66 %, were respectively achieved at 3 and 5 years. When limited to SCC only, LC of 88% and 88%, mDFS of 94 % and 94%, and OS of 87% and 70 %, were respectively achieved at 3 and 5 years. There were only 4 local relapses, which all occurred within 8 months after treatment. One was a stage IV SCC at diagnosis, one had a squamous transitional carcinoma, one was a clear cell carcinoma, and the last one had concomitant multiple distant metastasis at time of local relapse. There were no late G3-4 GU/GI toxicity. Acute and late G3 vaginal toxicity (stenosis) occurred in 19% and 42% of patients, respectively. 3 cases of vaginal necrosis and 1 suspicion of fistula were reported, all associated with a local progression of the disease except for one case where necrosis was limited and healed spontaneously. No patient needed Hyperbaric Oxygen Therapy (HBOT). Excellent local control can be achieved with the use of TRUS/TVUS-guided vaginal brachytherapy in primary vaginal cancer, especially for Squamous Cell Carcinoma, with a favorable toxicity profile. GU and GI toxicities are mild, but there is a significant number of G3 vaginal stenosis in this cohort of older patients. This might be reduced with the regular use of a vaginal dilator.

Crohn's Disease Evolving the Small Bowel Alone: In Witch Symptoms We Need to Investigate to Make an Earlier Diagnostic?

Crohn’s Disease Evolving the Small Bowel Alone: In Witch Symptoms We Need to Investigate to Make an Earlier Diagnostic? Paula B. Poletti, Thiago F. Secchi, Ying Tung, Artur A. Parada Crohn’s disease involves the small bowel alone in 30-40% of cases and in most cases the diagnostic is performed when the patients have symptoms of intestinal occlusion, denoting an advanced disease. The aim of this study is to analyze the clinical symptoms presented in patients who had the diagnose of Crohn’s disease evolving the small bowel alone by Capsule Endoscopy (CE) without an initial clinical suspicion of this disease, so that, we could evaluate in witch patients we need to study small bowel to diagnose and treat more earlier lesions, and so, prevent small bowel occlusions. Methods: We retrospectively study the clinical symptoms and small bowel lesions in 28 patients submitted to small bowel examination with the CE with prior negatives GI, Ileum distal and Colon endoscopies examinations, who had the diagnose of Crohn’s Disease according with the endoscopic criterions of the 4th International Conference of Capsule Endoscopy (2005) by CE. The capsule diagnose was made by the concordance of tree blinded different experts. These patients were referred for this exam without any clinical, laboratorial or radiologic suspicion of small bowel Crohn’s disease. Results: In these 28 patients, 11 (39,28%) male and 17 (60,71%) female, with ages ranging between 5 and 66 years: 8 (28,57%) had episodes of diarrhea without blood, 3 (10,71%) had repetitive abdominal distension and pain, and 17 (60,71%) had Obscure Gastrointestinal Bleeding (OGB), 8 (28,57%) with overt bleeding and 9 (32,14%) with anemia and positive occult blood tests. Just one patient had difficulties in the Capsule transit, but in all of them the capsule richened the colon. In 12 (42,85%) the small bowel findings were aphthoid, linear erosions and superficial ulcers evolving the Jejunum and/or Ileum, in other 12 (42,57%), were erosions and confluents or circumferential ulcers, in 2 (7,14%) were erosions and scars, in 1 (3,57%) were erosions, ulcers and suspicion of fistula and another 1 (3,57%) with erosions, ulcers and areas of reduction of the diameter of the small bowel. The more severe lesions were diagnosed in patients with OGB: 4 (14,28%). All patients improved their symptoms with the introduction of the specific therapeutic for Crohn’s Disease. Conclusions: The Capsule Endoscopy permits the diagnose of Crohn’s disease involving the small bowel alone in patients without occlusions symptoms. In this group the most frequent clinical apresentation was overt and occult OGB and corresponded to the more profound lesions in the intestinal wall compared with the patients with diarrhea and abdominal pain.