Unusual Fistula Research Articles

A RARE CASE OF TUBERCULAR LYMPHO-TRACHEAL FISTULA

Tuberculosis can affect any organ of the body. Tracheal manifestations due to mycobacterium tuberculosis are unusual and lympho-tracheal fistula exceptionally rare. In such rare cases early diagnosis and management is often delayed and may lead to complications. To the best of our knowledge, this rare case represents the first report of successful treatment of tuberculous lympho-tracheal fistula with anti-tubercular drugs with strict control of Diabetes mellitus.

Severe Ulcerative Colitis-like Pattern of Segmental Colitis Associated with Diverticulosis Complicated with a Colo-umbilical Fistula: Case Report

A 49-year-old African American male with history of diverticulitis presented to the ED with abdominal pain and feculent discharge from the umbilicus. CT scan of the abdomen showed a fistulous tract from the sigmoid colon to the umbilicus. Labs revealed a markedly elevated fecal calprotectin level and colonoscopy demonstrated friable-appearing mucosa of the sigmoid colon. Segmental colitis associated with diverticulosis (SCAD) refers to a chronic, localized, nongranulomatous inflammation, usually in the sigmoid colon. SCAD spares the rectum and the proximal colon endoscopically and histologically. We present a case of diverticular disease associated with an unusual fistula and features of SCAD.

Abstract 17237: A Pair Of Diaphragm-Crossed Organs: A Pancreatico-Pericardial Fistula

Introduction: Pseudocysts are a known complication of chronic pancreatitis, occurring in 30-40% of patients. They form when disruption of the pancreatic duct system creates fluid-filled pockets with high concentrations of digestive enzymes. Leakage of these enzymes can create pancreatic fistulas. Here, we present a case of an unusual fistula that occurred in an immunocompromised individual. Case Description: A 34-year-old man with a history of Acquired Immunodeficiency Syndrome, alcohol use disorder, and chronic pancreatitis who had recently recovered from acute pancreatitis complicated by pericardial effusion was readmitted with worsening pleuritic chest pain and shortness of breath. He was hemodynamically stable with a normal cardiopulmonary exam without jugular venous distention or pulsus paradoxus. Labs were at his baseline other than an elevated d-dimer level. Computed tomography scan revealed a large, loculated pericardial effusion with a fistula extending through the diaphragm to a large peripancreatic pseudocyst. Gastroenterology performed pancreatic ductal stenting via endoscopic retrograde cholangiopancreatography and Interventional Radiology placed a percutaneous drainage catheter to facilitate resolution of the pseudocyst. Discussion: A pancreatico-pericardial fistula is a very rare complication of chronic pancreatitis. A 2016 review detailed only fifteen cases over a 40-year span with surgical management providing the best outcomes. Given this patient’s immunocompromise and malnutrition surgery was not offered, but endoscopic stenting and percutaneous drainage allowed for successful resolution of his fistula.

High and intermediate anorectal malformation in males with perineal fistula: Beware of urethral involvement

Anorectal malformation (ARM) with recto-perineal fistula is considered low-type anomaly and standard management of perineal anoplasty without colostomy is recommended. Unusual variants are scarcely reported and present unique challenges in management. We present two cases of ARM with unusual fistula managed in our hospital. Case 1 A term baby boy status-post colostomy creation at birth in an overseas hospital for ARM presented to us at 4 months of age for definitive surgery. Distal loopogram demonstrated a very fine recto-penile fistulous opening at the peno-scrotal area hence perineal anorectoplasty was planned. Intra-operatively, the bulbar urethra was laid open for complete fistula tract excision due to a 3cm shared common wall between fistula tract and urethra. A double-layered urethral repair was performed and a neoanus created after mobilisation of a high rectal pouch. The baby recovered well post-operatively after 3 weeks of urethral stenting and is currently awaiting stoma closure. Case 2 A term male newborn was noted to have ARM with a recto-scrotal fistula. After initial stabilisation and workup, he was scheduled for perineal anoplasty on day 2 of life. Intra-operatively, we noted a fine, long cutaneous track running in the scrotal raphe close to the bulbar urethra. The bulbar urethra was inadvertently entered during fistula tract excision and needed repair. The rectal pouch located above the levator muscle was mobilised and anorectoplasty was performed. The baby was managed post-operatively with gut rest and total parenteral nutrition, and recovered well. Rare-variant ARM with recto-penile/recto-scrotal fistulae can be associated with high or intermediate type anomalies in contrary to classical recto-perineal fistula. Management of these cases should be planned carefully, with possible need for urethral repair during anorectoplasty.

The Way to Man's Heart Is through the Stomach.

Organ systems do not exist in a vacuum. However, in an era of increasingly specialized medicine, the focus is often on the organ system alone. Many symptoms are associated with differential diagnoses from upper gastrointestinal (GI) and cardiovascular medical and surgical specialties. Furthermore, a large number of rare but deadly conditions cross paths between the upper GI tract and cardiovascular system; a significant proportion of these are iatrogenic injuries from a parallel specialty. These include unusual fistulae, herniae, and embolisms that transcend specialties. This review highlights these conditions and the shared anatomy and embryology of the two organ systems.

Urethrocutaneous fistula mimicking vesicocutaneous fistula: a rare entity

Urethral fistulas arising from the anterior urethra usually open on the ventral aspect and are located in the penile, scrotal or perineal region. A diabetic 65-year-old man presented with suprapubic...

CORONARY ARTERY ANEURYSMAL FISTULA PRESENTING WITH ACUTE CORONARY SYNDROME

Coronary arteriovenous fistula is a rare defect that is mostly congenital in origin. This is a case report of a patient who presented with very unusual fistula which originates from proximal left anterior descending coronary artery aneurysmal drainage into the pulmonary artery. We are presenting a

The Surgical Management of Complex Fistulas After Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as the preferred option for treating obesity. Risks of leak and subsequent fistula after sleeve gastrectomy still present significant concerns in clinical practice. This current series presents unusual fistulas post-LSG and their surgical management. The series presents chronic leaks that have progressed into fistulas. Three patients with fistulas are presented: gastrocolic, gastropleural, and gastrosplenic. Surgical intervention was warranted in all cases with en-bloc resection of the fistula with subtotal gastrectomy and Roux-en-Y esophagojejunostomy reconstruction. A subtotal colectomy with ileo-descending colon anastomosis was additionally necessary in the gastrocolic patient. The patients with the gastropleural and gastrosplenic fistulas were discharged home on postoperative Day 6 and Day 7, respectively. The patient with the gastrocolic fistula had an extended postoperative hospital course and was discharged home on postoperative Day 35. All cases were negative for staple line leaks. To date, the fistulas healed with no recurrence. En-bloc resection of the fistula with proximal gastrectomy and Roux-en-Y esophagojejunostomy (PGRYEJ) is a surgical option to treat chronic staple line leakage when non-operative therapy is rendered ineffective. Adequate preoperative planning with optimization of nutritional status and control of local and systemic sepsis is paramount for ultimate success. A symptomatic leak requires immediate operation regardless of the time interval between the primary sleeve operation and appearance of the leak.

Congenital periauricular fistulas: Possible variants of the preauricular sinus

ObjectiveAlthough most preauricular sinuses are located near the anterior limb of the ascending helix, some are located in unusual areas around the auricle, as shown previously in limited reports. This study analyzed the clinical manifestations of congenital periauricular fistulas with unusual fistula locations and the possible relationship with the classical preauricular sinus. MethodsWe reviewed the medical records of patients who underwent congenital periauricular sinus excision by three surgeons and followed them for more than 6 months. Clinical manifestations were compared between classical preauricular sinus (classical group) and congenital periauricular fistula (variant group) patients. ResultsThe classical and variant groups included 192 and 20 ears each, respectively. In the variant group, the fistula locations were in the ascending helix crus (15 ears, most common), infra-auricular area (3 ears), supra-auricular area (1 ear), and anterior to tragus (1 ear). In ears with fistulas in the ascending helix crus, the fistulous tract most often showed a medial direction (9 ears). There were 4 ears in the variant group with fistulous tracts running toward the postauricular area. ConclusionsCongenital periauricular fistulas can be located anywhere around the auricle, and also considered the variant of preauricular sinus because the whole tracts were limited to lateral side of temporalis muscle and parotid gland as well as not associated with external auditory canal and facial nerve. Among them, the most common variant was a fistula on the ascending helix crus with short fistulous tract directed medially.

Laryngotracheobronchoscopy prior to esophageal atresia and tracheoesophageal fistula repair—its use and importance

BackgroundPure esophageal atresia (EA) and esophageal atresia with tracheoesophageal fistula (EA-TEF) are commonly associated with various anomalies. Associated anomalies, especially those of upper airways may alter the management strategies. This study was designed to find out the role of preoperative laryngotracheobronchoscopy (LTB) just prior to the standard surgical procedure. Study designThis was a retrospective study. The data of all the newborn babies (n=88) with a provisional diagnosis of EA or EA-TEF with preoperative rigid LTB, using 2.5/3.0/3.5F rigid bronchoscope were analyzed. This additional procedure entailed documenting the abnormalities, endoscopic lavage and noting the site of the fistula. The fistula was cannulated by 3.0F ureteric catheter just prior to the standard surgical procedure. Management strategies were changed as per the additional findings. ResultsOut of 88 patients, 77 had EA-TEF while 11 had pure EA. LTB was performed in all of them. Additional findings in bronchoscopy were noted in 18 (20.46%) babies. These additional findings were: fistula at unusual site in 12, laryngotracheal cleft in 2 and vallecular cyst in 1 neonate. The diagnosis of pure EA turned out to be EA-TEF in 3 cases. Unusual fistula sites were carinal/subcarinal in 4/12 (33.33%), upper pouch fistula in 1/12 (8.33%), double fistula in 2/12 (16.67%) and fistula from main bronchus in 5/12 (41.67%) cases. ConclusionsLTB performed just prior to the definitive surgical procedure in EA and EA-TEF would diagnose, document and may aid in the surgical management strategies.

Unusual fistulas and connections in the cardiovascular system: A pictorial review.

A fistula is an abnormal vascular connection leading to diversion of blood from a high resistance arterial circuit to low resistance venous circuit. Coronary artery fistulas are abnormal communications of the coronary artery with a chamber of the heart, or with any segment of systemic or pulmonary circulation, bypassing the myocardial capillaries. Other unusual fistulas include connection between aorta and the right atrium/superior vena cava, aorta and the inferior vena cava or between a coronary artery bypass graft and a cardiac vein. Abnormal connections also include origin of the coronary artery from the pulmonary artery. In this article, we review the imaging, particularly computed tomography and magnetic resonance imaging of unusual fistulas and connections involving the cardiovascular system, particularly the coronary arteries and the aorta.

Lessons Learned From Endovascular Management of Ureteroarterial Fistula

Stent graft placement for ureteroarterial fistula is the preferred treatment. However, some pitfalls may occur during the procedure. Chronic inflammation process will induce longer adhesion area between artery and ureter, which results in unusual fistula site and rigid iliac arteries. This further leads to difficulty in advancing the endograft delivery system, even when access route is large enough. Multiple attempts to pass the iliac artery may result in "incidental" mechanical provocative angiography with subsequent massive bleeding. These suggested us not only to be careful and prepared but also to consider that angiography after inserting the delivery system could give additional information on the exact fistula site.

Large aneurysm in saphenous vein coronary artery graft with fistula: case report and review

Aneurysms developing in a saphenous vein graft (SVG) after coronary artery bypass grafting (CABG) are an unusual complication and fistulae forming between an SVG aneurysm and a cardiac chamber are even rarer. A 71-year-old man had undergone a triple CABG with the left internal thoracic artery and double SVGs. Twenty years later, he was admitted with repeated congestive heart failure. A large true aneurysm (99 × 60 mm) developed in the mid portion of a saphenous vein graft to the right coronary artery together with a fistula with a diameter of 8 mm in the right atrium. The aneurysm was surgically resected and the fistula was closed.

Endoscopic management of an unusual biliary-enteric fistula

Endoscopic management of an unusual biliary-enteric fistula

Endoscopic management of an unusual biliary-enteric fistula

Endoscopic management of an unusual biliary-enteric fistula

The clinical application and nursing of unusual arteriovenous fistula

Objective To observe the clinical effect of unusual arteriovenous fistula in maintenance hemodialysis patients.Methods Hemodialysis nursing characteristics and nursing management for 60 patients with unusal hemodialysis arteriovenous fistula were analyzed retroactively and nursing experience were summarized. Results After establishment of unusual arteriovenous fistula of 60 cases of patients vascular patency rate was 100％,40 cases started using after 3 months of postoperative,11 cases after 5 months and 9 cases after 6 ～ 8 months,lasting use over 2 ～ 3 years,all of cases had no infection and blocking.Conclusions Unusual arteriovenous fistula is a additional way of patients with permanent hemodialysis vascular access,careful care is the key to extend the service life. Key words: Hemodialysis; Unusual arteriovenous fistula; Clinical application; Nursing

An unusual fistula closed by percutaneous coil embolisation

A 25-year-old male patient was admitted for assessment of increasing shortness of breath and decreased transcutaneous oxygen saturation (91 %). He had a complex congenital heart defect, involving a dysplastic monocusp tricuspid valve and pulmonary valve atresia. The latter was palliated shortly after birth by a Brock procedure (entailing infundibular resection and pulmonary valvotomy). An atrial septal defect was surgically closed when he was 6 years old and a homograft was inserted in the right ventricular outflow tract at the age of 15. Replacement by a second homograft at the age of 23 was necessary together with tricuspid valvoplasty because of severe insufficiency of both valves. Apart from moderate pulmonary homograft stenosis (PHS) and re-occurrence of moderate to severe tricuspid insufficiency (TI) resulting in right heart failure, a right-left shunt was detected on transoesophageal echocardiography during intravenous agitated saline bubble-contrast injection, although the repaired atrial septum was intact. Invasive evaluation confirmed moderate to severe TI and a peak-to-peak gradient of 40 mmHg over the homograft. Right atrial pressures were above 20 mmHg. Contrast injection in the superior vena cava showed a very tortuous fistulous connection originating from the left axillary vein and draining towards the left atrium (Fig. 1, panel A and B). It was decided to close the fistula percutaneously and 4 coils (3 x IMWCE-3-PDA3 and 1 x IMWCE-3-PDA5, COOK MEDICAL, Bloomington, USA) were placed in the fistula, effectively occluding the vessel (panel C). The transcutaneous oxygen saturation increased slightly. Further management regarding the TI and PHS will be discussed with one option being percutaneous placement of a pulmonary valve (Medtronic, Minneapolis, USA), possibly in combination with another transcatheter valve prosthesis in tricuspid position to lower the right heart filling pressures. Fig. 1 a Contrast injection in the superior vena cava (SVC) showing a fistula (arrow) originating from the left axillary vein (AV). The right atrium (RA) is grossly enlarged (LIV left innominate vein). b Selective contrast injection in the fistula (arrow) reveals ...

Tuberculous Mastoiditis: Report of an Uncommon Case in Morocco

Although tuberculosis is a major problem of public health in Morocco, the tuberculous mastoiditis remains extremely rare, and its diagnosis is often delayed. We report here the case of a 3-year-old child who had unusual chronic left mastoiditis and retro-auricular fistula, associated with spontaneous discharge of bony sequestrum. CT scan of temporal bones showed complete destruction of left mastoid cells. A left mastoidectomy confirmed the tuberculous mastoiditis diagnosis after histopathological examination. The clinical outcome was favorable after anti-tuberculosis treatment. Otologic tuberculosis of the ear is well described in the literature and symptoms include chronic otorrhea with audio-vestibular symptoms. The specificity of this case is that the child had an isolated involvement of the mastoid with spontaneous bony sequestrum discharge, but without otorrhea.

An Unusual Recurrence of Obscure Gastrointestinal Bleeding

Purpose: A 66-year-old female presented with melena and hematochezia for the past 3 weeks. She had a history of peptic ulcer disease and abdominal aortic aneurysm repair in 1989. She denied NSAID use or abdominal pain. Two months ago, she presented with melena and had an upper endoscopy (EGD) that showed 5 arteriovenous malformations in the duodenal bulb which were treated with thermal therapy successfully. Subsequently, she was seen multiple times in the hospital with melena and hematochezia. Prior work-up with an EGD was normal and a colonoscopy showed bright red blood in the colon with no bleeding source. Tag RBC was negative. After transfer, a repeated EGD up to the distal duodenum was normal and colonoscopy revealed blood in the entire colon but no source of bleeding identified. To evaluate for possible aortoenteric fistula (AEF), a CT showed a graft bypassing the native abdominal aorta and iliac arteries with inflammation around the infrarenal abdominal aortic bypass graft. Also, there was an occlusion of the bypass right iliac artery system with a surrounding fluid collection suggestive of infection. No fistulas were seen. Since the patient continued bleeding, a video capsule was recommended and showed a submucosal mass in the proximal jejunum with failure of the capsule to progress beyond the small bowel. A following enteroscopy showed a foreign body in the mid jejunum suspicious for an endovascular graft eroding through the small bowel wall. She went to surgery for axillary bifemoral bypass. An exploratory laparotomy showed an infected aortic graft with a large AEF connecting the right iliac graft limb with the jejunum. The infected graft was removed and the affected jejunum was resected. AEF is a rare cause of acute GI bleed but is associated with high mortality if undiagnosed and untreated. The distal duodenum is the most common site for AEF, however, in our case, we presented an unusual fistula between the infected iliac limb graft and the jejunum. This should be considered in all patients with recurrent GI bleed and a history of infected prosthetic vascular graft. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival.Figure: No Caption available.

Tracheotomy bleeding from an unusual tracheo-arterial fistula: involvement of an aberrant right subclavian artery

The development of a tracheo-arterial fistula is a rare but severe complication of tracheotomy. The reported patient presented with such a fistula involving an aberrant right subclavian artery, termed an arteria lusoria, an aortic arch abnormality which is usually asymptomatic. A 30-year-old man was admitted to our institution for bleeding through his tracheotomy. He had been treated for advanced Duchenne muscular dystrophy, involving invasive assisted ventilation, since the age of 10 years. Surgical exploration and computed tomography scanning revealed a tracheo-arterial fistula involving an aberrant right subclavian artery, associated with severe scoliosis. Emergency, transient haemostasis was achieved by over-inflation of the tracheostomy tube cuff. Aneurysm ablation was successfully achieved as the result of an endovascular interventional radiology procedure. Arteria lusoria is one of the most common aortic arch abnormalities. The occurrence of an aneurysm of this artery in a tracheotomised patient has not previously been described. In Duchenne muscular dystrophy patients, spinal deformities may result in thoracic compression, which may alter the anatomical relations of mediastinal vessels. Such deformities are slowly progressive. Thus, vigilance is required in the long term management of Duchenne muscular dystrophy patients with a tracheostomy.