Successful transvaginal repair of a vesicouterine fistula with delayed presentation.

A G4P4 woman in her 30s with a type II vesicouterine fistula, as defined by the Jozwik classification system, presented with symptoms of menouria, vaginal menses and urinary incontinence 8 years after caesarean delivery, the time of probable origination of the fistula tract. Transvaginal ultrasound identified a fistula tract communicating between the bladder and uterus, a rare finding that many years remote from caesarean delivery. Traditional surgical technique includes laparoscopic, abdominal and endoscopic methods of repair, sometimes using a transvesical approach. Transvesical repair can be associated with subsequent inpatient hospital stays and prolonged catheterisation. Our technique proposes a transvaginal surgical approach as an outpatient procedure with decreased operating time (40 min), postoperative pain and catheterisation requirement. It is the authors' belief that a transvaginal approach is less invasive and allows for better preservation of the uterus for future pregnancies and vaginal deliveries, as desired by the patient.

[A Case of Urethral Foreign Body from 40 Years Ago with Scrotum Abscess and Urethroscrotal Fistula].

A 70-year-old male came to our clinic with a high fever and left scrotal swelling. Following a diagnosis of left-side epididymitis, antibiotic treatment was started, though the swelling did not improve. Since an additional examination revealed an abscess in the left scrotum, scrotal incision and drainage were performed. Although the symptoms subsided, urine outflow from the incision was observed. The patient then noted that he had inserted a glass ball into the urethral meatus when he was about 30 years old. It was considered that an abscess and fistula had formed due to inflammation caused by the foreign body. Thus a transurethral surgical procedure was used for crushing and removal. The fistula disappeared within three months after the operation and the patient has not been affected by dysuria since that time. Symptoms may appear several years following insertion of a foreign body into the urethra. To the best of our knowledge, the present case is the longest term of indwelling, approximately 40 years, following insertion of a foreign body reported in Japan.

[A case of eyelid fistula after cosmetic lateral canthoplasty].

A 35-year-old female presented with a chief complaint of exudates from the outer corner of the left eye for more than half a year after cosmetic lateral canthoplasty. A fistula was seen in the skin of the left eye 5 mm from the lateral canthus, with clear fluid inside it. Left eyelid fistula was diagnosed and surgically removed. The histopathological examination confirmed that the tissue connected with the fistula was lacrimal gland tissue. No recurrence was found during the 2-month follow-up.

Cardiac-to-Bronchial Fistula in Hepatocellular Carcinoma: A Case Report.

Hepatocellular carcinoma (HCC) stands as a significant contributor to cancer-related mortality globally. While the acute and often fatal manifestations of locally advanced HCC primarily present within the abdomen, it is crucial to recognize that the respiratory and circulatory systems can also fall victim due to the liver's unique anatomical position within the body. Here, we present the case of a 63-year-old male recently diagnosed with locally advanced HCC with vascular invasion. Shortly after receiving target therapy and focal radiotherapy, the patient developed repeated secondary infections and a persistent diaphragmatic defect. As the necrotic tissue invaded the pleural space, subsequent tumor-to-bronchial and tumor-to-cardiac fistulas emerged, resulting in an abnormal connection between the respiratory and cardiovascular systems, leading to massive air emboli in circulation. This report highlights the risk of supradiaphragmatic complications in HCC patients with post-treatment secondary infections, particularly in patients predisposed to developing diaphragmatic defects.

Gastropericardial fistula: A successfully operated heart code.

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common aetiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

Equivalence between physicians and associate clinicians in the frequency of iatrogenic urogenital fistula following cesarean section in Tanzania and Malawi.

BACKGROUND: Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor. METHODS: This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity. RESULTS: Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33). CONCLUSIONS: Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.

Redo partial aortic root remodelling in type A dissection with an aorto-left atrial fistula.

A 72-year-old male with a history of a triple-vessel coronary artery bypass graft years ago presented with a DeBakey type 2 aortic dissection and an aorto-left atrial fistula with patent bypass grafts (left internal mammary artery and saphenous vein grafts). He developed pulmonary oedema and required intubation. The right axillary artery was cannulated. After the ascending aorta and left internal mammary artery were clamped, the aorta was transected, leaving aortic tissue around two saphenous vein grafts as two separate patches. An entry tear was found adjacent to the proximal anastomosis of the saphenous vein graft to the posterior descending artery. A fistula, which was located between a false lumen in the non-coronary sinus and the dome of the left atrium, was primarily closed. Because the adventitia was thinned out in the non-coronary sinus due to aortic dissection, partial aortic root remodelling was performed with resuspension of the commissures. Hemiarch repair was performed under moderate hypothermia and unilateral antegrade cerebral perfusion. After systemic perfusion was resumed, the locations of the saphenous vein graft buttons were determined. The ascending graft was cross-clamped again; the saphenous vein graft to the obtuse marginal branch graft was reimplanted using the Carrel patch technique while a saphenous vein graft to the posterior descending artery required interposition of a 10-mm Dacron graft to accommodate the length.

Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy.

PURPOSE: Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. PATIENTS AND METHODS: Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects. RESULTS: The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. CONCLUSIONS: Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.

Microtia, Branchial Cleft Fistula, and Tetralogy of Fallot: A Possible Association.

When searching over associations between congenital ear abnormalities, especially microtia and affiliated deformities like cleft lip or palate and congenital heart diseases, some clinical analysis and genetic theories are found. A 10-year-old boy sent to the plastic surgery hospital was puzzled by a congenital anterior auricular fistula with fluid trace for more than 9 years. The preoperative diagnoses were branchial cleft fistula and congenital left ear deformity with postoperation of TOF. By browsing over studies on genetic concerns and clinical performance, it may be attributed to a possible association between microtia, branchial cleft fistula, and tetralogy of Fallot, though whose fundamental mechanisms remain concerned.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review.

BACKGROUND: A fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention. CASE PRESENTATION: A 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4. CONCLUSIONS: The clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient's condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

An indocyanine green fluorescence-guided operation for diagnosing and treating pleuroperitoneal communication.

Pleuroperitoneal communication occurs when ascites moves from the abdominal cavity to the pleural cavity via a diaphragmatic fistula. Managing large pleural fluid volumes is challenging, often requiring an operation. Identifying small diaphragmatic fistulas during the operation can be problematic, but ensuring their detection improves outcomes. This video tutorial presents a recent empirical case in which we successfully identified and closed a pleuroperitoneal contact using a thoracoscopic surgical procedure aided by indocyanine green fluorescence imaging. The patient, a 66-year-old woman, was hospitalized due to acute dyspnoea from a right thoracic pleural effusion during hepatic ascites treatment for cirrhosis. Because ascites decreased with pleural fluid drainage, surgical intervention was considered due to suspicion of a pleuroperitoneal connection. During the operation, indocyanine green was injected intraperitoneally, and near-infrared fluorescence-guided thoracoscopy pinpointed the location of the diaphragmatic fistula. The fistula was sutured and reinforced with a polyglycolic acid sheet and fibrin glue. Detecting the fistula intraoperatively is crucial to prevent recurrence, and the indocyanine green fluorescence method is a safe and effective technique for detecting small fistulas.

The use of superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis to treat inguinal lymphatic fistula: A case report.

The management of lymphatic fistulas following surgical procedures, in particular after inguinal lymphadenectomy, represents a significant clinical challenge. The current case report shows the novel use of the superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis (LVA) to treat a chronic inguinal lymphatic fistula in a 58-year-old male patient. This patient had developed a persistent lymphorrhea and wound dehiscence after a right inguinal lymph node biopsy performed for oncological reasons 1.5 months before. Pre-operative assessment with indocyanine green (ICG) lymphography confirmed a substantial lymphatic contribution to the wound discharge, thus guiding the surgical strategy. During the procedure, a pedicled tissue segment containing the SCIV was dissected and utilized to fill the wound's dead space and facilitate LVA with the leaking lymphatic vessel. Notably, a coupler device was employed for the anastomosis due to the large caliber of the lymphatic vessel involved, a technique not commonly reported in lymphatic surgeries. The result of the procedure was successful, with intra-operative ICG imaging confirming the patency of the anastomosis. After surgery the wound healed without complications. This case illustrates the potential of SCIV employment in lymphatic fistula repair in the inguinal region. While further research is needed to validate these findings, this report provides an unconventional approach to a relatively common problem in clinical practice.

Development of postoperative bronchopleural fistula after neoadjuvant immunochemotherapy in non-small cell lung cancer: case reports and review of the literature.

BACKGROUND: The advent of immune checkpoint inhibitors has dramatically changed the treatment paradigm for advanced non-small-cell lung cancer (NSCLC). Due to the complexity and diversity of stage III disease, the inclusion of immune checkpoint inhibitors (ICIs) in neoadjuvant treatment regimens is also required. However, immune-related adverse events (irAEs) limit the application of ICIs to a certain extent. Bronchopleural fistula (BPF) is a serious and fatal complication after pneumonectomy that is rarely reported, especially in patients who accept neoadjuvant immunotherapy or chemoimmunotherapy. CASE PRESENTATION: Herein, we reported four patients with postoperative BPF who received a neoadjuvant regimen of sintilimab plus chemotherapy. Postoperative BPF occurred in the late stage in three patients; one patient underwent bronchoscopic fistula repair, and the fistula was closed well after surgery, and the other two patients gradually recovered within 1-2 months after symptomatic treatment with antibiotics. One patient with BPF after left pneumonectomy died of respiratory failure due to pulmonary infection. We also reviewed the literature on the development of postoperative BPF in patients receiving immuno-neoadjuvant therapy to discuss the clinical process further, postoperative pathological changes, as well as risk factors of BPF patients. CONCLUSIONS: Central type lung cancer with stage III may be the risk factors of BPF in cases of neoadjuvant immunochemotherapy for lung cancers patients.

Aorto-left atrial fistula secondary to aortic infective endocarditis in a dog with a bicuspid aortic valve.

An 11-year-old male neutered American bulldog was presented for evaluation of thrombocytopenia, acute onset of ataxia, and vomiting. A new murmur was auscultated on physical examination. Transthoracic echocardiographic examination revealed a bicuspid aortic valve, vegetative lesions on the aortic valve, and continuous shunting from the aortic root to the left atrium through an aorta to left atrial fistula. The dog was euthanized due to its guarded prognosis and critical condition. Pathological examination confirmed presence of a bicuspid aortic valve, aorto-left atrial fistula, and aortic infective endocarditis. Antemortem blood culture revealed two unusual organisms: Achromobacter xylosoxidans and Fusobacterium mortiferum.

Mapping the risk factors, pathogens, and antibiotic of pharyngocutaneous fistula in patients after neck open surgery.

PURPOSE: Current literature lacks consensus on risk factors for pharyngocutaneous fistula (PCF), and empirical antibiotic guidelines for PCF are limited. The aim of this study was to reduce the incidence of PCF and improve antibiotic treatment efficacy for patients with PCF after open neck surgery by analyzing their clinical characteristics, pathogenic bacteria, and antibiotic susceptibility. METHODS: This study was a 13-year single-center retrospective cohort study, including 699 patients who underwent open neck surgery for laryngeal and hypopharyngeal cancer. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors associated with the occurrence of PCF after surgery. The microbial species causing PCF were analyzed, and the antibiotic sensitivity of the top three pathogens was assessed. Venn diagrams were used to illustrate the antibiotics that exhibited 100% sensitivity against all three identified pathogens. RESULTS: The incidence of PCF after open neck surgery was 8%. Logistic univariate and multivariate analyses revealed that flap reconstruction (OR = 3.62, 95% CI [2.02-6.52]), history of preoperative radiotherapy (OR = 2.01, 95% CI [1.31-2.73]), significant postoperative bleeding (OR = 1.79, 95% CI [1.11-2.69]), and history of diabetes (OR = 1.34, 95% CI [1.29-2.46]) were significantly associated with PCF occurrence. Among the 38 cases of PCF patients, the top three identified pathogens were Pseudomonas aeruginosa, Escherichia coli, and Enterobacter cloacae. The antibiotics cefepime, meropenem, ticarcillin/clavulanic acid, and cefoperazone/sulbactam showed 100% sensitivity against these top three pathogens. CONCLUSION: Special attention should be given to patients undergoing open neck surgery, especially those with intraoperative flap reconstruction, a history of preoperative radiotherapy, postoperative bleeding, or diabetes. Strengthening monitoring and care is crucial in preventing the occurrence of PCF. According to antibiotic usage guidelines and considering the distribution of pathogens in PCF patients, empirical antibiotic treatment with cefoperazone/sulbactam or ticarcillin/clavulanic acid is recommended prior to obtaining susceptibility test results.