Efficacy and Safety of Hyperbaric Oxygen Therapy in Fistulizing Crohn's Disease: A Systematic Review and Meta-analysis.

BACKGROUND: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen in a pressurized chamber, increasing tissue oxygen levels and regulating inflammatory pathways. Mounting evidence suggests that HBOT may be effective for inflammatory bowel disease. Our systematic review and meta-analysis aimed to quantify the efficacy and safety of HBOT in fistulizing Crohn's disease (CD). METHODS: A systematic review was conducted using the EMBASE, Web of Science, Pubmed, and Cochrane Library databases according to the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" criteria. Study bias was assessed using the Cochrane Handbook guidelines. RESULTS: Sixteen studies with 164 patients were included in the analysis. For all fistula subtypes, the pooled overall clinical response was 87% (95% CI: 0.70-0.95, I2 = 0) and the pooled clinical remission was 59% (95% CI: 0.35-0.80, I2 = 0). The overall clinical response was 89%, 84%, and 29% for perianal, enterocutaneous, and rectovaginal fistulas, respectively. On meta-regression, hours in the chamber and the number of HBOT sessions were not found to correlate with clinical response. The pooled number of adverse events was low at 51.7 per 10,000 HBOT sessions for all fistula types (95% CI: 16.8-159.3, I2 = 0). The risk of bias was observed across all studies. CONCLUSION: HBOT is a safe and potentially effective treatment option for fistulizing CD. Randomized control trials are needed to substantiate the benefit of HBOT in fistulizing CD.

Late-Onset Chronic Corneal Fistula Following Phototherapeutic Keratectomy: A Case Report and Importance of Early Detection.

BACKGROUND We report a case of late-onset chronic fistula in a decompensated cornea after multiple ocular surgeries and a recent phototherapeutic keratectomy (PTK). CASE REPORT A 73-year-old woman presented to our service with a past ocular history of bilateral chronic angle closure glaucoma and pseudophakic bullous keratopathy in the left eye. Given a history of long-term uncontrolled glaucoma with advanced disc cupping and poor visual potential, the patient underwent multiple palliative procedures, including, most recently, a PTK. Few years later she presented with a spontaneous late onset of slowly appearing corneal leak on fluorescein staining upon routine clinical examination. Corrected distance visual acuity was hand motion and intraocular pressure (IOP) was 40 mmHg in the affected eye. Serial anterior segment optical coherence tomography (AS-OCT) sections were obtained, which aided in understanding the current presentation and revealed distinctive multilayer corneal changes during the healing process. The patient was successfully managed with cyanoacrylate corneal gluing and ocular hypotensive medications, which halted the corneal leak. CONCLUSIONS We report a case of a rare finding of corneal fistula in an eye with multiple previous ocular surgeries, and provide an explanation of the possible etiopathogenesis. We also highlight the pivotal role of AS-OCT for evaluating such cases and stress the importance of early detection of similar subtle leaks in the setting of a formed anterior chamber, which can often be missed, carrying a risk of infection.

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review.

BACKGROUND: Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL. METHOD: A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA. RESULTS: From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments. CONCLUSION: CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL. KEY POINTS: · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps.. CITATION FORMAT: · Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

Successful embolisation of pelvic fistulating vessels to the prostate arising after TURP - a rare cause of postoperative bleeding.

Transurethral resection of the prostate (TURP) is considered the gold-standard operation to treat lower urinary tract symptoms due to benign prostatic enlargement in men. Postoperative bleeding is a recognised complication and managing it is a core skill required by attending urologists. We report a rare case of postoperative bleeding caused by fistulating vessels to the prostate which developed after TURP. These fistulas arose from the right internal iliac vessels and communicated with pre-existing pelvic varices affecting the right paraprostaticand seminal vesicle tissues. The fistulating vessels were successfully embolised with liquid embolic agent. Surgeons should be aware that persisting haemorrhage can occur post-TURP from the rare presence of fistulating vessels communicating with pelvic varices. Early computed tomography angiographic assessment is warranted in cases where bleeding is prolonged and refractory to standard management in view of timely referral for percutaneous embolisation.

Conservative management of postoperative chylous fistula with octreotide and peripheral total parenteral nutrition.

Postoperative chylous fistula after neck dissection is an uncommon complication associated with significant patient morbidity. Octreotide acetate is a somatostatin analogue established in the treatment of chylothorax; however, its utility in the management of cervical chylous fistulae has not been fully evaluated. The investigators hypothesized that chylous fistula can be managed by a combination of octreotide and peripheral total parenteral nutrition (TPN). A retrospective review of cases compiled at our institution from 2009 to 2015 was conducted. Ten patients, all men, were identified as having a postoperative chylous fistula after a neck dissection. All patients were treated with peripheral TPN and intravenous octreotide. Mean age of the patients was 63.0 years (range 49 to 82). Five (50.0%) had a neck dissection for the management of metastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8 (80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of the leaks occurred within the first 2 postoperative days. Eight (80%) leaks were controlled using TPN and octreotide, with 2 (20%) patients requiring surgical intervention. No factors were significant in the successful conservative management of chylous fistulae. One patient with a chylous fistula of 1,800 ml/day was managed successfully without surgical intervention. The results of this case series suggest that chylous fistulae may be managed conservatively with octreotide and TPN. However, long-term evaluation is needed to define if and when surgical intervention is required for control.

Hyperbaric oxygen therapy as an alternative to surgery for non-healing pharyngocutaneous fistula.

The aim of the study is to examine the utilization of hyperbaric oxygen treatment (HBOT) as an alternative to surgical treatment for non-healing postoperative phayngocutaneous fistula (POPCF). A retrospective study was conducted between 2012 and 2014 of referred patients who had failed conservative treatment for POPCF at other medical centers. Reevaluation at our department was followed by therapeutic management including daily HBOT. Eight male patients with a mean age of 62.3 years were included. The average period of conservative treatment was 1 month before admittance to our department. All patients were managed with HBOT and local debridement. Closure of the POPCF was proved by a barium swallow test in seven patients (87.5 %). HBOT is recommended for patients who have failed conservative treatment for POPCF post-laryngectomy, due to a high rate of successful (87.5 %) closure and should be considered as an alternative to surgical treatment.

Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management.

BACKGROUND: To evaluate the effectiveness of lymphography as a minimally invasive treatment option of lymphatic leakage in terms of local control and to investigate which parameters influence the success rate. METHOD: This retrospective study protocol was approved by the ethic committee. Patient history, imaging data, therapeutic options and follow-up were recorded and retrospectively analyzed. Between June 1998 and February 2013, 71 patients (m:w = 42:29, mean age, 52.4; range 42­75 years) with lymphatic leakage in form of lymphatic fistulas (n = 37), lymphocele (n = 11), chylothorax (n = 13) and chylous ascites (n = 10)underwent lymphography. Sixty-four patients (90.1%) underwent successful lymphography while lymphography failed in 7 cases. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage and to the volume of the applied iodized oil. RESULT: Signs of leakage or contrast extravasation were directly detected in 64 patients. Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients when the lymphatic drainage volume was less than 200 mL/day (n = 33). Even when lymphatic drainage was higher than 200 mL/day (n = 31),therapeutic lymphography was still successful in 58.1% of the patients. CONCLUSION: Lymphography is an effective, minimally invasive method in the detection and treatment of lymphatic leakage. The volume of lymphatic drainage per day is a significant predictor of the therapeutic success rate.

The effect of hyperbaric oxygen therapy on treatment of wound complications after oral, pharyngeal and laryngeal salvage surgery.

INTRODUCTION: Radiation therapy alone, or combined with chemotherapy, are both used for cancer in the head and neck. This can lead to damage of tissue cells and vasculature. Surgery in such compromised tissues has increased complication rates, because wound healing with angiogenesis and fibroplasias requires normal cell growth conditions. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasia. In this report, we review the clinical value of hyperbaric oxygen therapy for major wounds that had shown no signs of healing as well as fistulas after salvage surgery in patients treated with (chemo)radiation of the head and neck regions. METHODS: In this retrospective study, 16 patients with soft-tissue wounds without signs of healing after salvage surgery, after radiation, and most after chemotherapy were treated in the head and neck regions with hyperbaric oxygen therapy. The patients were treated by HBO2, 2.5 bars 90 minutes daily, usually 20 treatments. RESULTS: The healing processes seemed to be initiated and accelerated by HBO2. Fourteen of the 16 patients healed completely. There were no life-threatening complications. CONCLUSION: Radiotherapy and combined chemoradiation therapy leads to damage of tissue cells and vasculature. Salvage surgery in such tissues has an increased complications rate, because wound healing requires angiogenesis and fibroplasias, all of which are jeopardized. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasias and is an effective and powerful treatment for postoperative wounds in oral, pharyngeal and laryngeal carcinomas surgery.

Treatment of lymphocutaneous fistulas after vascular procedures of the lower limb: accurate wound reclosure and 3 weeks of consistent and continuing drainage.

BACKGROUND: Lymphocutaneous fistulas occurring after vascular procedures of the lower limb are a rare, but frustrating, complication. Many treatment options exist, but may lead to inconsistent results, with infection, delayed wound healing, and prolonged hospital stay. We present a simple surgical treatment of wound closure and drainage. METHODS: In this single-center, single-intervention, observational clinical study (case series), prospectively collected data of 23 consecutive lymphocutaneous fistulas in 22 patients (19 male and three female; age, 42 to 91 years) treated between June 2005 and October 2008 were retrospectively analyzed. Twenty-two fistulas were situated in the groin and one at the knee incision. The standardized therapy consisted of the installation of a Redon to drain the lymph, and accurate closure of the wound. Postoperatively, drainage was maintained for 21 days: suction Redon drainage for the first 7 days, passive Redon drainage for the next 7 days, and further drainage in a pouch after removal of the drain for the last 7 days. RESULTS: In 19 of the initial 23 lymphocutaneous fistulas, the whole drainage procedure was completed, with healing of the wound, without infection, recurrence, or lymphocele formation after 1 year of follow-up. In these cases, there had been a steady decrease of daily lymph drainage: a mean of 163.4 (standard error on the mean, 39.6) mL on the first day of suction, 56.8 (15.5) mL on the first day of passive drainage, 11.6 (4.3) mL on the last day of passive drainage, and 2.1 (0.9) mL on the 21st day when the drainage treatment was stopped. In four fistulas, this treatment was considered a failure because of inadvertent early drain removal (two cases), infection (one case), and lymphorrhea recurrence with wound breakdown (one case). CONCLUSION: This standardized surgical therapy, consisting of accurate wound closure and 3 weeks of drainage, allowed the healing of 19 of 23 postoperative lymphocutaneous fistulas (an 82.6 % success rate), without infection, recurrence, or lymphocele formation after 1 year of follow up.

Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy.

BACKGROUND: Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life. AIMS: To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients. RESULTS: A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases. CONCLUSION: Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.

Hyperbaric oxygen for treatment of problem wounds.

Hyperbaric oxygen treatment has seen a resurgence of interest in recent years, with more academic medical centers building facilities and more physicians becoming board-certified in undersea and hyperbaric medicine.The reason for the growing interest is better understanding of the role of hypoxia in wound healing and an appreciation for the role of HBOT in reversing tissue hypoxia and enhancing the healing process.This has resulted in a number of new evidence-based indications for HBOT. This article describes the role of HBOT in wound healing and how it specifically applies to treatment of delayed radiation injury, one of the conditions for which it is commonly used.

Thread-dragging therapy in treatment of a rat model of infected subcutaneous fistula.

OBJECTIVE: This study was to develop an experimental rat model of subcutaneous fistula induced by bacteria infection and treat it with thread-dragging therapy. METHODS: A spring-gauze was surgically implanted into 24 male Sprague-Dawley rats' dorsal muscles, respectively, then mixed Staphylococcus aureus and Escherichia coli were injected into the spring-gauze. After 45 d, all the spring-gauzes were removed from the rats under anesthesia. X-ray and ultrasound were performed to assess the fistula tract. Each rat was examined by a fistula probe and four rats were randomly selected for histological assessment. The residual rats were randomly divided into two groups. Group A was treated with thread-dragging therapy, and group B was treated with fistulotomy. The healing time and body weight of the two groups were compared. RESULTS: On the 45th day of the spring-gauze implantation, imaging assessment proved a tract with two openings in all rats and histological results proved that lumen and surrounding granulation tissue with epithelium were similar to the features of fistula in human beings. The mean healing time of rats in group A was shorter than that of the rats in group B (P<0.01). The body weight of rats in group A was heavier than that of the rats in group B on the 7th and 14th day after surgery, respectively (P<0.05). CONCLUSION: A rat model of subcutaneous fistula induced by mixed Staphylococcus aureus and Escherichia coli infection was successfully established. Traditional Chinese medicine thread-dragging therapy is less invasive and safer than fistulotomy.

Effectiveness of therapeutic lymphography on lymphatic leakage.

BACKGROUND: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography. PURPOSE: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate. MATERIAL AND METHODS: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage. RESULTS: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention. CONCLUSION: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.

Fístula linfática cervical: manejo conservador / Neck chylous fistula: conservative treatment

La fístula quilosa, por daño del conducto torácico, aparece en el 1-2,5% de los pacientes sometidos a disección cervical. Las complicaciones asociadas incluyen desnutrición, compromiso inmune, formación de fístulas y necrosis cutánea con exposición carotídea, e incluso ruptura. De la literatura actual no se puede deducir ningún algoritmo de tratamiento definitivo, pero parece existir un consenso en realizar un manejo conservador de la mayoría de los casos. El manejo médico se basa en la teoría de que si se disminuye el flujo de quilo se permitirá el cierre espontáneo de la fístula, e incluye: drenaje conectado a vacío, reposo, vendaje compresivo (en discusión),intervención nutricional y uso de análogos de somatostatina. El manejo nutricional implica el uso de dietas bajas en grasa suplementadas con Triglicéridos de Cadena Media (MCT), Nutrición Enteral con TCM o Nutrición Parenteral total (NPT) (AU)

Injury to the thoracic duct, leading to chyle leak, occursin 1-2,5% of patients who undergo neck dissection. Associated complications include malnutrition, immunecompromise, fistula formation and carotid blowout. No definitive treatment algorithm can be deduced from the current literature, but on last reviews, there is an agreementon the conservative management. Medical managementis based on that decreasing chyle flow will allow for spontaneous closure of the chyle leak. Conservative treatment includes: closed vacuum drainage, bed-rest,nutrition modification and synthetic somatostatin analog. Nutrition modification involves a low-fat diet supplemented with medium-chain triglycerides (MCT),enteral nutrition with high percentage of MCT or parenteral nutrition (AU)

[Neck chylous fistula: conservative treatment]. / Fístula linfática cervical: manejo conservador.

Injury to the thoracic duct, leading to chyle leak, occurs in 1-2,5% of patients who undergo neck dissection. Associated complications include malnutrition, immune compromise, fistula formation and carotid blowout. No definitive treatment algorithm can be deduced from the current literature, but on last reviews, there is an agreement on the conservative management. Medical management is based on that decreasing chyle flow will allow for spontaneous closure of the chyle leak. Conservative treatment includes: closed vacuum drainage, bed-rest, nutrition modification and synthetic somatostatin analog. Nutrition modification involves a low-fat diet supplemented with medium-chain triglycerides (MCT), enteral nutrition with high percentage of MCT or parenteral nutrition.

Ear trauma caused by a yucca plant leaf spine.

Three uncommon cases of ear trauma caused by a yucca plant leaf spine are presented. One patient presented with tympanic perforation and the second with mixed hearing loss after spontaneous closure. The third patient probably had a perilymphatic fistula with subsequent labyrinthitis and hearing loss. Although the yucca is a ubiquitous plant, to the best of our knowledge, such incidents have not been previously reported.

Non-surgical management of a lymphatic fistula, after laparoscopic colorectal surgery, with total parenteral nutrition, octreotide, and somatostatin.

OBJECTIVE: We report the case of an external lymphatic fistula that appeared through an abdominal drainage after laparoscopic resection of the rectum and sigmoid colon for cancer, with lymphadenectomy. There was no chylous ascites because of controlled external drainage. METHODS: The fistula was managed conservatively by interruption of oral feeding and administration of total parenteral nutrition and subcutaneous octreotide and management then shifted to intravenous somatostatin, with decreased lymph output through the fistula to 100 to 200 mL/d. RESULTS AND CONCLUSION: Somatostatin seemed to be more effective than subcutaneous octreotide. At postoperative day 18, refusal of treatment by the patient with oral resumption of clear liquids resulted in a transient increase in lymph output to 600 mL/d, and treatment was resumed. Subsequently, progressive withdrawal of the abdominal drainage was associated with complete healing of the fistula. The drain was removed at day 28, treatment was interrupted at day 30 after verifying by ultrasound the absence of chyloperitoneum, and the patient was discharged without further problems.