Selective occlusion with fibrin glue under fistuloscopy: seven cases of postoperative management for intractable complex fistulas.

BACKGROUND AND STUDY AIM: Fistula occlusion is not achieved in some fistulas with complex branches. To obtain early fistula closure in such cases, we insert a double-lumen catheter into each fistula branch, with the aid of a guide wire positioned using a small-caliber endoscope, and attempt selective infusion of fibrin glue. PATIENTS AND METHODS: Following removal of foreign bodies and necrotic granulation, we applied the selective occlusion method under fistuloscopic control to seven intractable external fistulas with complex branches, in which fistula closure had not been obtained by a simple occlusion method (SOM). All the fistulas were complex with more than two branches. RESULTS: Fistula occlusion was obtained within 2 weeks in six of the seven patients, and there has been no sign of recurrence over a follow-up period of 4 - 59 months (average 29.8 months). CONCLUSION: Selective occlusion under fistuloscopy is highly effective for intractable external fistulas with complex branches.

Appropriate blood flow for arterio-portal shunt in acute hypoxic liver failure.

Hepatic arterial interruption inevitably leads to fatal liver hypoxia when all the collateral arteries to the liver have been eradicated. To prevent such hypoxia, we aimed to determine the appropriate flow of arterial blood in the arterio-portal shunt (APS). After division of all the arteries to the liver, we created three types of APSs between the common hepatic artery (CHA) and the portal vein in dogs, using catheters which were adjusted to pass blood flows of approximately half (group I), equal to (group II) and twice (group III) the CHA blood flow before shunting, except in the control (no-shunt) group. Postoperatively, at 1 and 48 h, we examined the hemodynamics of the liver biochemically and pathologically. After shunting, portal blood flow and oxygen saturation markedly increased, whereas portal venous pressure did not rise significantly. The serum alanine aminotransferase level was significantly higher in the no-shunt group and group I than in group II. Only in group II was the preoperative energy charge maintained, and light- and electron-microscopic examinations revealed no degeneration of the hepatocytes. APS blood flow similar to the original CHA (as in group II) is most appropriate for preventing liver hypoxia.

Experimental study of tracheal patch reconstruction with a covered expandable metallic stent.

BACKGROUND: We evaluated the efficacy of tracheal patch reconstruction with a covered expandable metallic stent (EMS) with omentoplasty. METHODS: After resecting the right half of the circumferential wall of two tracheal rings in adult beagle dogs, we inserted a covered EMS to reconstruct the defect interiorly. Then, through laparotomy, we made an omental pedicle flap and wrapped it around the EMS-interposed area. For comparison with the group without omentoplasty, we periodically examined the healing process macroscopically and histologically. RESULTS: Bronchofiberscopic observations revealed that incorporation of the covered EMS progressed with the passage of time and tracheal luminal patency was maintained well in both groups. However, polyplike granulation developed gradually at both ends of the EMS. Histologically, epithelium was regenerated in the patched area 4 weeks postoperatively and the area was covered with pseudostratified ciliated epithelium at 12 weeks postoperatively. Quantitative analysis of the macroscopic and histologic findings showed that the inflammatory polyps were reduced and epithelialization was promoted in the group with omentoplasty. CONCLUSIONS: Tracheal patch reconstruction with a covered EMS, when combined with omentoplasty, promoted early epithelial regeneration and suppressed the development of inflammatory polyps.