Low incidence of milk fistula with continued breastfeeding following radiologic and surgical interventions on the lactating breast.

BACKGROUND: Milk fistula is a potential complication of radiologic and surgical procedures on the lactating breast, though its incidence is unknown. Some postulate that larger defects and/or closer proximity to the nipple increase the risk of fistula. OBJECTIVE: This study aimed to estimate the incidence of milk fistula and characterize risk factors in patients who continued breastfeeding after surgical or radiological procedures. METHODS: A retrospective cohort analysis of pregnant or lactating women treated at a multidisciplinary breast clinic from July 2016 through August 2019 was performed. Demographic and clinical variables were analyzed using ANOVA and Pearson's Chi-square. RESULTS: Two pregnant and 43 lactating patients underwent 71 interventions. The incidence of milk fistula within one week of intervention was 1.4%. One fistula was diagnosed six days after retroareolar abscess drainage. The fistula closed successfully with continued breastfeeding. When categorized by the caliber of the most invasive intervention (large-caliber: mass excision, n = 7; medium-caliber: percutaneous drain insertion, n = 18; small-caliber: stab incision, aspiration, core needle biopsy, n = 20), patients were similar in age, race/ethnicity, weeks postpartum, and frequency of central versus peripheral interventions. The low incidence of fistula prevented quantitative evaluation of potential risk factors. CONCLUSIONS: Milk fistula is a rare occurrence following radiologic or surgical breast interventions performed during pregnancy or lactation. Indicated procedures should not be deferred, but periareolar approaches should be avoided when possible. Cessation of lactation is not mandatory for fistula closure, and continued breastfeeding should be recommended.

Clinical Characteristics of Patients with Cochlear Fistulas Caused by Chronic Otitis Media with Cholesteatoma.

OBJECTIVES: To analyze the clinical characteristics of cochlear fistulas (CFs) and propose a new fistula classification system with regard to the cochlea. MATERIALS AND METHODS: A retrospective chart review was conducted between January 2008 and December 2015 to identify patients who had undergone surgery for cholesteatoma with an associated CF. The following data were collected: preoperative symptoms, findings of temporal bone computed tomography (TBCT), fistula stage, cholesteatoma classification, surgical technique, and pre- and postoperative pure-tone audiometry. RESULTS: We analyzed a total of 159 patients, out of which 9 (5.7%) were diagnosed with a CF. The average duration of the chronic otitis media was 19.8 years. Cholesteatomas that induced CF rarely existed in the nonaggressive state; recurrent otorrhea was observed in all but one of our subjects. All the patients with CF had a distinct origin of cholesteatoma that developed from the retraction of posterior pars tensa; further, 88.9% cholesteatomas extended to and filled the sinus tympani. Preoperative audiometry revealed total hearing loss in 4 (44.4%) patients. Further, five patients with residual hearing before surgery had stage I fistulas, and the bone conduction thresholds remained stable after surgery. CONCLUSION: Cochlear fistulas were often detected in patients with (1) a history of chronic otitis media (exceeding 10 years), (2) frequently recurring otorrhea, and (3) pars tensa cholesteatomas that extended to the posterior mesotympanum and filled the sinus tympani. Such patients can suffer from potentially severe and irreparable sensorineural hearing loss.

[Research progress of congenital preauricular fistula].

Congenital preauricular fistula can be sporadic or genetic. When inherited, it exhibits incomplete autosomal dominant genetic patterns. It can occur alone or with other diseases such as branchio-oto-renal syndrome. According to the position of fistula opening, congenital ear fistula can be divided into four categories: congenital preauricular fistula, congenital posterior ear fistula, congenital auricular fistula and congenital external auditory canal fistula. Congenital auricle fistula can be subdivided into congenital auricular fistula, congenital teal fistula, congenital earlobe fistula and so on. The diagnosis of preauricular fistula should be based on its clinical manifestation, and the diagnosis and treatment of special type of preauricular fistula should be emphasized. The treatment methods of congenital preauricular fistula include medicine, incision and surgical excision. According to the clinical practice of us and other scholars, surgical treatment is recommended in the period of acute infection, and the recurrence rate is not increased. The operation method of preauricular fistula, the application of microscope, dye tracer, probe and general anesthesia, and the clear surgical visualization are all helpful to reduce the recurrence rate.

Pharyngocutaneous fistula after total laryngectomy: multivariate analysis of risk factors and a severity-based classification proposal.

PURPOSE: The aim of the study is to determine the predisposing factors for pharyngocutaneous fistula (PCF) in patients undergoing total laryngectomy (TL) or extended TL and, secondarily, to propose a new severity-based classification system. METHODS: This is a retrospective study of 400 patients who underwent TL or extended TL. Major fistula was defined as a fistula (1) persisting for ≥ 4 weeks, (2) requiring surgical treatment, or (3) associated with perioperative mortality. RESULTS: PCF formation occurred in 93 patients (23.3%) and major fistula in 72 (18.0%). Extended surgery with partial or total pharyngectomy, previous treatment with radiotherapy, and postoperative hemoglobin levels < 99 g/L were associated with a significantly higher risk of developing major fistula. CONCLUSIONS: We propose a new PCF classification system according to clinical severity. Predictors of major fistula were the type of surgery, previous radiotherapy, and low (< 99 g/L) postoperative hemoglobin levels. We consider the use of onlay flaps in irradiated patients who require partial pharyngectomy.

Incidence of Palatal Fistula at Time of Secondary Alveolar Cleft Reconstruction.

OBJECTIVE: We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature. DESIGN: An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015. MAIN OUTCOME MEASURES: Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured. RESULTS: We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89). CONCLUSIONS: Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.

Fístulas perianales: caracterización con resonancia magnética / Perianal fistulas: magnetic resonance classification

Las fístulas perianales constituyen una problemática frecuente en la consulta médica actual, con un gran impacto en la morbilidad. Su tratamiento no está exento de complicaciones, como la recurrencia local y la incontinencia fecal. La resonancia magnética (RM) cumple un rol fundamental en la planificación preoperatoria de estos casos, ya que la notable resolución espacial de los equipos de última generación permite generar un mapa de la anatomía de la pelvis menor, señalando el número y la relación de los trayectos con el esfínter anal. El objetivo del presente trabajo es identificar los distintos tipos de fístulas en base a sus características por RM, haciendo énfasis en la anatomía de la región y la técnica de estudio de esta entidad.

Perianal fistulas are a prevalent problem in current medical practice, with a high impact on morbidity. The treatment is not exempt from complications, such as local recurrence and faecal incontinence. Magnetic resonance imaging (MRI) performs an essential role insurgical planning of these patients, since the high spatial resolution of the latest equipment provides more precise information of the pelvis anatomy, indicating the number and relationship of the fistulous tracks with the anal sphincter. The aim of this work is to identify the different types of fistulas based on MRI classification, with particular emphasis on the local anatomy and study techniques.

Parity as a predictor of obstetric fistula classification.

INTRODUCTION AND HYPOTHESIS: Obstetric fistulas are injuries to the genital tract in women without emergency obstetric services. Parity may predict the characteristics of fistulas that affect closure success and residual incontinence. Circumferential fistulas may predispose patients to postoperative incontinence. We hypothesized that primiparous women have more distal fistulas than multiparous women, leading to more scarring and circumferential fistulas. METHODS: A retrospective observational study was conducted on 1,856 women with obstetric fistula evaluated at three sites by three providers. Fistulas were classified using the Goh classification system. Women aged 10 to 55 years were classified as primiparas or multiparas. Analysis by parity of fistula type and size, degree of scarring, and presence of circumferential defect used the Chi squared or Fisher's exact test, and binary logistic regression. RESULTS: Of the 1,841 (99.2 %) women included, 878 (47.7 %) were primiparas and 963 (52.3 %) were multiparas. Primiparas were more likely to have distal fistulas, type 4 being most common (31.5 %), whereas multiparas were more likely to have proximal fistulas, most commonly type 1 (48.1 %). Primiparas were more likely to have moderate to severe scarring (11.7 % vs 5.6 %; p < 0.001), and category III (57.1 % vs 39.2 %; p < 0.001), but not to develop circumferential fistulas (5.6 % vs 4.0 %; p = 0.127), be present for repeat surgery (7.1 % vs 7.6 %; p = 0.721), or have ureteric involvement (1.5 % vs 2.2 %; p = 0.301). Multivariate analyses confirmed increased risk with primiparity for distal fistula and scarring. CONCLUSIONS: As hypothesized, primiparas were more likely to have distal fistulas and more scarring, but were not more likely to have circumferential fistulas. Surgeons should plan accordingly.

Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification.

PURPOSE: The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification. METHODS: From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification. RESULTS: Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p=0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation. CONCLUSIONS: Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.

Non-cameral coronary artery fistulae after pediatric cardiac transplantation: a multicenter study.

BACKGROUND: Cameral coronary artery fistulae (C-CAFs) are common after heart transplantation (HTx) and typically drain into the right ventricle. The development of CAFs to non-cameral structures after HTx has not been systematically investigated. We studied the incidence, anatomic distribution, and natural history of non-cameral CAFs (NC-CAFs) in a multicenter pediatric population. METHODS: Medical records from pediatric HTx patients at 2 centers from January 1, 1999, to August 31, 2009 were reviewed. A classification system for CAF size was developed, and serial angiograms were evaluated for CAF presence, size, and anatomy. Risk factors and outcomes were determined. RESULTS: Identified were 100 patients with a median age at HTx of 8.7 years. Median follow-up was 4.2 years. NC-CAFs occurred in 52 patients, C-CAFs in 20, with both types noted in 11. NC-CAFs originated from coronary arteries and drained predominantly into ipsilateral recipient pulmonary vasculature. Multiple NC-CAFs occurred in 19 patients (19%) for a total of 77 fistulae in 52 patients. Fistulae were classified as small (56%), moderate (36%), and large (8%). NC-CAFs were present at the first post-HTx angiogram in 95% of cases (median 1 year after HTx). Longer donor ischemic time was associated with the development (p = 0.043) and size (p = 0.05) of NC-CAFs. NC-CAFs were not associated with rejection, death, re-transplantation, or coronary revascularization, and none required intervention. CONCLUSIONS: Fistulae from donor coronary arteries to recipient pulmonary vasculature develop frequently and early after pediatric HTx. These correlate with graft ischemic time, but are not associated with early graft loss or death.

"Spontaneous" perilymph fistula: a case report.

A surgically documented case of barotrauma-induced perilymph fistula is presented in this case report. A brief review of the literature on this entity confirms the difficulty of making a definitive preoperative diagnosis in most instances. Clinical, audiometric, radiologic, and intraoperative findings are presented, and the classic presumed mechanisms for this uncommon cause of sudden sensorineural hearing loss are discussed. The presence of intact evoked otoacoustic emissions in an ear demonstrating a severe cochlear-type loss was considered helpful in narrowing the differential diagnosis in this case, and may suggest a productive avenue for future study.

Three different types of congenital lacrimal sac fistulas.

Three different symptoms in 4 patients with congenital lacrimal sac fistulas are presented. The first symptom was epiphora since birth, the second symptom was infection of the lower eyelid, and the third symptom was tearing from the eye in a 76-year-old patient. This patient had nasolacrimal obstruction at the canal level and no symptoms of congenital lacrimal sac fistula. She had undergone excision, including dacryocystorhinostomy. Three of the 4 patients underwent excision of the fistulous tract. The fistula originated from the lacrimal sac in all patients. Symptomatic congenital lacrimal sac fistulas can be treated successfully with excision alone or with excision and dacryocystorhinostomy in cases of nasolacrimal obstruction.

Clinical classification of vesicouterine fistula.

UNLABELLED: OBJECTIVE AND METHODSs: The aim of this paper is to propose a classification of vesicouterine fistula based on the routes of menstrual flow. RESULTS: Three types of the fistula are distinguished: type I - with menouria; type II - with dual flow via both the bladder and vagina; and type III - with normal vaginal menses. CONCLUSIONS: There is relevance of such division to both diagnosis and treatment. The simplicity and clinical utility of this classification warrant its widespread use.

Fístula liquórica.

Apresenta texto sobre fístulas liquóricas, com classificação (rinorréia liquórica - RL e otorréia liquórica - OL), fisiopatologia (RL traumática, RL não traumática, OL traumática e OL não traumática), diagnóstico (sintomas da RL e da OL, diagnóstico do liquor extracraniano e localização do sítio da fístula), tratamento (fístula liquórica não traumática de alta pressão, de pressão nl, e pós traumática), acessos cirúrgicos (intracraniano e extracraniano), tratamento cirúrgico em locais específicos (teto do etmóide - placa cribiforme, seio frontal, seio esfenoidal e ouvido), técnica endoscópica, resultados e highlights. Documento em formato PDF, requer Acrobat Reader.

Fístulas carótido-cavernosas: informe de una experiencia de 15 años / Carotid-cavernous sinus fístulas: information of a experience of 15 years

Los autores dan a conocer una experiencia clínica de 15 años (julio 1980/mayo 1995), en pacientes con fístulas carótido-cavernosas traumáticas y espontáneas, evaluadas y tratadas en la Unidad de Neuro-Oftalmología del Hospital Vargas de Caracas y en la consulta privada de uno de ellos (R.M.M.). De un total de 42 pacientes, 29 (69 por ciento) fueron espontáneas y 13 (31 por ciento) traumáticas. La incidencia de fístulas espontáneas fue mayor en mujeres en la edad media de la vida (x=51 años), mientras que las traumáticas se presentó en hombres jóvenes (x=25 años). Entre otros signos clínicos, la "arterialización" de los vasos conjuntivales constituyó un marcador de la condición, siendo decididamente diagnóstico en el 100 por ciento de las traumáticas y 96.5 por ciento de las espontáneas, seguido del exoftalmos en 100 por ciento de las traumáticas y 96.5 por ciento de las espontáneas. El estudio enfatiza la necesidad de un conocimiento de la enfermedad entre los especialistas que reciben estos pacientes, y la sensibilidad del examen clínico en el diagnóstico temprano. Se revisan las modalidades de tratamiento empleado

The various types of anorectal fistula in male imperforate anus.

The purpose of this paper is to provide a review of the anorectal fistulas occurring in male imperforate anus, with a suggested classification based on the site of termination of the fistula, namely, the bladder, the urethra, and the perineum. The fistulas included in these categories are discussed in some detail, with reference to previous cases or descriptions in the literature and with some personal observations.

[Possibilities for preserving hearing in labyrinth fistulas of different degrees of severity]. / Möglichkeiten des Hörerhalts bei Labyrinth-Fisteln von unterschiedlichem Schweregrad.

The labyrinthine fistula continues to be one of the most common complications in ears with cholesteatoma. Fifty-one patients with labyrinthine fistula were identified in a series of 1243 cases with cholesteatoma operated upon between 1989 and 1993 at the University ENT Clinic Wuerzburg. The surgical management concept comprised of removing the cholesteatoma matrix, categorizing the fistula type, and immediate covering of the labyrinthine capsule defect with bone dust, perichondrium and fibrin glue. The classification system of the fistulae used in the study used the depth of labyrinthine involvement as a criterion and also took into account the possibility of intentional or accidental damage to the labyrinth during surgical manipulation (Fig. 1). From 1991 on, patients were treated with 500 mg of Presnisolon 21 hydrogen succinate in a single intravenous dose, at the time the fistula was corrected. The postoperative hearing results were graded based on the extend of preservation of inner ear function at or near the preoperative level. None of the patients who had corticosteroid therapy suffered a profound sensory neural hearing loss (Fig. 2, 3), whereas five ears without steroids and a deep fistula lost function completely. The study concluded that corticosteroids have a beneficial impact on postoperative outcome in cases with severe injury to the membranous labyrinth.

Management of the open labyrinth.

Labyrinthine fistulas occur in approximately 5% of cholesteatoma cases, but the management of this difficult problem remains controversial. This study assessed the preoperative presentation and outcome in 37 patients operated on for cholestatoma complicated by labyrinthine fistula. Therapy involved removing the matrix from each fistula and reconstructing the bony wall of the labyrinth with bone dust, fibrin glue, and perichondrium. Corticosteroids were added to the management protocol in more recent cases. A fistula classification scheme was introduced to standardize the reporting of the extent of labyrinthine involvement and results of treatment. The most common preoperative symptoms, sensorineural hearing loss and vertigo, were notably lacking in more than 30% of patients. The fistula test was positive in only 32% of cases. Corticosteroids were seen to have a beneficial impact on postoperative outcome in those cases involving injury to the membranous labyrinth or removal of perilymph.