Traumatic Fistula Research Articles

Traumatic carotid artery–cavernous sinus fistula treated with a covered stent

The authors describe the cases of two patients with unilateral traumatic caroticocavernous fistulas in whom a self-expanding covered stent was successfully used to obliterate the fistula after failed occlusion with detachable balloons and coils. They discuss this option as a primary therapeutic modality in cases in which detachable balloons or coils, with or without a bare stent, have failed to obliterate the fistula. The placement of a covered stent to occlude the lesion from the outset may represent a new therapeutic approach to the treatment of these lesions.

Botulinumtoxin A zur Therapie traumatischer Speichelfisteln

Injury of salivary gland tissue in the head and neck, as the result of extensive trauma, can often be overlooked on initial examination. In two case reports, the primary treatment and further follow-up of injuries of the head resulting in a parotid-maxillary sinus fistula as well as a fistula between the skin and sublingual gland are illustrated. The successful use of botulinum toxin in the treatment of traumatic salivary gland fistulas is documented in both cases. Alternative diagnostic and treatment measures of salivary gland fistulas are discussed. Surgical repair of salivary fistulas as primary treatment should be carefully considered. Treatment of a salivary fistula with the injection of botulinum toxin is possibly advantageous compared to spontaneous fistula closure. The injection of botulinum toxin shortens fistula closure time, is minimally invasive, effective and tolerable for the patient.

Delayed presentation of traumatic aortocaval fistula: A report of two cases and a review of the associated compensatory hemodynamic and structural changes

Chronic aortocaval fistula (ACF) is a rare complication of gunshot wounds to the abdomen. Herein we report two cases of traumatic ACF: one asymptomatic and the other presenting with congestive heart failure (CHF) 20 and 30 years, respectively, after their initial injury. The recent onset of CHF, the presence of a continuous abdominal bruit, and, in the second patient, a history of penetrating trauma suggested the diagnosis of ACF. The diagnosis was confirmed by computed tomography scanning in both patients. Surgical repair of the ACF in the symptomatic patient resulted in resolution of the CHF and reversed the dilatation of the aorta and inferior vena cava. The asymptomatic patient was lost to follow-up. CHF in a young male patient with a history of penetrating abdominal trauma should alert the surgeon to this rare complication.

Traumatic tracheoesophageal fistula in a 5-year old

Tracheosophageal fistula following blunt trauma is rare and diagnosis and management can be difficult. All reported cases have involved victims above 12 years of age. Here we report the anesthesia management, for surgery, of a tracheoesophageal fistula caused by blunt trauma in a 5-year-old boy.

New Technique for Reconstruction of the Female Urethra

Defects of the female urethra includes wide variety of conditions, from small urethrovaginal fistulas to losses of total urethra and bladder neck. Failed surgical repairs produce more loss of tissue than the original traumas. We present an unusual case series of complicated urethrovaginal fistulas, which were treated using labial skin flaps supported by maritus pads of fat. A young girl had an accident producing a traumatic urinary fistula in her left thigh. Surprisingly, this was a continent type of fistula, the patient voided through the fistula naturally. There was total loss of the urethra with a bony block. A portion of bone was removed to approach the bladder neck and her urethra was reconstructed using a labial skin flap supported by a martius pad of fat. Subsequently, this technique was used in 4 other cases of complex urethrovaginal fistulas of various etiologies. This is a totally new technique used to reconstruct the urethra and is useful when other simple techniques may not work or are associated with very high failure rates. The technique can be used to bridge even very large urethral defects. Such use of labial skin to reconstruct the female urethra has not been reported earlier. (J GYNECOL SURG 22:23)

Karotisangiographie bei zentro-lateralen Schädelbasisfrakturen?

Background: In latero-basal, central or spheno-fronto-orbital skull base fractures the internal carotid artery is more frequently involved in severe lesions than expected. Patients and Methods: Between 1996 and 2003 we examined 684 patients with Glasgow Coma Scales (GCS) between 2 and 15, median 7.2, using computed tomography (CT). In suspicion of a latero-basal, central or spheno-fronto-orbital fractur they got an additional high resolution skull base CT. If the bony canal of the internal carotid artery (ICA) was involved the patient underwent digital subtraction angiography (DSA). The ICA lesion was treated either interventional neuroradiologically, by surgery or only conservatively. Results: Of the 684 patients 33 (4.8%) had fractures of the ICA bony canal and therefore underwent DSA. Among them were 25 men and 8 women (mean age 35.3 years). Lesions of the ICA were seen in 1.9% of the patients. A traumatic cavernous-carotid fistula was found in 7 patients (1 %) and in 6 patients (0.9%) a dissection and/or an aneurysm of the ICA was diagnosed. Six of the patients had clinical symptoms. The lesions were treated primarily interventional neuroradiologically (n = 5) as well as surgically in two cases by clipping the aneurysm and closing the sphenoid sinus, respectively. - Conclusions: Vessel lesions of the ICA in skull base fractures and involvement of the bony carotid canal are more frequent than mentioned in current literature. A solid diagnosis can only be achieved by DSA. Early diagnosis and treatment is important for improving the prognosis of these often multiply injured patients.

Karotisangiographie bei zentro-lateralen Schädelbasisfrakturen?

In latero-basal, central or spheno-fronto-orbital skull base fractures the internal carotid artery is more frequently involved in severe lesions than expected. Between 1996 and 2003 we examined 684 patients with Glasgow Coma Scales (GCS) between 2 and 15, median 7.2, using computed tomography (CT). In suspicion of a latero-basal, central or spheno-fronto-orbital fractur they got an additional high resolution skull base CT. If the bony canal of the internal carotid artery (ICA) was involved the patient underwent digital subtraction angiography (DSA). The ICA lesion was treated either interventional neuroradiologically, by surgery or only conservatively. Of the 684 patients 33 (4.8 %) had fractures of the ICA bony canal and therefore underwent DSA. Among them were 25 men and 8 women (mean age 35.3 years). Lesions of the ICA were seen in 1.9 % of the patients. A traumatic cavernous-carotid fistula was found in 7 patients (1 %) and in 6 patients (0.9 %) a dissection and/or an aneurysm of the ICA was diagnosed. Six of the patients had clinical symptoms. The lesions were treated primarily interventional neuroradiologically (n = 5) as well as surgically in two cases by clipping the aneurysm and closing the sphenoid sinus, respectively. Vessel lesions of the ICA in skull base fractures and involvement of the bony carotid canal are more frequent than mentioned in current literature. A solid diagnosis can only be achieved by DSA. Early diagnosis and treatment is important for improving the prognosis of these often multiply injured patients.

Traumatic Aorto-Right Ventricular Fistula With Aortic Insufficiency

We present a case of a traumatic aorto-right ventricular fistula coexistent with aortic insufficiency due to perforation of the left coronary leaflet, which is a lesion rarely described in the literature. We compare our experience with reports from the literature.

Complications of vasectomy

Vasectomy is a common method of sterilisation. However, it is less popular than tubal ligation world-wide. It is also a frequent cause of litigation relating to its complications. This article reviews the early and late risks associated with the procedure. Data collection was done using the internet to search Medline for obtaining evidence-based medicine reviews. Cross-references were obtained from key articles. Websites of government bodies and medical associations were searched for guidelines relating to vasectomy. Early complications include haematoma, wound and genito-urinary infections, and traumatic fistulae. Vasectomy failure occurs in 0-2% of patients. Late recanalisation causes failure in 0.2% of vasectomies. Significant chronic orchalgia may occur in up to 15% of men after vasectomy, and may require epididyectomy or vasectomy reversal. Antisperm antibodies develop in a significant proportion of men post-vasectomy, but do not increase the risk of immune-complex or atherosclerotic heart disease. Similarly, vasectomy does not enhance risk of testicular or prostate cancer. Vasectomy has a lower mortality as compared to tubal occlusion, but is still significantly high in non-industrialised countries because of infections. Vasectomy, though safe and relatively simple, requires a high level of expertise to minimise complications. Adequate pre-operative counselling is essential to increase patient acceptability of this method of permanent contraception.

Traumatic Articular-Bursal Fistula in a Collegiate Football Player

A collegiate football player suffered a direct blow to the distal quadriceps mechanism, resulting in a partial tear of the vastus medialis obliquus. Over time, he began to develop activity-related swelling of his prepatellar bursa. By 6 weeks after his injury, an area of swelling the size of a golf ball would rapidly develop with just 5 minutes of quadriceps exercises. Swelling would diminish within a few hours of rest. A magnetic resonance imaging examination suggested a fistula track from the articular space through the vastus medialis obliquus into the prepatellar bursal area. When prolonged rest did not improve his symptoms, he was taken to surgery. Arthroscopic visualization confirmed a traumatic fistula between the articular space and the prepatellar bursa, allowing free egress of fluid. A spinal needle was used to localize the fistula tract to allow this to be identified for an open, layered suture closure. An area of traumatic chondrosis on the medial side of the patella with loose chondral flaps was also debrided as the probable “fluid generator.” The patient enjoyed a full recovery and was back to playing college football 10 weeks after surgery.

Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report

Background Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described. Case Description A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence. Conclusions Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.

Traumatic high-flow priapism: treatment with super-selective micro-coil embolization

Priapism, a relatively uncommon disorder, is a prolonged penile erection not associated with sexual desire [1]. The term is derived from Priapus, the god of fertility in Greek and Roman mythology, who possessed a large phallus [2]. It is classified into two forms: low-flow or ischemic priapism and high-flow, non-ischemic priapism. Low-flow, the most common type, is due to a malfunction of normal veno-occlusive mechanisms resulting in outflow obstruction and high cavernous pressures. This severe decrease in venous drainage may lead to irreversible ischemic changes and permanent erectile dysfunction. High-flow priapism, far less common than the ischemic variant, involves unregulated cavernous arterial inflow. Patients typically present with a painless partial erection following some type of genito-perineal trauma; the resultant arterial damage leads to an arterial-lacunar fistula and occasionally, to an associated pseudoaneurysm. The current literature accounts for only a handful of case reports describing the use of micro-coils in the treatment of high-flow priapism [3–7]. We aim to report the case of a patient with moderately painful high-flow priapism, and the successful application of metallic micro-coils in embolization of a delayed traumatic arteriocavernosal fistula, associated with a pseudoaneurysm.

High-Flow Traumatic arotico-Jugular Fistula Manifesting as Venous Hypertensive Encephalopathy

We report the clinical and angiographic findings in a patient who presented with venous hypertensive encephalopathy secondary to a traumatic carotico-jugular fistula. Endovascular entrapment of the fistula by occluding the common carotid artery and internal jugular vein at the base of the skull resulted in near total improvement of the patient's neurological status.

Congenital palatal fistula: an isolated entity

Traumatic and postoperative palatal fistulae are common, but congenital palatal fistula is the rarest of all deformities. A case of isolated congenital palatal fistula is reported with an attempt to correlate the presented malformation with embryologic development of the palate.

The use of tissue flaps as an adjunct to pelvic surgery

Background The clinical problems of advanced malignancy with invasion of cancers into adjacent organs or structures, fistulizing complications from radiation therapy, postoperative infections, and delayed postoperative healing continue to challenge pelvic surgeons, regardless of subspecialty. The use of autologous muscle and myocutaneous flaps has been applied to the management and prevention of these clinical problems and found to be most helpful. Methods Records of patients undergoing abdominopelvic procedures in a single unit during the 15-year period from 1990 to 2005 were reviewed, and patients undergoing autologous tissue flaps were reviewed with respect to indications, complications, and outcomes. Results Thirty-four patients underwent 35 autologous muscle or myocutaneous flaps for the following indications: large anticipated defects in primary or reoperative cancer surgery (13 patients); malignant, traumatic, inflammatory, or radiation-induced fistulae (12 patients); excision of (an) adjacent organ(s) with need for reconstruction (7 patients); and chronic nonhealing pelvic wounds (2 patients). Wound complications occurred in 41% of patients; however, primary healing of flaps occurred in 88% of patients. Conclusions The use of autologous tissue flaps in select patients can be a useful adjunct in pelvic surgery in dealing with a wide variety of problems, specifically in filling large defects, providing vascularized tissue for fistula closure, and avoiding delayed wound healing commonly seen after high-dose radiation.

Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases

The aim of this study was to evaluate the results of conservative and surgical management options for traumatic cerebrospinal fluid (CSF) leakage complicating skull base fractures. The subjects were 81 patients who were treated between 1996 and 2003 for CSF leaks that had persisted for 24 h or longer after head injury. For each case the medical records were reviewed, and the data collected were as follows: demographic features, clinical and radiological findings, management options, complications and outcome scores. Analysis was done with patients grouped according to Glasgow coma scale (GCS) score at admission (<or=8 vs >8), and findings for three treatment methods (conservative, CSF drainage, surgery) were evaluated. In 32 cases (39.5%), the CSF leakage resolved spontaneously, and the mean hospital stay for these patients was 14+/-11 days. Twenty-four patients (29.6%) were treated by CSF drainage, and seven of these individuals ultimately required surgery to close the leak. Hospital stay was 17+/-7 days. Twenty-five patients (30.9%) underwent surgery as the initial treatment step, and the mean hospital stay for these individuals was 15+/-9 days. The large majority (74.2%) of patients with admission GCS scores <or=8 had poor outcomes. Compared with this group, a greater proportion of the CSF leaks in the patients with admission GCS scores >8 resolved spontaneously. The factors that had a critical influence on outcome in this series were level of consciousness on admission and presence of additional intracranial pathology associated with CSF leakage within cases of traumatic CSF fistulae due to skull base fractures. Treatment decisions should be dictated by the severity of neurological decline during the emergency period and the presence/absence of associated intracranial lesions. The timing for surgery and CSF drainage procedures must be decided with great care and with a clear strategy. The authors offer a treatment algorithm.

Traumatic Coronary Artery Fistula in a Child

An 8-year-old boy with an insignificant medical history presented to our institution after a motor vehicle accident that resulted in the deaths of his two siblings. He arrived in the emergency department hypotensive and unconscious. On initial evaluation, a heart rate of 174 bpm, blood pressure of 98/46 mm Hg, and agonal respirations were observed. He was immediately intubated and fluid-resuscitated. Work-up revealed diffuse axonal injury with right …

Management of urethral diverticulum complicating hypospadias repair

Background Urethral diverticula can occur after hypospadias repair, and may lead to stone formation, incomplete voiding, infection, postvoid dribbling, haematuria and other problems. We previously reviewed our experience with hypospadias complications. We separately analyzed those patients who developed urethral diverticula to attempt to identify predisposing factors and appropriate management strategies. Patients and methods We reviewed the available medical records and charts of 123 patients undergoing re-operation for hypospadias complications at The Children's Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias cripples, traumatic fistulae, complications after circumcision and true intersex patients were excluded. Results Diverticula accounted for 11% of all complications (13 patients). The patients with diverticula were more likely to have perineal/proximal hypospadias. The initial repair was island tube urethroplasty in five, island onlay urethroplasty in seven and bladder mucosal graft in one child. The repair of the diverticulum in one stage was successful in 10 of the 13 patients. There was one recurrent diverticulum and two fistulas. A stricture was present in only one of the 13 patients but was detected overall in 14 of the 123 patients (11%). Conclusion Diverticula are uncommon after hypospadias repair, accounting for 11% of all complications in the present series. The stricture was not causative in 12 of 13 children. Repair of the diverticulum was successful after one attempt in 10 of 13 patients. The management of this complication is discussed.

Management of the traumatic oronasal fistula in the cat with a conical silastic prosthetic device

Management of a traumatic oronasal fistula with a prosthetic device in an 8-year-old male neutered domestic shorthair cat is described. The animal had fallen from a height of three stories at the age of 1 year. The fall had resulted in a fracture of the hard palate and a split in the palatal mucosa. Two surgical attempts to close the defect had been unsuccessful and an autopolymerizable acrylic resin prosthesis had produced unsatisfactory results. The management of the chronic traumatic fistula with a conical prosthetic device was fast, easy and efficient. The device was removed and a second one was put in place after 2 years. This method would appear particularly useful for obturation of large palatal defects that have failed to heal after attempts at surgical closure and is an alternative treatment for debilitated cats which may not be candidates for longer surgical procedures.

Severe Refractory Hypoxemia Following a Gunshot Injury

We describe the case of a 57-year-old man with severe refractory hypoxemia, despite receiving ventilation therapy with 100% oxygen, following a gunshot wound to his left chest. A limited CT scan of the chest with contrast raised the suspicion of an arteriovenous (AV) fistula. Contrast-enhanced transthoracic echocardiography confirmed the presence of a pulmonary AV fistula. Traumatic pulmonary AV fistula is a rare, but serious and life-threatening condition that should be suspected in patients with thoracic injuries with persistent unexplained hypoxemia. Contrast echocardiography is a relatively simple, inexpensive, and readily available bedside test that can be used to confirm this diagnosis.