True Fistula Research Articles

Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials

The incidence of postoperative pancreatic fistula is influenced by the effectiveness of the pancreaticojejunostomy, and the most suitable pancreaticojejunostomy for pancreaticoduodenectomy remains uncertain. Since grade A postoperative pancreatic fistula is no longer considered a true fistula, the purpose of this meta-analysis was to compare the effectiveness of duct-to-mucosa anastomosis and invagination anastomosis in reducing the incidence of grade B/C postoperative pancreatic fistula. The meta-analysis was conducted using software Review Manager 5.3, and the fixed-effect model was employed for pooled statistic calculations. The Cochrane Collaboration Risk of Bias Tool was utilized for quality assessment. Ten randomized controlled trials from Embase, Web of Science, MEDLINE, and the Cochrane Library (1990.01–2022.10) including 1471 patients, met the inclusion criteria. This meta-analysis has been registered on PROSPERO with the registration number CRD42023491673. The incidence of grade B/C fistula was significantly lower in the invagination group (7.7 %) compared to the duct-to-mucosa group (12.8 %, mostly Cattell manner)(RR = 1.65, 95%CI: 1.14–2.39, P = 0.008; heterogeneity: P = 0.008, I2 = 68 %),heterogeneity among the results was addressed through sensitivity analysis. In patients with a soft pancreas, the incidence of grade B/C fistula was significantly lower in those who underwent invagination anastomosis (10 %) compared to those who underwent duct-to-mucosa anastomosis (41.9 %)(RR = 4.19, 95%CI: 1.33–13.25, P = 0.01).No significant differences were observed in terms of the occurrence of grade B/C fistula in firm pancreas, postoperative mortality, other major postoperative complications, anastomosis time, and postoperative bile leak. Therefore, we concluded that invagination anastomosis is significantly superior to duct-to-mucosa anastomosis in reducing the incidence of grade B/C fistula, especially in patients with a soft pancreas.

The Intersection of Human and Veterinary Medicine-A Possible Direction towards the Improvement of Cell Therapy Protocols in the Treatment of Perianal Fistulas.

The effective treatment of perianal fistulizing Crohn's disease is still a challenge. Local administration of mesenchymal stromal cells (MSCs) is becoming a part of accepted treatment options. However, as a fledgling technique, it still can be optimized. A new trend in translational research, which is in line with "One Health" approach, bases on exploiting parallels between naturally occurring diseases affecting humans and companion animals. Canine anal furunculosis (AF) has been indicated as condition analogous to human perianal Crohn's disease (pCD). This narrative review provides the first comprehensive comparative analysis of these two diseases based on the published data. The paper also outlines the molecular mechanisms of action of MSCs which are likely to have a role in modulating the perianal fistula niche in humans, and refers them to the current knowledge on the immunomodulatory properties of canine MSCs. Generally, the pathogenesis of both diseases shares main determinants such as the presence of genetic predispositions, dysregulation of immune response and the relation to intestine microbiota. However, we also identified many aspects which should be further specified, such as determining the frequency of true fistulas formation in AF patients, elucidating the role of TNF and Th17 pathway in the pathogenesis of AF, or clarifying the role of epithelial-to-mesenchymal transition phenomenon in the formation of canine fistulae. Nevertheless, the available data support the hypothesis that the results from testing cell therapies in dogs with anal furunculosis have a significant translational value in optimizing MSC transplants procedures in pCD patients.

Clinical presentation and management of corneal fistula.

To describe the clinical features and management of corneal fistula in patients of healed keratitis. Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated. The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10and60 years. Five of the patients were male while three were female. The size of the fistula measured between 1and2 mm. A surrounding cystic area of diameter ranging between 1and4.5 mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6-8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently. Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.

A STUDY ON MRI-FISTULOGRAM EVALUATION OF PERIANAL DISCHARGE IN AN INDIAN POPULATION

Objective: Pre-operative assessment of perianal fistulas is very important for best planning of surgery and prevention of relapse. The goal of magnetic resonance imaging (MRI) of perianal discharge is to demonstrate accurately the anatomy of the perianal region. MRI can clearly show the relationship of fistulas to the anal sphincter complex, levator plate, and the ischiorectal/ischioanal fossa. The aim of the study was to find out the various types of fistula and compare MRI fistulogram with surgery findings.Methods: In the present study, 38 number of patients were included who were sent for pre-operative MRI evaluation of perianal discharge and their post-operative data were collected for analysis. Surgical grading was according to Park’s surgical classification. Fistulas were graded in MRI according to St James’s University Hospital MRI classification of perianal fistulas.Results: It was found from the study that most of the patients were adults (35/38), whereas one was a child and one was adolescent. Almost all were male (36/38) except two were female. Around 50% of patients had previous history of surgery and had come for persistent/recurrent lesion. According to MRI, all except one had true fistula, rest one had sinus, and one had ischioanal abscess. Percentage of Grade I, Grade II, Grade III, and Grade IV fistula were 31.58, 13.16, 15.79, and 34.21, respectively. Percentage of intersphincteric (I and II) type was 44.74 (17 in no) and transsphincteric (III and IV) was 55.26 (21 in no.), and supra- and extra-sphincteric type was 0 in number. Most had internal anal canal opening posterior to transverse anal line, out of which most were around 6 o’clock position. MRI successfully described fistula tract in all except for two cases (36/38).Conclusion: MRI is very accurate in pre-operative evaluation and planning for surgery of perianal fistulas.

Dual Coronary Artery Fistula from Left Anterior Descending and Right Coronary Artery to Pulmonary Trunk in a Patient with Myocardial Infarction—A Case Report

Coronary artery fistulas (CAF) are precapillary communications between a coronary artery and a cardiac chamber or vessel. CAF have been described as the most common hemodynamically significant congenital coronary anomal. However, it remains a relatively uncommon clinical problem. Coronary fistulas originates slightly more common from the right than from the left coronary artery, but the bilateral fistulas—those that originate from both coronary arteries—accounts for only 5% of total cases. These bilateral fistulas have a unique tendency to terminate in the pulmonary artery. More than half of the bilateral and only 17% of unilateral fistulas, terminates in this manner [1]. CAF are believed to be embryological remnants of sinusoidal connections between the lumens of the primitive tubular heart. This was first described by Maude Abbott in 1908 [2]. These fistulas are usually discovered incidentally upon coronary angiography [3]. Their incidence in the overall population is reported about 0.002% and constitutes 0.13% of congenital cardiac lesion, however, they are found in 0.05% to 0.25% of patients who undergo coronary angiography. The most common site of drainage is the right ventricle seen in 41% of patients. Congenital CAFs usually result from abnormal embryological development of the myocardial vascular system. Acquired CAFs are seen after trauma, endovascular procedures like coronary angiography, endomyocardial biopsy etcor cardiac transplantation. True fistulas of the circulatory system are characterized by an ectatic vascular segment that shows aberrant flow connecting two vascular territories governed by large pressure differences. We report a case of double coronary to pulmonary artery fistula discovered during emergent coronary angiography for acute inferior wall ST-elevation myocardial infarction (STEMI) in a patient with no prior cardiac symptoms.

“Enteroatmospheric Fistulae”—Gastrointestinal Openings in the Open Abdomen: A Review and Recent Proposal of a Surgical Technique

The occurrence of an enteric fistula in the middle of an open abdomen is called an enteroatmospheric fistula, which is the most challenging and feared complication for a surgeon to deal with. It is in fact not a true fistula because it neither has a fistula tract nor is covered by a well-vascularized tissue. The mortality of enteroatmospheric fistulae was as high as 70% in past decades but is currently approximately 40% due to advanced modern intensive care and improved surgical techniques. Management of patients with an open abdomen and an enteroatmospheric fistula is very challenging. Intensive care support of organs and systems is vital in order to manage the severely septic patient and the associated multiple organ failure syndrome. Many of the principles applied to classic enterocutaneous fistulae are used as well. Control of enteric spillage, attempts to seal the fistula, and techniques of peritoneal access for excision of the involved loop are reviewed in this report. Additionally, we describe our recent proposal of a lateral surgical approach via the circumference of the open abdomen in order to avoid the hostile and granulated surface of the abdominal trauma, which is adhered to the intraperitoneal organs.

Incidence of Oronasal Fistulae and Velopharyngeal Insufficiency after Cleft Palate Repair: An Audit of 211 Children Born between 1990 and 2004

We present an audit of primary cleft palate surgery at our unit, including rates of oronasal fistula development, speech outcomes, and rates of velopharyngeal insufficiency requiring secondary surgery. A retrospective study of patients with all cleft palate types, born between January 1990 and December 2004, who underwent primary palatoplasty at Middlemore Hospital, Auckland, New Zealand. The study included 211 patients, collectively operated on by five different surgeons. The overall rate of true fistula development was 12.8% over a mean follow-up period of 4 years 10 months. The incidence of true fistulae that required surgical repair was 8.1%. Fistula rates were higher for more severe degrees of clefting but were not affected by gender or type of surgical repair. Overall, 31.8% of the study population had some degree of hypernasality following primary palatoplasty. Secondary surgery for velopharyngeal insufficiency was required in 13.3% of patients. Following surgical correction of velopharyngeal insufficiency, no patients were reported to have appreciable hypernasality and 21.7% were reported to have mild hypernasality, a result comparable to previously published audits. The requirement for secondary surgery was higher in patients with more severe clefts. Our results are comparable to other recent studies. We believe that highly coordinated cleft care helps ensure such outcomes. These data provide a benchmark against which we can measure future performance in our attempts to improve outcomes of cleft repair.

Unusual Type of Spinal Arteriovenous Malformation

We describe an uncommon type of spinal arteriovenous malformation that is intradural rather than dural and that consists of a true fistula rather than a nidus of abnormal vessels between the anterior spinal artery and a draining vein. Its clinical significance and treatment are discussed.

Anal, perianal, perineal and sacrococcygeal sinuses

In accordance with the accepted definitions of “sinus” and “fistula” an attempt has been made to indicate those lesions which are true fistulas and those which are true sinuses in the anal, perianal, perineal and sacrococcygeal regions. Inasmuch as the great majority of socalled “draining sinuses” in the anal, perianal and perineal skin are in reality the secondary openings of true anal fistulas, an effort has been made to clarify the pathogenesis of anal fistula. It is hoped that a proper understanding of this mechanism will lead to more accurate diagnosis and to adequate management. Pilonidal cyst is the most common “developmental” lesion dorsal to the sacrum and coccyx. The essential differential diagnostic features of anal, perianal, perineal and sacrococcygeal sinuses have been briefly stated.

Pseudo-Gastroduodenal Fistula

GASTRODUODENAL fistula as a complication of gastric ulcer is rare. Monroe (12), in 1927, in a summary of the literature on fistula as a complication of gastric ulcer, found ten cases and added one of his own. Of these only two, his own and that of Casellas (2), had been recognized by roentgenology. Low-Beer (8) refers to 12 cases, eight of which were on an ulcer basis, and adds one of his own. These 12 cases include six of those summarized by Monroe. Of the cases reviewed by Monroe and Low-Beer, five, those of Casellas, Monroe, Berg, Haudek, and Low-Beer, were recognized by roentgen examination. Melchart (10) reports two cases and points out that these, and some of those reported in the literature, although having a roentgen appearance of gastroduodenal fistula, are not true fistula, but are due to contraction of the lesser curvature drawing the pylorus upward and to the left. We have found reports of 11 cases, in addition to those mentioned by Monroe and Low-Beer, which have been recognized by roentgen e...