Cholecystoappendiceal Fistula From Appendiceal Adenocarcinoma Requiring a Right Hemicolectomy With Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

Bilioenteric fistulae are rare and difficult to manage complications of chronic cholecystitis. While cholecystoduodenal and cholecystocolic fistulae are more common, a cholecystoappendiceal fistula is an extremely rare finding. We report the presentation and operative management of a 59-year-old male with cholecystoappendiceal fistula and associated abscess in the gallbladder fossa. The patient was appropriately resuscitated, the abscess drained by interventional radiology, and after a complete workup, underwent a laparoscopic appendectomy and cholecystectomy. Pathology revealed moderately differentiated appendiceal adenocarcinoma requiring a right hemicolectomy with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). He has recovered well postoperatively with no complications. This case highlights the importance of having a very high index of suspicion for underlying malignancy when managing a fistula of any kind. To the best of our understanding, this is only the second reported case of a cholecystoappendiceal fistula.

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience.

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O2 therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

Hyperbaric oxygen therapy for wound breakdown after oronasal fistula and cleft palate repair: four cases.

We offer the first report of hyperbaric oxygen (HBO2) therapy to treat early surgical wound breakdown after oronasal fistula and cleft palate repair in the pediatric population. We present four patients' experiences after undergoing HBO2 therapy. HBO2 was initiated as soon as an oronasal fistula was identified. Three of the children underwent 10 HBO2 treatments with the fourth undergoing 11 treatments. There were no adverse effects during treatment; none of the patients required decompressive myringotomy. Follow-up shows portions of the repair have been salvaged by initiating HBO2 at the first sign of fistula formation. In our case series, the fistulas all decreased in size over the course of treatment and demonstrated granulation tissue at the wound edges. Given the positive outcomes from our preliminary results, our results suggest concurrent usage of HBO2 therapy for wound breakdown after cleft palate repair is an effective treatment option.

Contact-Force Catheters: Efficacy Versus Safety? Case Report of 2 Atrioesophageal Fistulae.

Contact-force (CF) catheters appear to be more effective compared to standard ablation catheters for complex radiofrequency ablation including atrial fibrillation (AF) ablation when optimal CF >10 g is achieved. Some have suggested that this technology could also improve procedural safety. We report 2 cases of atrioesophageal fistulae (AEF), a rare but catastrophic complication of AF ablation. These are to our knowledge the first cases of AEF described after using CF catheters.

Actualización en hidradenitis supurativa (II): aspectos terapéuticos / Update on Hidradenitis Suppurative (Part II): Treatment

A pesar de la importancia y de la gravedad de la hidradenitis supurativa, el tratamiento de esta enfermedad no se encuentra bien definido. Hoy en día, la hidradenitis es considerada una enfermedad cutánea que principalmente en las formas moderadas y severas se asocia a un marcado componente inflamatorio sistémico. Por lo tanto, el tratamiento de esta enfermedad irá enfocado hacia un manejo sistémico del control de la inflamación, que ocasionalmente irá acompañado de la intervención quirúrgica para reducir la carga de inflamación localizada en la piel. Los recientes avances en el conocimiento de la enfermedad se han acompañado de novedades terapéuticas, especialmente representadas por el desarrollo de ensayos clínicos de determinadas terapias biológicas, principalmente adalimumab, orientados al tratamiento específico de esta enfermedad. En la presente revisión se pretende analizar las diferentes alternativas terapéuticas existentes en el manejo de la hidradenitis supurativa

Although hidradenitis suppurativa is a common and serious skin condition, its treatment is not well established. It is now accepted that the moderate and severe forms of the disease are associated with marked systemic inflammation. The goal of treatment in hidradenitis suppurative is therefore to achieve systemic control of inflammation. In some cases, surgery may also be necessary to reduce the severity of the manifestations of cutaneous inflammation. Recent advances in our understanding of hidradenitis suppurativa have been accompanied by the emergence of novel approaches to its treatment, including the use of certain biologic drugs. Several clinical trials have been undertaken to test the effects of biologics (mainly adalimumab) in this setting. In this review, we analyze the different treatments available for hidradenitis suppurativa

[Nonsurgical and surgical treatment of an urachal fistula in an alpaca cria. A case report]. / Konservative und chirurgische Therapie der Urachusfistel bei einem Alpaka-Cria. Ein Fallbericht.

Urachal fistula is a neonatal condition. There are two reported forms: a congenital and an acquired form. We describe the case of a 6-hour-old female alpaca cria that was presented with a damp umbilicus and a meconium impaction. Conservative treatment of the urachal fistula with local and systemic medication was unsuccessful after 6 days; therefore, a resection of the umbilicus under general anaesthesia was performed. Reconvalescence was uneventful.

Hyperbaric oxygen therapy for treatment of neurologic sequela after atrioesophageal fistula.

Atrioesophageal fistula (AEF) is a rare complication after radiofrequency ablation for atrial fibrillation but is associated with high mortality, usually due to sepsis or neurologic injury. We report the case of a patient who presented with an AEF and dense neurologic deficits who had complete neurologic recovery after management with emergent surgical repair without the use of cardiopulmonary bypass and with implementation of postoperative hyperbaric oxygen therapy.

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.

Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy.

OBJECTIVE: To evaluate the functional outcomes after total laryngectomy (TLE) for a dysfunctional larynx in patients with head and neck cancer that is in complete remission after (chemo)radiotherapy. DESIGN: Retrospective cohort study. SETTING: Tertiary comprehensive cancer center. PATIENTS: The study included 25 patients from a cohort of 217 consecutive patients with TLE who were treated between January 2000 and July 2010. The inclusion criteria for this subgroup analysis were complete remission and functional problems for which TLE was considered to be the only resolution. Quality of life assessment was carried out using the European Organization for Research and Treatment of Cancer Quality of Life C30 and Head and Neck Module 35 questionnaires and an additional study-specific questionnaire covering functional aspects, such as swallowing and dyspnea, in more detail. INTERVENTION: Total laryngectomy. MAIN OUTCOME MEASURES: Morbidity, mortality, and functional outcomes. RESULTS The indication for TLE was chronic aspiration with or without recurrent pneumonia (n = 15 [60%]), debilitating dyspnea (n = 8 [32%]), and persistent profuse hemorrhage (radiation ulcer) (n = 2 [8%]). After TLE, 14 of the 25 patients (56%) had 20 major postoperative complications, including 11 pharyngocutaneous fistulas, requiring additional treatment. Tube feeding and recurrent pneumonia incidence had decreased from 80% and 28% to 29% and 0%, respectively, 2 years after surgery. Prosthetic voice rehabilitation was possible in 19 patients (76%). Two years after surgery, 10 of 14 patients (71%) still reported TLE-related pulmonary problems despite the consistent use of a heat and moisture exchanger. The 5-year overall survival rate was 35%. CONCLUSIONS: Total laryngectomy for a dysfunctional larynx tends to have a high complication rate. However, in this study, the initial functional problems (aspiration, recurrent pneumonia, and dyspnea) did not recur. Tube feeding was significantly reduced, and the quality of life of the surviving patients appeared to be reasonable.

Atrioesophageal fistula after cryoballoon pulmonary vein isolation.

The risk of atrioesophageal fistula after cryoballoon pulmonary vein isolation is thought to be much lower than after radiofrequency ablation, seeing that no data exist on this complication so far. We report for the first time on the occurrence of an atrioesophageal fistula 4 weeks after cryoballoon ablation at the site of the left inferior pulmonary vein. We suggest that even when using cryothermal ablation technique, an imaging modality to assess the proximity of esophagus and left atrium should be routinely performed to avoid this fatal complication.

Pharyngoesophageal junction neoplasia--therapeutic management.

Not only the anatomy but the treatment and the prognosis of these tumors are intermediate between hypopharyngeal and esophageal tumors. After a portion of the esophagus is removed or complete esophagectomy, a conduit must be established. The authors reviewed the experience of Prof. Cristian Popescu in total pharyngo-laryngectomy and his technique of pharyngoesophageal reconstruction with synthetic esophageal prosthesis. We have some 21 patients who underwent an esophageal reconstruction with Montgomery esophageal tube. This is a very important new, modem, interdisciplinary approach bewteen the head and neck surgeon and the general/thoracic surgeon to treat the pharyngo-laryngo-esofageal neoplasia with one stage reconstruction. The follow up for these patients shows that this reconstruction method is a good, reliable choice with low costs and considerable advantages for the quality of life. Surgery for these patients should be considered primarily palliative and the optimal reconstruction should preserve the quality of life for the duration of survival.

Enfermedad de zuska. Diagnóstico en atención primaria / Zuska disease. Diagnosis and treatment in primary care

Una fístula es una comunicación anómala patológica que comunica 2 órganos entre sí o con el exterior. Son trayectos fibrosos con revestimiento interno de tejido de granulación, que se extienden desde un orificio interno o primario hasta uno o varios orificios externos o secundarios situados en la piel. La constante recidiva de una mastitis suele ser consecuencia de una fístula entre conductos galactóforos y el límite areola-piel de la mama, llamándose a esto fistulización periareolar recidivante. Para integrar este cuadro en la terminología propuesta, enfermedad de Zuska, es indispensable pensar primero en su existencia para enfocar el tratamiento en su origen. El conocimiento de esta enfermedad y su diagnóstico y tratamiento correctos impedirán las constantes recidivas en forma de mastitis que presentan estas pacientes, evitando así su peregrinaje por distintos especialistas. En este artículo revisamos esta entidad, métodos diagnósticos y tratamiento (AU)

A fistula is an abnormal pathological communication which links two organs together or with the exterior. They are fibrous paths internally coated with granulation tissue, extending from an internal o primary opening to one or more openings located outside or on the skin. The recurrent mastitis that some patients suffer is due to a fistula between a lactiferous duct and the limit of the areola, and this condition is called a recurrent periareolar fistula.To incorporate this clinical condition into the proposed terminology, Zuska disease, is essential to believe in its existence, in order to to treat it from the source. The knowledge of this disease, a proper diagnosis and treatment will prevent the constant recurrence of mastitis as presented by these patients, avoiding their pilgrimage to various specialists. In this article we review this disease, methods of diagnosis and treatment (AU)

Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation.

BACKGROUND/PURPOSE: There has not been any study comparing laparoscopic abdominoperineal rectoplasty (ARP) with open ARP. This study investigated the true benefits of the laparoscopic approach in infants with high anorectal malformation. PATIENTS AND METHODS: A retrospective analysis was performed in 28 infants with high anorectal malformation treated between 1990 and 2007. Fifteen were treated by open ARP, and 13 were treated by laparoscopic ARP. Surgical durations, amount of bleeding, complications, anorectal pressure measurements, barium enema study, and clinical assessment were compared between the 2 groups. RESULTS: The amount of intraoperative bleeding was significantly less in laparoscopic ARP (12 ± 11 g) than in open ARP (65 ± 44 g) (P = .003). Anal resting pressure was 34 ± 9 cm H(2)O after laparoscopic ARP and 31 ± 14 cm H(2)O after open ARP. Anorectal reflex was positive in 1 (7%) of 15 after open ARP and 3 (23%) of 13 after laparoscopic ARP. There was no significant difference in barium enema study and clinical assessment between the 2 groups. With regard to postoperative complications, mucosal prolapse occurred in 10 (67%) of 15 after open ARP and in none of 13 after laparoscopic ARP (P = .003). CONCLUSION: Benefits of the laparoscopic approach were reduced intraoperative bleeding and a lower incidence of postoperative anal mucosal prolapse. These results indicate that minimal dissection of the mesorectum in laparoscopic ARP may provide those better outcomes.

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus.

AIM: The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgeson's laparoscopy-assisted colon PT (GPT) and Peña's posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA. METHODS: We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years. RESULTS: Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05). CONCLUSIONS: We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Persistent pleuropulmonary air leak treated with autologous blood: results from a university hospital and review of literature.

BACKGROUND: Persistent air leak after pulmonary resection is a difficult complication for thoracic surgeons to manage. OBJECTIVES: To show the results of our experience treating persistent pleuropulmonary air leak with autologous blood and review the literature on this specific method of treatment. METHODS: Retrospective study of patients with persistent aerial pleuropulmonary fistula treated with autologous blood. The patient's own blood was collected from a peripheral vein and directly introduced through the pleural drain. An inverted siphon was located in the drainage system to avoid prolonged clamping of the drain. This siphon impeded blood return but not air escape. RESULTS: Between January 2001 and August 2008, 27 patients were treated by the above method. Patient age ranged from 2 to 74 years, and 78% were male. Each procedure used a mean quantity of 92 ml blood. Mean persistent air leak time before pleurodesis was 10.6 days and mean time to fistula resolution after pleurodesis was 1.5 days. Twenty-three (85%) patients had persistent pleuropulmonary air leak closed with the above procedure. CONCLUSION: Treating persistent pleuropulmonary air leak with autologous blood is promising, but further studies are required to quantify its real effectiveness.

Single-stage repair of vestibular and perineal fistulae without colostomy.

PURPOSE: This retrospective study was undertaken to evaluate the feasibility of primary anorectoplasty without a covering colostomy using the anterior sagittal anorectoplasty (ASARP) or posterior sagittal anorectoplasty (PSARP) technique in patients having vestibular and perineal fistulae, its complications, results, and remote outcome in our institute. METHODS: From January 2000 to June 2007, patients with vestibular and perineal fistulae subjected to single-stage surgical correction at our institute were reviewed retrospectively from the data available in hospital records and follow-up complaints of patients and their parents in the outpatient department. Patients who had undergone a staged repair were excluded from the study. All patients were assessed for immediate and delayed complications including continence of the neorectum. RESULTS: From January 2000 to June 2007, 123 patients having vestibular (94) and perineal fistulae (29), age range from 28 days to 10 years, were subjected to primary repair either by the ASARP (34) or PSARP (89) technique. Follow-up period ranged from 3 months to 7 years. Mortality was nil. Constipation (25.68%) was the major long-term problem. Incontinence occurred in 1 patient (1.85%), who also had associated sacral agenesis. A total of 98.15% of patients were continent with stool frequency of 1 to 4 per day. Recurrence of fistula (0.81%), anal stenosis (6.76%), mucosal prolapse (2.70%), and anterior migration of the neoanus (1.35%) were the other major problems. Other minor problems like wound infection, superficial wound dehiscence, transient constipation, and diarrhea, etc, were successfully managed by local wound care, antibiotics, laxatives, enema, anal dilatation, and dietary changes. CONCLUSION: Primary anorectoplasty either by PSARP or ASARP is feasible in vestibular and perineal fistulae without covering colostomy. Associated sacral agenesis/hypoplasia, redundant rectosigmoid or pouch colon, and wound infections with dehiscence are the major confounding factors affecting overall outcome. Better outcome in terms of continence can be achieved by careful surgical technique and follow-up along with proper toilet training. Complication rate was greater in cases of vestibular fistula than of perineal fistula, regardless of technique used. Some sort of laxatives and enema are often required. Dilatation of the neoanus for varying periods is also needed.

Rectal duplication as an unusual cause of chronic perianal fistula in an adult: report of a case.

Duplication of the rectum is a rare embryologic event, but it should be considered as a possibility when perianal fistulas and abscesses remain resistant to conventional standard surgical treatment modalities over the long term. We report the case of a 57-year-old woman who underwent many operations over 30 years for persistent perianal fistulas. After radiological assay by computed tomography, fistulography, and barium enema studies, we performed surgery to remove a cystic mass in the retrorectal region, which was subsequently found to be a rectal duplication. The patient had an uneventful postoperative course and has been asymptomatic for 3 years.

[Iatrogenic prostatorectal fistula. Use of gracilis muscle pedicled flap for its reparation. Presentation of two cases]. / Fistula prostatorectal yatrogénica. Reparación con colgajo pediculado de músculo gracilis. Presentación de dos casos.

We present two cases in which during retropubic prostatectomy for benign prostatic disease a prostatorectal fistula ocurred. We describe its reparation using a pedicled flap of gracilis muscle. We also present cystographic and opaque enema images which shows the before and after of this surgery. Patients had good outcome without incontinence nor problems related to muscle desinsertion surgery.

Interposition of fallopian salpinges in the treatment of sigmoidovaginal fistula, secondary to vaginal hysterectomy with failure of previous repair.

A 50-year-old woman, para 4, suffering from uterine fibromatosis and recurrent menometrorrhagia, underwent vaginal hysterectomy with preservation of salpinges. About 15 days after surgery, hydrosoluble contrast enema showed sigmoidovaginal fistula; after about two months there was failure of surgery repair by the rectal endoscopic technique. A month later, we performed repair surgery by the abdominal approach interposing fallopian salpinges between the sigmoid and the vagina. About two months later, a enema showed absence of fistula and today the women is free from disease.