Case Of Fistula Research Articles

Lefamulin for Mycoplasma genitalium treatment failure in Australia and the USA: a case series and pilot open-label parallel arm randomised trial

ObjectivesMycoplasma genitalium (MG) causes urethritis and is associated with cervicitis, pelvic inflammatory disease and preterm delivery. Antimicrobial resistance is widespread and cure rates are declining. Lefamulin, a novel pleuromutilin, may...

A rare case of spinal dural arteriovenous fistula in a 22-year-old farmer

A rare case of spinal dural arteriovenous fistula in a 22-year-old farmer

BN SO54 - Complex Management of a Gastrocutaneous Fistula Following Pancreatic Necrosectomy: A Case Report

Abstract Background Gastrocutaneous fistulas are rare but serious complications that can arise following the surgical treatment of necrotizing pancreatitis. This post-operatory complication can be refractory to conservative management and may be further aggravated by severe skin injuries and malnutrition. This case report describes the comprehensive and multidisciplinary approach of a challenging case of gastrocutaneous fistula, ultimately requiring re-intervention. Method A 78-year-old female with a history of severe necrotizing pancreatitis underwent pancreatic necrosectomy by laparotomy. Postoperatively, she developed a gastric fistula, initially repaired with a double-layered suture. Recurrence led to a gastrocutaneous fistula with continuous gastric drainage and chemical burn of the surrounding skin. Initial conservative management included insertion of a nasogastric tube for gastric decompression, followed by placement of a PEG tube to redirect the drainage and prevent further skin damage and an esophagojejunal feeding tube to bypass the fistula and maintain nutrition. Nevertheless, the fistula persisted, resulting in significant skin erosion and deterioration of the patient’s condition. Results Given the failure of conservative measures and a concurrent diagnosis of a pancreatic fistula, a surgical approach was deemed necessary. The patient was transferred to a specialized hospital center, where she underwent fistulectomy with partial gastrectomy and wound closure. Negative pressure wound therapy (NPWT) was applied to the ulcerated skin to promote healing. This approach led to the successful closure of the gastrocutaneous fistula and healing of the skin wound. The patient showed marked clinical recovery, with no signs of infection or fistula recurrence and the nutritional status was successfully managed through enteral feeding leading to a notable functional recovery. Conclusion This case underlines the complexity of managing gastrocutaneous fistulas, demonstrating the efficacy of combining surgical and supportive therapies, serving as a reference for similar future cases and emphasizing the need for comprehensive management strategies for complex postoperative complications.

Trans-Tragal Approach for Mandibular Neck and Head Condylar Fractures.

This retrospective observational study evaluates the trans-tragal approach for the treatment of mandibular head and neck condylar fractures. From January 2009 to May 2024, 34 patients (20 males, 14 females, mean age 34 years) with 36 condylar fractures were treated using this approach. Surgical outcomes were assessed based on occlusal relationship, maximum mouth opening, and facial nerve function (House-Brackmann scale). Postoperative imaging included computed tomography scans, with follow-ups at 1, 3, 6 months, and 1 year. Complications such as wound infection, hematoma, and salivary fistula were also evaluated. Results showed satisfactory postoperative outcomes, with 32 patients maintaining normal occlusion and a mean interincisal opening distance of 40 mm. Three patients experienced complications, including temporary facial nerve numbness in one case, with complete recovery in 2 weeks, and 2 cases requiring reoperation due to condylar segment displacement. No cases of permanent facial nerve damage, salivary fistula, or tragal cartilage necrosis were observed. Aesthetic outcomes were satisfactory, with scars hidden in natural folds. The trans-tragal approach provides adequate surgical exposure to the posterior condylar region while minimizing the risk of facial nerve injury. Although the results of this study indicate favorable outcomes, further randomized controlled studies are required to validate these findings due to the non-randomized design and small sample size.

Endoluminal Visualization of Dural Arteriovenous Fistula Using Virtual Angioscopy

BackgroundVirtual Angioscopy (VA) has been used for vessel investigation and treatment planning in fields such as vascular surgery. To our knowledge, the utilization of VA in neurointerventional cases has not been demonstrated. Methods2 cases of dural arteriovenous fistula (dAVF) where virtual angioscopy was utilized were reviewed. Results2 cases of dAVF are reported where virtual angioscopic images were derived from 3D volume rendered (VR) images. The endoluminal visualization of the fistula served as additional tool that helped anatomic understanding and treatment planning. ConclusionThese cases demonstrate the utility of VA in endoluminal visualization of dural arteriovenous fistula that may aid in treatment planning considerations.

Feculent Drainage from Percutaneous Endoscopic Gastrostomy Tube due to Gastrocolocutaneous Fistula Found in Emergency Department: A Case Report

Introduction Percutaneous endoscopic gastrostomy (PEG) placement is a common procedure for patients requiring non-oral feeding. One rare complication of PEG placement is the formation of a gastrocolocutaneous fistula that develops when bowel is caught between the stomach and abdominal wall during placement. This report explores an elderly patient's gastrocolocutaneous fistula development months post-PEG placement who presented with malodorous leakage from the gastrostomy tube to the Emergency Department (ED). Case Report A 73-year-old male on hospice presented to the ED with malodorous leakage from his PEG tube. He had received the PEG tube four months prior to this presentation and had it replaced once at an outside hospital due to blockages. In the ED, his PEG tube was found to have a deflated balloon stopper. The PEG tube was replaced, but the feculent discharge persisted. Imaging showed the tube's position in the transverse colon. The patient underwent non-surgical management, with PEG tube removal and nutritional support via nasogastric tube. He was discharged with improvement of PEG site. Conclusion Gastrocolocutaneous fistula should be considered in patients experiencing unexpected PEG tube drainage or feeding-related complications such as diarrhea. Careful replacement techniques after dislodgement or blockage are important. Radiologic confirmation should be considered after replacement of tubes with feculent drainage. The rarity of gastrocolocutaneous fistula cases in literature explains the lack of standardized management approaches. Clinical signs such as feculent leakage through PEG tube site should prompt recognition and diagnosis by the ED clinician.

Identifying System-Level Strategies to Engage in HPV Prevention Across Oral Health and Primary Care Settings

Introduction: HPV vaccination prevents most HPV-related cancers, yet uptake remains low. HPV is linked to an estimated 70% of oropharyngeal cancers (OPCs) in the US and outnumber cases of HPV-related cervical cancers. Not all OPCs can be detected through routine screening, making HPV vaccination a more effective primary prevention strategy. However, bridging primary and oral healthcare faces challenges due to a lack of referral networks between practices. The purpose of this study is to identify key infrastructure elements and policies, as well as HPV prevention strategies, among an academic practice network of dental clinics and partnering community health clinics in a southeastern state. Methods: Researchers held interviews with directors and focus groups with staff at six dental clinics and eight associated community clinics in a southeastern state. Interviews and focus groups at dental and community clinics were analyzed by two study team members using thematic analysis with Nvivo software. Results: A total of 90 participants participated in all focus groups and interviews (N = 14 interviews, 10 focus groups (5–13 participants per focus group). Most participants identified as white (58.9%) and female (70%), with an average age of 38.5 years. Researchers identified nine key study themes: three specific to the dental clinics’ HPV conversations with patients, two related to community clinics’ vaccine provision, and four involving the relationship between the dental and co-located community clinics. Dental clinic staff do not currently discuss HPV with patients. They are open to discussing HPV with patients but anticipate barriers that require preparation to overcome them. Community clinics have demonstrated previous success with HPV vaccination, but patients over the age of 18 face financial barriers to vaccination. Community clinics and dental clinics report that they do not currently have existing referral networks but are open to a referral system between practices if infrastructure is put into place to support it. Conclusions: Our findings indicate that there is interest in, and potential for, increased discussion of HPV with dental patients and collaboration between dental and community clinics for HPV vaccination referral. The results of this investigation can be used to develop intervention strategies to increase HPV vaccination through referrals between dental clinics and nearby community clinics. Ultimately, this work can reduce health inequities in HPV-related cancers, serve as a model for US dental practices, and possibly influence public health policy.

Bridging the gap between neuroimaging and neurosurgery: a case of epidural arteriovenous fistula with an intradural presentation. Illustrative case.

Epidural arteriovenous fistulas (eAVFs) are rare vascular malformations often mistaken for their intradural counterparts due to similar angiographic features. Differentiation between epidural and intradural vascular lesions is crucial as it impacts surgical planning and prognosis. Despite advancements in diagnostic imaging, these entities can be misinterpreted and challenge management. The authors report the case of a 68-year-old male suspected to have a type I dural arteriovenous fistula based on magnetic resonance angiography and angiographic evaluation. He presented with progressive myelopathy and multiple neurological symptoms exacerbated by recent trauma. A superselective angiogram of the right T10 segmental artery suggested an intradural arteriovenous fistula; however, intraoperatively, the lesion was epidural. The arterialized venous structures were obliterated, and the patient reported significant postoperative symptomatic improvement. This case highlights the critical importance of comprehensive imaging and cautious interpretation in the diagnosis of spinal vascular malformations. It also underscores the need for a multidisciplinary approach to ensure accurate diagnosis and effective treatment. Surgeons must be prepared for intraoperative findings that diverge from preoperative imaging to adapt surgical strategies accordingly. Furthermore, this case contributes to the evolving understanding of eAVFs, suggesting that revised imaging protocols may be required to better distinguish epidural from intradural vascular abnormalities. https://thejns.org/doi/10.3171/CASE24331.

Carotid–cavernous sinus fistula with functional filtering bleb: A case report

We describe a rare case of carotid-cavernous sinus fistula (CCF) in a 91-year-old woman's right eye with a functional filtering bleb. Upon examination, best-corrected visual acuity was light perception and intraocular pressure (IOP) was 14 mmHg, and a shallow anterior chamber, a swollen filtering bleb, dilated episcleral veins, choroidal detachment, and ocular manifestations accompanied with CCF were observed. During the healing process post transcatheter arterial embolization (TAE), significant hypotony and prolonged choroidal detachment were observed. Generally, IOP elevation is known to be a common ocular manifestation in CCF cases. When CCF develops in an eye with a functional filtering bleb post trabeculectomy, no IOP elevation is observed because the aqueous humor drains from the bleb. Dilated episcleral veins and a shallow anterior chamber may be observed, and although significant hypotony can occur soon after TAE, closure of the CCF results in recovery of vision without ophthalmic intervention.

S3372 Difficult to Stomach: A Case of Esophagopleural Fistula Complicated by Stent Migration

S3372 Difficult to Stomach: A Case of Esophagopleural Fistula Complicated by Stent Migration

Assessing Google Search Trends for Mpox in the United States

Background and Aims: Mpox (formerly Monkeypox) is a zoonotic infectious disease with symptoms of rash, fever, and swollen lymph nodes. The most recent outbreak was reported in May 2022 with the first US case identified in the middle of the same month. Google Trends is a unique tool that quantifies frequencies of a specified search term in real-time, in a given time range, and by geographical location. The present study evaluates the utilisation of Google Trends data in understanding Mpox patterns in the US. Materials and Methods: On 29 September 2023, a Google Trends search was executed to analyse the popularity of the term Mpox for time range of 10 May 2022 to 28 September 2023. Data was exported into MS Excel and matched with the CDC’s Mpox case incidence data. Results: Mpox search was most popular in the District of Columbia (100) followed by Delaware (71), Maryland (70) and Georgia (68), respectively. The popularity scale of 24 was observed 2 days before the first US case was identified which could be attributed to the global rise in cases earlier in May 2022. Although a steep increase in Mpox searches was observed between July and August 2022, the trend aligned with the number of Mpox cases reported to the CDC during the same time frame. Conclusions: Google Trends data, if used in conjunction with other surveillance tools, can help in a better understanding of disease dynamics and may help validate trends obtained through other sources. Since Google Trends monitors and analyses searches in real-time, it can be valuable in establishing a robust action plan.

Application of modified grafted tubularized incised plate urethroplasty in hypospadias

To investigate the clinical feasibility and effectiveness of the modified grafted tubularized incised plate urethroplasty (G-TIP), namely "glans G-TIP (GG-TIP) ", in treatment of hypospadias. A clinical data of 137 children with hypospadias qualified by the selection criteria between January 2021 and June 2023 was retrospectively analyzed. Among them, 75 children were treated with GG-TIP (GG-TIP group) and 62 with G-TIP (G-TIP group). There was no significant difference ( P>0.05) between the two groups in terms of age, hypospadias type, penile length, penile head width, penile head height, penile curvature, meatus-apex distance, urethral plate width, and distance from the distal endpoint of navicular groove to the dorsal or ventral midline point of the glans corona, and the difference between the two. The operation time, reconstructed urethral length, distance from meatus to ventral glans corona, postoperative complications, maximum urinary flow rate at 2 weeks after operation, and the hypospadias objective scoring evaluation (HOSE) score at 6 months after operation in the two groups were recorded and analyzed. The operation time was significantly shorter in GG-TIP group than in G-TIP group ( P<0.05); but there was no significant difference ( P>0.05) between the two groups in terms of reconstructed urethral length and distance from meatus to ventral glans corona. All urinary meatus located at the tip of glans with vertical fissure shape. All children in the two groups were followed up 6-35 months (median, 26 months). During follow-up, there were 3 cases of urethral fistula, 2 cases of urethral stricture, and 1 case of glans separation in GG-TIP group, and 3, 3, and 1 cases in the G-TIP group, respectively. There was no significant difference in the incidence of complications between the two groups ( P>0.05). The maximum urinary flow rate at 2 weeks and the HOSE score at 6 months after operation were significantly higher in GG-TIP group than in G-TIP group ( P<0.05). GG-TIP is safe and effective for repairing hypospadias in children. Compared with G-TIP, it has the advantages of relatively simple operation, shortened operation time, significant improvement in urinary flow rate, and better cosmetic results.

A rare case of pancreatic pseudocyst-portal vein fistula in a patient with chronic pancreatitis.

A 60-year-old female with chronic pancreatitis and a history of splenectomy presented with epigastric pain, vomiting, and asthenia. Elevated pancreatic enzymes and CT imaging revealed a pseudocyst in the pancreatic head with suspected communication to the portal vein, confirmed by MR Cholangiopancreatography and endoscopic ultrasound (EUS). EUS-guided puncture revealed high amylase levels. Given her manageable symptoms, a conservative approach was adopted, leading to symptomatic relief and pseudocyst size reduction. Pancreatic pseudocyst-portal vein fistula is a rare pancreatitis complication, challenging to diagnose, with no gold-standard treatment. Endoscopic stenting offers a promising alternative to surgery for severe cases.

Three Faces of Innovation Competition: Choosing the Framework for Horizontal Merger Assessment

Abstract This article discusses the assessment of horizontal mergers and harm to innovation when there is innovation competition. The goal is to establish a methodology for selecting the appropriate analytical framework for each situation, outlining mechanisms for recognizing innovation competition, defining relevant markets, evaluating the competitive significance of firms, identifying suitable theories of harm, and gathering pertinent evidence for each scenario. We review the literature on Competition Policy and on Economics of Innovation and take examples from the US and European case law. We also briefly discuss the strategic management literature to provide insights for the assessment. Considering post-merger reductions on innovation incentives as harm to innovation, we find differences of traditional merger procedure adequacy and challenges to build evidence, considering three faces of innovation, including possible combinations of these faces within a same merger case: (i) continuous innovation efforts in the product market, (ii) ongoing innovation efforts for developing new products, and (iii) future innovation efforts. In instances where the conventional approach to mergers falls short, exploring a capabilities-based assessment is recommended. Given the gaps found in the existing literature, we provide insights to the analysis as steps towards an agenda of capabilities-based merger assessment.

394. ESOPHAGEAL STENTING IN ESOPHAGEAL CANCER PATIENTS WITH PERFORATION AND FISTULA

Abstract Background Esophageal perforation and fistula to the respiratory system are serious problems in esophageal cancer patients. Esophageal self-expandable metal stent (SEMS) placement has become a popular treatment for this problem. This retrospective study aimed to evaluate the factors associated with clinical outcomes following the placement of a SEMS in esophageal cancer patients with perforation and fistula. Methods Data from 43 esophageal cancer patients with perforation and fistula who underwent esophageal SEMS placement at Prince of Songkla University Hospital between January 2008 and June 2023 were reviewed. Statistical analyses, including chi-square tests and Kaplan-Meier methods, were employed for comparisons and survival calculations. Results The SEMS location was the middle esophagus in 76.8% and 11.6% in each of the lower and upper esophagus. The disease was stage IV in 62.8% and stage III in 37.2%. 46.5% had a history of chemoradiotherapy. The perforation and fistula penetrated into the left bronchus in 39.5%, right bronchus 18.6%, trachea 16.3%, lung 14% and mediastinum 11.6%. The SEMS technique was successful in all patients. The median stent patency was 38.5 days. Tumor overgrowth was the major cause of stent obstruction. The median overall survival was 40 days. Initial success of the SEMS placement was the only predictor of better survival. Conclusion Esophageal SEMS placement in esophageal cancer perforation and fistula cases is technically uncomplicated. Although these advanced esophageal cancer patients had a poor prognosis, the esophageal SEMS provided symptom relief and improved quality of life for their remaining time.

Usefulness of Hem-o-lok® clips to ligate the gastroduodenal artery in pancreatoduodenectomy

Background/purposePost-pancreatectomy hemorrhage (PPH) is a fatal complication of pancreatoduodenectomy. When complicated by a pancreatic fistula, pancreatic juice contacting the artery may form a pseudoaneurysm and cause arterial bleeding. We used Hem-o-lok® clips to prevent damage to the outer wall of the gastroduodenal artery (GDA). This study evaluated the usefulness of using Hem-o-lok® clips to ligate the GDA stump to prevent PPH. MethodsOverall, 468 patients who underwent PD at our hospital were included. Before July 2020, we ligated the GDA stump using the knot-tying method, which involves double ligation. After July 2020, the GDA stump was double clipped using a 10-mm Hem-o-lok® clip to the residual side without tension on the GDA. Propensity score matching was used to compare cases of pancreatic fistulas that underwent clipping vs. knot-tying. ResultsPropensity score matching resulted in 37 patients in each group. PPH occurred in 12 (16.4%) and 4 (6.9%) patients in the knot-tying and clipping groups, respectively. PPH from the GDA stump occurred in eight (11.0%) and one (1.7%) patient in the knot tying and clipping groups, respectively (P = 0.044). ConclusionsHem-o-lok® clips are safe to apply on the GDA stump during pancreatoduodenectomy to prevent PPH.

Underreporting of complications following AF ablation: Comparison of the manufacturer and user facility device experience FDA database and a voluntary invitation-based registry: The POTTER-AF 3 study

BackgroundThe Manufacturer and User Facility Device Experience (MAUDE) database houses medical device reports of adverse events involving medical devices marketed in the United States submitted to the U.S. Food and Drug Administration (FDA) by mandatory and voluntary reporters. The MAUDE database is frequently used in clinical studies to report on device-related complications. Data about its efficacy are scarce. ObjectiveWe aimed to compare the mandatory MAUDE database (MAUDE group) with the invitation-based POTTER-AF study (POTTER-AF 1 group) regarding data quality, procedural characteristics, diagnosis, treatment, and survival. MethodsThe reports of esophageal fistula esophageal fistula following atrial fibrillation (AF) ablation in the MAUDE database were compared with those in the POTTER-AF study between August 1, 2009, and August 31, 2019. ResultsEsophageal fistulas were reported in 47 patients in the MAUDE group and in 81 in the POTTER-AF 1 group. Procedures were performed with radiofrequency, cryoenergy, or laser energy in 66.0%, 31.9%, and 2.1% (MAUDE group) and in 96.3%, 2.5%, and 1.2% (POTTER-AF 1 group). The median time to symptoms was 21 (14, 32.5) days (MAUDE group) and 18.0 (6.8, 22.3) days (POTTER-AF 1 group; P = .031). The diagnostic method was reported in 38.3% of patients in the MAUDE group and in 98.8% in the POTTER-AF 1 group, the treatment in 57.4% and 100%, and the outcome in all patients. In the MAUDE group, treatment was surgical (51.9%), endoscopic (37.0%), combined (3.7%), or conservative (7.4%), compared with 43.2%, 19.8%, 7.4%, and 29.6% in the POTTER-AF 1 group. Overall mortality was 76.6% in the MAUDE group and 61.7% in the POTTER-AF 1 group (P = .118). ConclusionIn the mandatory MAUDE database, fewer esophageal fistula cases were reported compared with an invitation-based study. The data quality in the MAUDE database was significantly poorer.

The use of an autologous platelet-rich fibrin membrane in urethroplasty for cases of distal hypospadias

BackgroundAmong pediatric surgical procedures, hypospadias surgery is one of the most difficult. The most prevalent complication following hypospadias repair is urethrocutaneous fistula. Numerous procedures have been developed to prevent and resolve this issue. One such method is platelet-rich fibrin (PRF) membrane preparation, which is a straightforward process requiring only the patient’s serum. It has already been utilized successfully in plastic and reconstructive surgeries, where it significantly enhances the healing capacity and decreases the risk of infections. The purpose of this study is to assess the efficacy of an autologous PRF membrane in promoting healing and reducing fistula occurrence in cases of de novo distal hypospadias.MethodsForty patients with primary distal hypospadias underwent TIP repair, as a part of a prospective controlled randomized study from April 2017 to February 2018. The cases were randomly allocated into two categories. TIP repair done in all cases by the same surgeon. Twenty cases comprised group A, which utilized a preputial or local dartos flap as an additional protective layer over the urethroplasty. In contrast, group B comprised 20 cases in which the urethroplasty was covered with a PRF membrane. The initial follow-up duration was 6 months. Each group’s fistula incidence and other associated complications were documented.ResultsTwo groups were compared during the initial 6-month follow-up period. There were seven cases of urethrocutaneous fistula in group A, representing a 35% incidence rate. In group B, there were two cases that had fistula with an incidence of 10% in the early postoperative period. Two patients (10%) in group A developed meatal stenosis and only one patient in group B (5%) developed meatal stenosis. Glandular dehiscence occurred in one patient (5%) in group B. There was no skin wound infection in both groups.ConclusionThe PRF membrane may be a promising method as a coverage layer over the urethroplasty aiming to reduce the fistula rate after the repair. A larger comparative study is needed to evaluate the efficacy of PRF membranes in promoting wound healing.

Application of folded flap in laryngeal and hypopharyngeal function reconstructions after surgery of piriform sinus cancer

Objective: To investigate the use of folded flap for repair of laryngeal and hypopharyngeal defect and the clinical efficacies of laryngeal and hypopharyngeal function reconstructions after surgery of piriform sinus cancer. Methods: A retrospective analysis was performed for 10 cases of piriform sinus cancer that were treated in the Second Norman Bethune Hospital of Jilin University from January 2020 to April 2023 and all patients were males, aged 42-68 years. The first choice of treatment for all patients was surgery. After function neck dissection and tracheotomy, partial laryngectomy and hypopharyngectomy were carried out. The folded island flaps were prepared and used for the repairs of laryngeal and hypopharyngeal defects and the reconstructions laryngeal and hypopharyngeal functions. The patients were followed up. Results: The laryngeal and pharyngeal cavities were reconstructed well in 10 patients, and all the flaps survived, with no case of pharyngeal fistula. All patients were able to eat normally through the mouth at 2 weeks after surgery without obvious choking, and 4 patients completed the swallowing function evaluation without aspiration or only a small amount of aspiration. All the 10 patients underwent postoperative radiotherapy. The postoperative follow-up time was 5.4-41.4 months, and there was no case with tumor recurrence or death. Laryngoscopy showed that 8 patients had a spacious new laryngeal orifice, which met the conditions for extubation, of whom 7 patients had their tracheal tubes removed and 1 patient was still under observation, and that 2 patients had a slightly narrowed new laryngeal orifice due to a thick skin flap, with further follow-up observation. All patients retained their phonatory functions after surgery. Conclusion: Folded island flap can be used for the function reconstructions of the larynx and hypopharynx after surgery of pyriform sinus cancer.

Sinocutaneous Fistula: A Long-term Complication After Surgical Feminization of the Forehead.

Facial feminization surgery is part of the process of treating patients with gender dysphoria. Forehead contouring, a common part of facial feminization surgery, modifies masculine facial features of the upper third, especially decreasing the thickness of their frontal sinuses and the orbital bossing. Forehead contouring is considered a safe procedure with minor complications and high patient satisfaction. However, rare cases of sinocutaneous fistula have been reported as long-term complications. The diagnosis and therapeutic management of this complication are challenging. Therefore, the authors report a case of frontal sinocutaneous fistula occurring 2 years and 10 months after forehead contouring with its clinical presentation and treatment modalities. Surgeons practicing forehead contouring and patients undergoing this procedure should be aware of the risk of sinocutaneous fistula, a rare but severe complication that requires multidisciplinary medico-surgical care.