Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial.

BACKGROUND: The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment. PATIENTS AND METHODS: Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications. RESULTS: Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur. CONCLUSION: Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Autologous platelet-rich plasma covering urethroplasty versus dartos flap in distal hypospadias repair: A prospective randomized study.

OBJECTIVE: To compare the outcome and complication rate of the platelet-rich plasma applied as a coverage layer and dartos flap layer during primary repair of distal hypospadias. METHODS: A prospective randomized study was carried out comprising 180 boys (age range 12-65 months) from October 2011 to December 2016 at Al-Azhar University Hospitals, Cairo, Egypt. A single surgeon carried out all urethroplasty. Patients were randomly divided into two groups: group A (tubularized incised plate urethroplasty with platelet-rich plasma coverage layer) and group B (ventral dartos flap). Complication rates were compared between two groups. RESULTS: There was a significant difference in the occurrence of complications between the two groups. A total of 36 (20%) complications were recorded in 26 patients, just 12 (13.3%) reported in group A, but 24 (26.7%) complications were reported in group B. Urethrocutaneous fistula was observed in nine patients (10%) in group A, and 12 (13.3%) in group B. Partial glans dehiscence occurred in one patient in group A, and four patients in group B. No patient in group A had a superficial wound infection, compared with six patients in group B. One case of meatal stenosis and urethral stricture was recorded in each group, all of which were managed conservatively. The resultant urinary stream was single and good in 154 patients of both groups. CONCLUSIONS: Platelet-rich plasma sheet might be considered as an alternative coverage layer for distal hypospadias repair, especially in the absence of a healthy layer.

Perioperative Management of Total Laryngectomy Patients: A Survey of American Head and Neck Society Surgeons.

OBJECTIVES: Standards of care for total laryngectomy (TL) patients in the postoperative period have not been established. Perioperative care remains highly variable and perhaps primarily anecdotally based. The aim of this study was to survey members of the American Head and Neck Society to capture management practices in the perioperative care of TL patients. METHODS: In this survey study, an electronic survey was distributed to the international attending physician body of the American Head and Neck Society. Forty-five-question electronic surveys were distributed. A total of 777 members were invited to respond, of whom 177 (22.8%) fully completed the survey. The survey elicited information on management preferences in the perioperative care of TL patients. Differences in management on the basis of irradiation status and pharyngeal repair (primary closure vs regional or free flap reconstruction) were ascertained. Main outcomes and measures were time to initiate oral feeding, perioperative antibiotic selection and duration, and estimated pharyngocutaneous fistula rates. These measures were stratified by patient type. RESULTS: Most respondents completed head and neck fellowships (77.0%) and practice at academic tertiary centers (72.3%). Ampicillin/sulbactam was the most preferred perioperative antibiotic (43.2%-49.1% depending on patient type), followed by cefazolin and metronidazole in combination (32.0%-33.7%) and then clindamycin (10.8%-12.6%). Compared with nonirradiated patients, irradiated patients were significantly more likely to have longer durations of antibiotics ( P < .05), longer postoperative times to initiate oral feeding ( P < .05), and higher estimated fistula rates ( P < .05). Additionally, in nonirradiated patients, flap-repaired patients (vs primary repair) were significantly more likely to have longer durations of antibiotics (odds ratio, 1.29; 95% confidence interval, 1.13-1.48) and postoperative times to initiate oral feeding (odds ratio, 2.24; 95% confidence interval, 1.76-2.84). CONCLUSIONS: Perioperative management of TL patients is highly variable. Management of antibiotics and oral feeding are significantly affected by irradiation status and scope of pharyngeal repair. Further studies are needed to standardize perioperative care for this unique patient population.

Broken Sacral Neuromodulation Lead Migration Into the Sigmoid Colon: A Case Report.

Sacral neuromodulation is an effective treatment of urinary incontinence, fecal incontinence, and idiopathic urinary retention. The procedure is considered low risk with overall low complication rates. This report describes a 40-year-old woman who underwent sacral neuromodulation explant and full-system implant for weaning efficacy of her device. During device removal, the tined lead broke and was left in situ. Four months later, she was diagnosed as having a wound infection at the site of the retained lead. Imaging revealed lead fragment migration into the sigmoid colon. A colocutaneous fistula was noted soon thereafter. The retained lead was removed during a colonoscopy and the fistula healed. A retained lead can result in migration through the peritoneum and into the colon. This can be managed with assistance from colorectal or gastroenterology consultants.

Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae.

BACKGROUND: The development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. METHODS: This is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. RESULTS: Sixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients' gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. CONCLUSIONS: Our study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

Healing of spongiosus-cutaneous fistula with Hyperbaric Oxygen Therapy (HBOT): a case report.

INTRODUCTION: We present a case of a spongiosus-cutaneous fistula in a 39-year-old man with recurrent episodes of cutaneous abscess in dorsal middle third penis (5 × 3 cm) treated with Hyperbaric Oxygen Therapy (HBOT). CASE REPORT: After emptying nodular abscess, the patient was noncompliant for further surgery. Therefore, it was suggested the association between HBOT and antibiotic therapy. HBOT is carried out in a hyperbaric room, where the internal pressure is increased (compression phase) by entering compressed air up to 283.71 kPa in about 10 minutes. Every HBOT cycle lasted 24 days in which the patient had been taking Amoxicillin/Clavulanic Acid 875 mg/125 mg 3 tabs/day and Sulfamethoxazole/Trimethoprim 160 mg/800 mg 2 tabs/day for 2 weeks. At the end of the treatment, a penile magnetic resonance imaging and an ultrasonography were executed and they evidenced a complete remission of the lesion. In the subsequent 22 months, there was no recurrence. CONCLUSIONS: Our results suggest that HBOT is an effective treatment for chronic wounds, including a spongiosus-cutaneous fistula of unknown cause, when used in combination with conventional standard therapy or further interventions. At present time, the gold standard remains surgery; nevertheless, our experience with HBOT may stimulate its use in clinical trials.

Early Experience in the Management of Postoperative Lymphatic Leakage Using Lipiodol Lymphangiography and Adjunctive Glue Embolization.

PURPOSE: To evaluate the safety and efficacy of Lipiodol lymphangiography and 3 adjunctive N-butyl cyanoacrylate (NBCA) glue embolization techniques for the management of postoperative lymphatic leakage. MATERIALS AND METHODS: This retrospective study included 27 patients with postoperative lymphatic leakage (17 with ascites, 3 with chylothorax, 6 with lymphoceles, and 1 with a skin fistula) who underwent Lipiodol lymphangiography for diagnostic and therapeutic purposes in 3 tertiary referral centers between August 2010 and January 2016. Adjunctive glue embolization was performed as needed by using 3 different techniques: "lymphopseudoaneurysm" embolization, closest upstream lymph node embolization, or direct upstream lymphatic vessel embolization. RESULTS: Sixteen patients were observed to determine the therapeutic effect of lymphangiography, and 8 patients (50%) recovered without further embolization. In 16 patients, including 11 who underwent immediate embolization after lymphangiography and 5 who underwent delayed embolization, a total of 28 embolizations (12 lymphopseudoaneurysms, 14 lymph nodes, and 2 lymphatic vessels) were performed. The technical and clinical success rates of the adjunctive embolizations were 89% (25 of 28) and 94% (15 of 16), respectively. The overall clinical success rate was 85% (23 of 27). The median time from initial lymphangiography to recovery was 5 days. No procedure-related major complications were reported. CONCLUSIONS: Lipiodol lymphangiography and adjunctive glue embolization techniques appear safe and provide promising efficacy for the management of postoperative lymphatic leakage.

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.

A minimally invasive method to prevent postlaryngectomy major pharyngocutaneous fistula using infrahyoid myofascial flap.

INTRODUCTION: To prevent postoperative pharyngocutaneous fistula (PCF) after total (pharyngo)laryngectomy, simultaneous coverage of pharyngeal anastomosis with vascularised flaps such as pectoralis major muscle, anterolateral thigh or radial forearm, has been reported to be effective. As an alternative to the invasive methods using distant flaps, we used the infrahyoid myofascial flap (IHMFF), which was harvested from the same operation field of (pharyngo)laryngectomy, for covering the site of pharyngeal anastomosis. Herein, we describe the safety and effectiveness of our minimally invasive method for preventing PCF. METHODS: Eleven patients who were at a high risk of developing PCF due to previous chemoradiotherapy underwent simultaneous coverage of pharyngeal anastomosis with IHMFF after total (pharyngo)laryngectomy. The incidence of PCF and the rate of major fistula requiring surgical closure were determined, and the results were compared with the control group (23 patients without IHMFF cover after laryngectomy). RESULTS: PCF developed in 2 of the 11 patients (18.2%). The fistulae of these two patients were closed conservatively and did not require additional surgery. PCF developed in 6 of 23 patients (26.1%) in patients without IHMFF cover. All the six patients with fistula required additional closure surgery. The incidence of PCF did not differ in patients with or without IHMFF cover (Fisher's exact probability test; p=0.939, NS). However, the rate of major PCF requiring surgical closure was significantly lower in patients with IHMFF cover (Fisher's exact probability test; p=0.036<0.05). CONCLUSIONS: For (pharyngo)laryngectomy patients, IHMFF cover is a minimally invasive method that can prevent major PCF.

[Sigmoido-buttock fistula by diverticulitis: report of a rare complication]. / Fístula sigmoideo-glútea por diverticulitis. Reporte de una rara complicación.

INTRODUCTION: The complicated diverticulitis of the colon is characterized by its association with abscesses, bleeding, stenosis, perforation, obstruction or fistula. We report a case of spontaneous sigmoido-cutaneous fistula from diverticulitis to an unusual place in the gluteal region. CLINICAL CASE: A 59-year-old male patient presented an inflammatory wound in left buttock without response to the conservative medical treatment. The fistulography, colonoscopy, barium enema and computed tomography showed a sigmoido-cutaneous fistula to the left buttock from diverticulitis. The biopsy of the lesion ruled out malignancy. We performed an elective sigmoid resection with primary colorectal anastomosis, partial fistulectomy and injection of a fibrin sealant in the residual tract. DISCUSSION: The colon-cutaneous fistulas from diverticulitis are relatively rare. We report a spontaneous fistula with origin in a single diverticulum in the sigmoid colon and that drained through the piriform fossa of the pelvic floor to the skin of the left buttock. CONCLUSIONS: A high index of suspiscion is necessary to not confuse the colo-buttock fistula with local abscesses.

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.

Endoscopic ultrasound for perianal Crohn's disease: disease and fistula characteristics, and impact on therapy.

BACKGROUND AND AIM: Appropriate treatment of perianal fistulas in Crohn's disease (CD) involves accurate anatomic evaluation. EUS is an accepted imaging method for this purpose. The aim of the current study was to evaluate the clinical and endosonographic characteristics of perianal fistula in CD and to assess its impact on therapy. METHODS: All CD patients referred to the Sheba medical center from June 2004 to August 2008 for EUS examination of perianal fistulas were included. Perianal fistulas were diagnosed based on a clinical examination revealing at least one perianal cutaneous orifice. Demographic, clinical and therapeutic data was obtained. EUS was performed using an ultrasound scanner producing a 360° cross sectional image of the anal sphincters. RESULTS: Fifty six patients were included in the study. Four patients were excluded from the final analysis: 3 because no fistula could be detected by EUS, and one due to inability to tolerate the examination. The mean CD duration was 10±9.16 years (range 1-37). Mean perianal disease duration was 5.3±6.5 (range 1-29) years. 27 patients had perianal involvement at presentation. Among the fistulas diagnosed, 13 were simple (25%) and 39 were (75%) complex. No correlation was found between CD duration or location, patients' age and gender or fistula location with fistula type or complexity. EUS results influenced patient management in 86% of the patients. CONCLUSIONS: CD-associated perianal fistulas are mainly complex. EUS is a well tolerated and informative imaging modality, with significant impact on treatment.

Post-operative wound infection in salvage laryngectomy: does antibiotic prophylaxis have an impact?

Salvage laryngectomy carries a high risk of post-operative infection with reported rates of 40-61%. The purpose of this study was to analyse infections in our own patients and review the potential impact of our current antibiotic prophylaxis (AP). A retrospective analysis of infection in 26 consecutive patients between 2000 and 2010 undergoing salvage total laryngectomy (SL) following recurrent laryngeal cancer after failed radiotherapy or chemo-radiation was undertaken. The antibiotic prophylaxis was intravenous teicoplanin, cefuroxime and metronidazole at induction and for the following 24 h. Infection was defined by Tabet and Johnson's grade 5, categorized as pharyngocutaneous fistula. Fifteen patients (58%) developed a post-operative wound infection, which occurred on average at 12 days after surgery. Univariate analysis demonstrated three risk variables that had a significant correlation with infection: alcohol consumption (p = 0.01), cN stage of tumour (p < 0.01), and pre-operative albumin levels <3.2 g/L (p = 0.012). There was a trend, though not significant, for increased infection in patients with high or low BMIs. The most common organisms isolated from clinical samples from infected patients were methicillin-resistant Staphylococcus aureus MRSA (43%), Pseudomonas aeruginosa (36%), Serratia marcescens, Proteus mirabilis and Enterococcus faecalis (7% each). All these organisms are typical hospital-acquired pathogens. Pseudomonas and Serratia were not covered by the prophylactic regime we used. The current antibiotic regime following SL is inadequate as the rate of infection is high. It would therefore seem logical to trial a separate antibiotic protocol of AP for patients undergoing SL that would include an extended course of antibiotics after the standard prophylaxis. In addition, infection rates may also be reduced by improving the metabolic state of patients pre-operatively by multi-disciplinary action. Steps should also be taken to reduce cross-infection with nosocomial pathogens in these patients. Other aspects of surgical management should be also taken in consideration.

Transurethral plasma vaporization of the prostate: 3-month functional outcome and complications.

UNLABELLED: Study Type - Therapy (multi-centre cohort). Level of Evidence 2b. OBJECTIVE: To evaluate the early functional outcomes of transurethral plasma vaporization of the prostate (TUVis) in a multicentre study. PATIENTS AND METHODS: A prospective multicentre observational study was conducted in eight urology departments. The inclusion criterion was benign prostatic hyperplasia (BPH) requiring surgical treatment. Patients on anti-coagulant therapy were not excluded. The TUVis procedure was performed according to a classic transurethral resection of the prostate (TURP) scheme following the manufacturer's recommendations. We evaluated subjective functional outcome using self-questionnaires (International Prostate Symptom Score [IPSS] and five-item International Index of Erectile Function [IIEF-5]) and objective criteria (prostate volume, prostate-specific antigen [PSA], uroflowmetry, post residual volume) at baseline and at 1- and 3-month follow-ups. All types of complications were systematically recorded. RESULTS: Despite 52% of patients receiving anticoagulant therapy before surgery, we reported only 3% with haemorrhagic complications, no blood transfusion, a mean catheterization time of 44 h and a mean postoperative stay of 2.9 nights. No significant change in irrigation time, catheter time or hospital stay was observed in patients with or without anticoagulant therapy. The IPSS and bother scores significantly decreased after the 3-month follow-up (57% and 59%, respectively), but the average remaining prostate volume was 29 cc and the tissue ablation rate was only 0.5 cc/min. Three major complications occurred, consisting of two urinary fistulas and one partial bladder coagulation. CONCLUSIONS: The TUVis procedure has a proven fast postoperative recovery time, good short-term functional outcome and good haemostatic efficiency. However, the tissue ablation rate was lower than expected and we encountered three major complications, the mechanisms of which remain unclear. Considering the high energy level required to create the plasma effect, the generator, cable and resectoscope must be carefully checked before each procedure.

Dribbling diversion in Y-V glanuloplasty modified Mathieu repair.

INTRODUCTION: Aim of the study was to determine the impact of an indwelling transurethral catheter on surgical outcome and postoperative micturation in Y-V glanuloplasty modified Mathieu repair for primary hypospadias. MATERIALS AND METHODS: Fifty-nine consecutive boys underwent Y-V glanuloplasty modified Mathieu repair for primary distal hypospadias in our institution. The first 37 patients (group A) had catheterless repair. Due to significant painful postoperative urination, the next 22 children (group B) had an indwelling transurethral catheter (5 Fr feeding tube) for 24-48 hours. Adjunct caudal analgesia and penile block was given in both groups. Pain during postoperative voiding, urinary retention, meatal stenosis and fistula formation was statistically analysed with Wilcoxon's signed rank test. RESULTS: All patients in group A had distressing painful first micturation (p < 0.05). Eight children did not pass urine for more than 8 hours. Five (13.5 %) patients had urinary retention, 3 of whom required catheterisation (p < 0.05). Six (16 %) boys developed meatal stenosis and a further 5 (13.5 %) had urethrocutaneous fistula. In group B all patients had easy micturation after removal of the catheter. Only 1 boy developed a urethrocutaneous fistula and none of the boys in this group presented with meatal stenosis. CONCLUSION: An indwelling transurethral catheter obviates urinary retention and avoids distressing postoperative micturation. It minimises the chance of urethrocutaneous fistula and meatal stenosis in Y-V glanuloplasty modified Mathieu repair.

Mechanical bowel preparation for elective colorectal surgery with primary intraperitoneal anastomosis by a single surgeon: interim analysis of a prospective single-blinded randomized trial.

We report an interim analysis of a prospective single-blinded randomized trial designed to investigate whether preoperative mechanical bowel preparation influences the rate of surgical-site infection and anastomotic failure after elective colorectal surgery with primary intraperitoneal anastomosis performed by a single surgeon. Patients scheduled to undergo an elective colorectal procedure with a primary intraperitoneal anastomosis were randomized to receive either oral polyethylene glycol lavage solution and enemas (group A) or no preparation (group B). Surgical-site infection and anastomotic failure were investigated. Of 97 patients included, 48 were assigned to group A and 49 to group B. Twelve (12.4%) developed wound infections, six in each group (12.5 vs. 12.2%; NS). Intra-abdominal sepsis was only seen in group A (n = 3, 6.3%). Anastomotic failure occurred in four patients in group A (8.3%) vs. two patients in group B (4.1%) (NS). The overall complication rate in group A was 27.1%, vs. 16.3% in group B. The number needed to harm was 9.3. Our interim analysis of a prospective single-blinded randomized trial suggests that a surgeon may have the same or even worse outcomes when mechanical bowel preparation is routinely used for colorectal surgery with primary intraperitoneal anastomosis.

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy.

CONCLUSION: Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology. OBJECTIVES: A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications. MATERIAL AND METHODS: A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation. RESULTS: A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.