Successful thoracoscopic enucleation of a calcifying fibrous tumor of the lower mediastinum in a young woman.

BACKGROUND: Calcifying fibrous tumor (CFT) arising from the pleura is a relatively rare benign lesion in young and middle-aged adults. We report a 31-year-old woman with pleural CFT who underwent successful complete thoracoscopic enucleation. CASE PRESENTATION: An asymptomatic woman presented with a mass in the right lower lung field that was incidentally detected on a chest X-ray during a routine medical checkup. Chest computed tomography showed a well-defined mass in the lower mediastinum, with a maximum diameter of approximately 5.5 cm. Esophagogastroduodenoscopy showed no abnormal findings in the esophagus. An endoscopic ultrasonography (EUS) revealed a well-defined tumor with no internal blood flow. EUS-fine needle aspiration failed to establish a definitive diagnosis. Therefore, thoracoscopic tumor enucleation was performed for diagnostic and therapeutic purposes. Based on the histopathological findings of the resected specimen, the presence of a tumor with a high fibrous component in a young woman, and the identification of granulomatous calcifications, a diagnosis of CFT was established. CONCLUSIONS: Complete thoracoscopic tumor enucleation was successfully performed for CFT arising from the pleura in a young adult woman.

Survival impact of surgical site infection in esophageal cancer surgery: A multicenter retrospective cohort study.

Aim: This study was performed to evaluate the oncological impact of surgical site infection (SSI) and pneumonia on long-term outcomes after esophagectomy. Methods: The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 407 patients with curative stage I/II/III esophageal cancer at 11 centers from April 2013 to March 2015. We investigated the association of SSI and postoperative pneumonia with oncological outcomes in terms of relapse-free survival (RFS) and overall survival (OS). Results: Ninety (22.1%), 65 (16.0%), and 22 (5.4%) patients had SSI, pneumonia, and both SSI and pneumonia, respectively. The univariate analysis demonstrated that SSI and pneumonia were associated with worse RFS and OS. In the multivariate analysis, however, only SSI had a significant negative impact on RFS (HR, 1.63; 95% confidence interval, 1.12-2.36; P = 0.010) and OS (HR, 2.06; 95% confidence interval, 1.41-3.01; P < 0.001). The presence of both SSI and pneumonia and the presence of severe SSI had profound negative oncological impacts. Diabetes mellitus and an American Society of Anesthesiologists score of III were independent predictive factors for both SSI and pneumonia. The subgroup analysis showed that three-field lymph node dissection and neoadjuvant therapy canceled out the negative oncological impact of SSI on RFS. Conclusion: Our study demonstrated that SSI, rather than pneumonia, after esophagectomy was associated with impaired oncological outcomes. Further progress in the development of strategies for SSI prevention may improve the quality of care and oncological outcomes in patients undergoing curative esophagectomy.

Feeding gastrostomy and duodenostomy using the round ligament of the liver versus conventional feeding jejunostomy after esophagectomy: a meta-analysis.

Esophageal cancer patients require enteral nutritional support after esophagectomy. Conventional feeding enterostomy to the jejunum (FJ) is occasionally associated with small bowel obstruction because the jejunum is fixed to the abdominal wall. Feeding through an enteral feeding tube inserted through the reconstructed gastric tube (FG) or the duodenum (FD) using the round ligament of the liver have been suggested as alternatives. This meta-analysis aimed to compare short-term outcomes between FG/FD and FJ. Studies published prior to May 2022 that compared FG or FD with FJ in cancer patients who underwent esophagectomy were identified via electronic literature search. Meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate Odds Ratios (ORs) with 95% confidence intervals (CIs). Five studies met inclusion criteria to yield a total of 1687 patients. Compared with the FJ group, the odds of small bowel obstruction (OR 0.09; 95% CI, 0.02-0.33), catheter site infection (OR 0.18; 95% CI, 0.06-0.51) and anastomotic leakage (OR 0.53; 95% CI, 0.32-0.89) were lower for the FG/FD group. Odds of pneumonia, recurrent laryngeal nerve palsy, chylothorax and hospital mortality did not significantly differ between the groups. The length of hospital stay was shorter for the FG/FD group (median difference, -10.83; 95% CI, -18.55 to -3.11). FG and FD using the round ligament of the liver were associated with lower odds of small bowel obstruction, catheter site infection and anastomotic leakage than FJ in esophageal cancer patients who underwent esophagectomy.

Laparoscopic Repair Using Self-Fixating Mesh in an Adult Patient with a Sciatic Hernia and Irreducible Small Bowel: A Case Report and Literature Review.

Sciatic hernia is a rare type of pelvic floor hernia. The herniated tissue can include the ureter, small and large bowel, and ovary, among other tissues. Only a few cases of laparoscopic treatment for a sciatic hernia with small-bowel incarceration have been reported. We report our experience using a laparoscopic approach for treatment of sciatic hernia in an 83-year-old woman and review the literature on sciatic hernias. The patient was referred to our hospital complaining of constipation and abdominal bloating. Computed tomography (CT) scanning showed a right sciatic hernia containing the small bowel. Laparoscopic repair of the sciatic hernia was performed using a self-fixating mesh. The patient was discharged after an uneventful postoperative course and has not developed abdominal bloating or constipation postoperatively. In conclusion, a sciatic hernia was successfully repaired using a laparoscopic trans-preperitoneal approach and ProGrip Self-Fixating Mesh.

Relationship between pharyngeal or esophageal reconstruction and esophageal pressure after swallowing.

BACKGROUND: High-resolution manometry, which measures esophageal luminal pressure changes after swallowing, could shed more light on food-transport dynamics after pharyngeal/esophageal reconstruction. This prospective cohort study assessed the influence of two head-and-neck and esophageal tumor-resection and reconstruction approaches on esophageal pressure. METHODS: The cohort consisted of 17 patients who underwent esophageal/pharyngeal resection/reconstruction for cancer and then participated in postoperative high-resolution manometry. Five healthy controls also underwent manometry for comparison. RESULTS: Partial pharyngectomy with patch grafts associated with smooth and continuous esophageal/pharyngeal movement. By contrast, surgery that removed the thoracic esophagus led to complete loss of peristalsis and poor food transport. CONCLUSIONS: High-resolution manometry effectively characterized the changes in food-transport dynamics caused by pharyngeal/esophageal resection/reconstruction. These findings suggest that continuous and smooth movement of the pharynx and esophagus is important for swallowing and high resolution manometry could be useful in patients after pharyngeal/esophageal resection/reconstruction.

Huge esophageal gastrointestinal stromal tumor successfully resected under mediastino-laparoscopic transhiatal esophagectomy: a case report.

BACKGROUND: Esophageal gastrointestinal stromal tumors (E-GISTs) are often diagnosed early due to complaints such as dysphagia and are rarely found to be huge in size. Here, we report the treatment of a case of huge E-GIST successfully resected by minimally invasive surgery after neoadjuvant imatinib therapy. CASE PRESENTATION: An 86-year-old male patient with a 3-month history of dysphagia was referred to our hospital because of a suspected mediastinal tumor on chest X-ray. The chest computed tomography scan revealed a huge solid tumor, of about 100 mm in diameter, protruding into the left thoracic cavity. Histopathological examination results of fine-needle aspiration biopsy under endoscopic ultrasonography revealed a c-kit and CD34-positive esophageal gastrointestinal stromal tumor. The patient received neoadjuvant therapy with imatinib (400 mg/day) to reduce the size of the tumor and prevent rupture during resection. After 28 days of oral administration of imatinib, the tumor size decreased. However, the patient refused to continue treatment with imatinib and therefore underwent mediastino-laparoscopic transhiatal esophagectomy. We successfully resected the tumor completely with mediastino-laparoscopic surgical techniques. Esophageal reconstruction was performed using a gastric tube in the posterior sternal route. After an uneventful postoperative course, the patient was discharged postoperative day 14. Immunohistochemical findings of the resected specimen showed that the tumor cells were positive for c-kit, DOG-1 and CD34 and negative for smooth muscle actin and S100. CONCLUSIONS: Hybrid surgical procedure utilizing mediastino-laparoscopy might be useful for high-risk patient with esophageal tumors.

Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study.

BACKGROUND: The treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA. METHODS: We retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA. RESULTS: In the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73-18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19-11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02). CONCLUSIONS: The presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.

Impact of serine protease inhibitor alpha1-antitrypsin on expression of endoplasmic reticulum stress-induced proinflammatory factors in adipocytes.

Obesity-induced endoplasmic reticulum (ER) stress contributes to low-grade chronic inflammation in adipose tissue and may cause metabolic disorders such as diabetes mellitus and dyslipidemia. Identification of high serpina A1 (alpha-1 antitrypsin, A1AT) expression in mouse adipose tissue and adipocytes prompted us to explore the role of A1AT in the inflammatory response of adipocytes under ER stress. We aimed to determine the role of A1AT expression in adipocytes with ER stress during regulation of adipocyte homeostasis and inflammation. To this end, we chemically induced ER stress in A1AT small interfering RNA-transfected differentiating adipocytes using thapsigargin. Induction of CCAAT-enhancer-binding protein homologous protein (CHOP), an ER stress marker, by thapsigargin was lower in A1AT-deficient SW872 adipocytes. Thapsigargin or the proinflammatory cytokine tumor necrosis factor (TNF)α increased basal expression of cytokines such as interleukin (IL)-1ß and IL-8 in both SW872 and primary omental adipocytes. This thapsigargin- or TNFα-induced expression of proinflammatory genes was increased by A1AT deficiency. These findings indicate that adipose A1AT may suppress the ER stress response to block excessive expression of proinflammatory factors, which suggests that A1AT protects against adipose tissue dysfunction associated with ER stress activation.

Diaphragmatic plication for diaphragmatic eventration caused by chronic constipation: a case report.

Diaphragmatic eventration in an adult patient is a rare condition. We describe a case of an elderly patient with hemidiaphragm dysfunction caused due to chronic constipation. A 67-year-old woman with a medical history of descending colon cancer that was treated 24 years before undergoing partial colectomy was admitted to our hospital with complaints of progressive shortness of breath and dyspnea on exertion for the past few months. She had no past history of any trauma. The patient had previously been suffering from chronic constipation after surgery. Physical examination revealed distension and incisional hernia of the abdomen. Chest X-ray demonstrated the high position of the left dome of the diaphragm with the megacolon gas. Chest and abdominal computed tomographic scans disclosed left diaphragmatic displacement containing the stomach and megacolon and abdominal incisional hernia. We performed open laparotomy, repair of abdominal incisional hernia using mesh, and diaphragmatic plication with nonabsorbable polyester suture and pledgets. Postoperative imaging confirmed the significant improvement of the patient's left lung space and clinical resolution of her respiratory symptoms. We describe the case of a patient with diaphragmatic eventration that was caused due to chronic constipation who underwent successful surgical repair.

Laparoscopic repair of a Bochdalek hernia in an elderly patient: a case report with a review from 1999 to 2019 in Japan.

BACKGROUND: A Bochdalek hernia (BH) is a congenital defect of the diaphragm that generally presents in the newborn as life-threatening cardiorespiratory distress. In contrast, the diagnosis of a BH in adults is rare. Surgical repair for adult BH is recommended, but the optimal surgical method remains unclear. CASE PRESENTATION: A 75-year-old woman presented with progressive dyspnea and back pain, and a diagnosis of BH was made based on chest X-ray and computed tomography. Laparoscopic evaluation revealed a defect in the left posterior attachment of the diaphragm, and a left-sided BH without hernia sac was diagnosed. Parts of the stomach, small intestine, colon, pancreas, and spleen had prolapsed into the left thoracic cavity, without ischemic change, and these herniated organs were reduced to the abdominal cavity. A direct closure of the hernia orifice was possible by the laparoscopic suture technique using a mesh reinforcement. The patient made an uneventful recovery, and no recurrence was found in the 2-year follow-up. CONCLUSION: A recently published study reviewing detailed cases of repair of adult BH from 1999 to 2019 identified 96 cases, including the present case. The number of reports on laparoscopic and/or thoracoscopic surgery for BH in adults has recently increased, and the approach for repairing BH should be selected carefully on a case-by-case basis.

Pedunculated esophageal carcinoma endoscopically removed using SB knife Jr with detachable snare after neoadjuvant chemotherapy.

An 82-year-old Japanese man with alcoholic liver cirrhosis was referred to our hospital for treatment of advanced esophageal cancer. A protruding tumor was endoscopically observed in the middle thoracic esophagus, and pathological findings of the biopsy specimens revealed a squamous cell carcinoma. The clinical tumor staging was stage II (T3N0M0). The patient received two courses of neoadjuvant chemotherapy with 5-fluorouracil and nedaplatin. After the treatments, computed tomography showed significant reductions in the size of the target tumor. However, radical esophagectomy was not performed because the patient refused major invasive treatments. Instead, endoscopic resection was performed using a combination of polypectomy and endoscopic submucosal resection (ESD). To prevent bleeding during endoscopic treatment, we applied a detachable snare to the base of the tumor and cut the stalk using by an SB knife Jr, without hemorrhage. The pathohistology of the resected specimen was positively showed cancer cells on the margin of the esophageal carcinoma stalk. At 4 weeks after the initial operation, an additional ESD was successfully performed, which pathologically led to radical removal. The patient survived for more than 18 months after beginning the initial treatment. We describe a successful treatment using endoscopic resection after chemotherapy for advanced esophageal cancer with high surgical treatment risks.

Pulmonary metastasectomy for esophageal basaloid squamous cell carcinoma component at 66 months after esophagectomy.

BACKGROUND: Solitary pulmonary metastasis from esophageal basaloid squamous cell carcinoma (BSCC) components is an extremely rare recurrence of esophageal squamous cell carcinoma (SCC). CASE PRESENTATION: A 68-year-old Japanese woman was found to have a suspected malignant mass, approximately 2 cm in diameter, in her left lower pulmonary lobe, at 66 months after undergoing a curative esophagectomy with three-field lymph node dissection for esophageal SCC with a focal basaloid component. After a CT-guided biopsy, pathological examination indicated a metastasis from esophageal BSCC components. She underwent a thoracoscopic partial resection of the left lower pulmonary lobe for the solitary pulmonary metastasis. The pathohistology of the resected specimen led to diagnosis of metastatic esophageal BSCC, which showed immunohistochemical findings similar to those of the primary esophageal carcinoma. The patient received two courses of adjuvant chemotherapy (5-fluorouracil, docetaxel plus nedaplatin) and recovered to resume a normal life with maintenance therapy. However, multiple lung and brain metastases were diagnosed at 2 years after the pulmonary metastasectomy. She survived 5 years and 6 months after the pulmonary metastasectomy, but died at 10 years and 6 months after her initial esophagectomy. CONCLUSION: This was a rare surgical resected case of solitary pulmonary metastasis from esophageal BSCC components.

Racemose hemangioma of the bronchial artery mimicking esophageal submucosal tumor: a case report.

Primary racemose hemangioma of the bronchial artery is a rare congenital disease that is occasionally complicated by aneurysms. An asymptomatic 78-year-old man was referred to our hospital with an esophageal submucosal tumor that was endoscopically found in the upper thoracic esophagus in a health check-up. Physical examination findings were unremarkable. Contrast-enhanced chest computed tomography with three-dimensional image reconstruction and selective bronchial arteriography resulted in a definitive diagnosis of primary racemose hemangiomas of the bronchial arteries accompanied by left bronchial artery aneurysm. Because rupture of a bronchial artery aneurysm can cause critical life-threatening hemorrhage, bronchial arterial embolization using coils and a mixture of N-butyl-2-cyanoacrylate and iodized oil was thus performed for bronchial artery aneurysm. Postoperative course was uneventful, and the patient was discharged on the third postoperative day. Computed tomography performed after 6 months revealed no enhancement of the aneurysms. In conclusion, we report a case of an asymptomatic primary racemose hemangioma of the bronchial artery accompanied by an aneurysm that mimicked a submucosal esophageal tumor. We also reviewed other Japanese case of primary racemose hemangioma of the bronchial artery accompanied by aneurysm based on the literature.

Pyogenic spondylodiscitis of the lumbar spine related to anastomotic fistula after surgery for esophageal cancer: a case report.

BACKGROUND: Pyogenic spondylodiscitis is an extremely rare complication of esophagectomy for esophageal cancer. CASE PRESENTATION: A 70-year-old Japanese man, with a previous medical history of type 2 diabetes mellitus, coronary artery disease, and laryngeal cancer, received neoadjuvant chemotherapy and underwent thoracoscopic esophagectomy with gastric tube reconstruction for advanced esophageal cancer. Cervical esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. However, partial necrosis in the gastric tube developed to form refractory anastomotic fistula. Two months after the initial surgery, debridement and free jejunal transfer reconstruction with the pectoralis major muscle flap were performed. Although the postoperative course of the second surgery was uneventful, the patient complained of severe lower back pain and fever. The patient was diagnosed with pyogenic spondylodiscitis according to the results of the magnetic resonance imaging. Enterobacter cloacae were isolated from the arterial blood culture. Sensitive antibiotics were administered continuously, and the patient required to use a lumbar corset for 2 months. Subsequently, his physiological signs and symptoms had completely disappeared. CONCLUSION: To the best of our knowledge, this case study is the first study that reported pyogenic spondylodiscitis of the lumbar spine, a complication of cervical anastomotic fistula after surgery for advanced esophageal cancer.

Sarcoid-like reaction in lymphadenopathy associated with superficial esophageal squamous cell carcinoma.

Correctly distinguishing metastasis and sarcoid-like reaction in patients with mediastinal lymphadenopathy is clinically important in esophageal cancer. A patient was a 52-year-old Japanese woman with superficial esophageal squamous cell carcinoma and rare case of sarcoid-like reaction. The patient was admitted with pharyngeal discomfort and an upper gastrointestinal endoscopy detected a superficial tumor in the middle thoracic esophagus. Biopsy confirmed a diagnosis of squamous cell carcinoma. Chest computed tomography (CT) showed enlarged lymph nodes around the trachea and in the bilateral hilum of the lung that were found to accumulate label on positron emission tomography CT. One course of chemotherapy in 5-fluorouracil, docetaxel and cisplatin did not affect the lymphadenopathy, which suggested that it was reactive rather than metastatic. The patient had undergone thoracoscopic esophagectomy with lymph node dissection. The pathohistology of the dissected lymph nodes showed noncaseating epithelioid-cell granuloma and no malignant cells. No clinical findings indicative of systemic sarcoidosis were observed, leading to a diagnosis of sarcoid-like reaction with the esophageal cancer. The patient has survived without recurrence for 4 years after beginning the initial treatment. Monitoring the response to chemotherapy may be helpful in distinguishing between metastasis and sarcoidosis-associated lymphadenopathy in esophageal cancer.

Blood Galectin-3 Levels Predict Postoperative Complications after Colorectal Cancer Surgery.

BACKGROUND: Recent studies suggested that galectin-3 may act as a pro-inflammatory damage-associated molecular pattern. The aim of this study is to investigate the association between blood galectin-3 and postoperative complications (POC) after colorectal cancer (CRC) surgery. METHODS: Blood samples were taken from 35 patients with CRC before surgery, immediately after surgery, and on postoperative days (POD) 1, 3, 5, and 7. Blood galectin-3 and interleukin-6 levels were measured by commercially available ELISA. Patients were divided into those with (POC group) and without POC (no-POC group). RESULTS: Significantly higher galectin-3 levels were observed pre- and postoperatively in the POC group (n=10) compared with those of the no-POC group (n=25). Galectin-3 levels on POD1 showed the best predictive potential for POC (cut-off: 3.18 pg/mL, area under the curve: 0.868). CONCLUSIONS: These results indicate that increased perioperative blood galectin-3 levels may be associated with POC after CRC surgery.

Short-term outcomes of a self-expandable metallic stent as a bridge to surgery vs. a transanal decompression tube for malignant large-bowel obstruction: a meta-analysis.

PURPOSE: Preoperative intestinal decompression, using either a self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) or a transanal decompression tube (TDT), provides an alternative to emergency surgery for malignant large-bowel obstruction (MLBO). We conducted this meta-analysis to compare the short-term outcomes of SEMS placement as a BTS vs. TDT placement for MLBO. METHODS: We conducted a comprehensive electronic search of literature published up to March, 2018, to identify studies comparing the short-term outcomes of BTS vs. TDT. Decompression device-related and surgery-related variables were evaluated and a meta-analysis was performed using random-effects models to calculate odd ratios with 95% confidence intervals. RESULTS: We analyzed 14 nonrandomized studies with a collective total of 581 patients: 307 (52.8%) who underwent SEMS placement as a BTS and 274 (47.2%) who underwent TDT placement. The meta-analyses showed that the BTS strategy conferred significantly better technical and clinical success, helped to maintain quality of life by allowing free food intake and temporal discharge, promoted laparoscopic one-stage surgery without stoma creation, and had equivalent morbidity and mortality to TDT placement. CONCLUSIONS: Although the long-term outcomes are as yet undetermined, the BTS strategy using SEMS placement could be a new standard of care for preoperative decompression to manage MLBO.

Metastasis of Hepatocellular Carcinoma to the Esophagus: Case Report and Review.

A follow-up endoscopy in a 71-year-old Japanese man who had undergone a left lateral segmentectomy for HCC two years ago revealed an approximately 2 cm in diameter pedunculated polypoid mass in the middle part of the thoracic esophagus. Immunohistochemical staining of the endoscopic biopsy revealed a metastatic HCC esophageal tumor. As the patient's disease could be radically removed by preoperative examinations, we resected the metastatic esophageal tumor via right thoracotomy and esophagogastrostomy reconstruction. Histological examination of the resected specimen revealed that the esophageal tumor was compatible with a HCC metastasis. This is an extremely rare case of a solitary metastasis to the esophagus from HCC in the literature.

A Novel Tube-Drainage Technique of Negative Pressure Wound Therapy for Fistulae after Reconstructive Surgery.

BACKGROUND: Patients with head and neck or esophageal cancer who undergo resection and reconstructive surgery sometimes develop fistulae that exhibit delayed wound healing. We developed a novel negative pressure wound therapy (NPWT) that employs a Penrose drain. This case series report describes its effect on the wound healing and treatment duration of cancer patients with postoperative fistulae. METHODS: This consecutive case series consisted of all patients from February 2014 to February 2017 who underwent resection and reconstruction for head and neck or esophageal cancer and who then developed a fistula that was treated with either NPWT or a second flap that did not resolve the fistula or led to fistula recurrence and was then treated with NPWT. A Penrose drainage tube was inserted into the fistula, and a NPWT device was applied. RESULTS: Eleven patients (10 males, 1 female; mean age, 67.4 years) underwent NPWT for fistulae that arose after tumor resection and reconstruction (n = 6) or after fistula reconstruction (n = 5). The resection was for esophageal (n = 4), laryngeal (n = 3), oral (n = 2), and hypopharyngeal (n = 2) cancer. In 9 cases, 1 week of NPWT led to rapid and complete wound healing. In 2 cases, complete healing occurred after 3-4 weeks of NPWT. CONCLUSIONS: Our NPWT applies continuous negative pressure inside the fistula only and dramatically promoted fistula healing. This approach may work by cleaning the fistula and promoting mucosal surface adhesion. It is particularly effective when the tissue surrounding the fistula is soft due to fresh tissue transfer.