Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula.

BACKGROUND: Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF. METHODS: We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test. RESULTS: There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test). CONCLUSION: TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

Role of Exosomes in Pharyngucutaneous Fistula After Total Laryngectomy.

Pharyngocutaneous fistula is the most common complication after total laryngectomy and is difficult to heal. Although conservative treatment and surgical repair are effective, they often take longer and additional trips to the operating room, which undoubtedly increases the financial burden on patients. Especially in combination with diseases such as diabetes and hypertension, which affect the efficacy of surgery. Adding growth factors into the repair material can promote fibroblast proliferation, angiogenesis, and accelerate wound healing. A substantial number of studies have shown that a type of nanoscale extracellular vesicle, called exosomes, facilitates organization repair by promoting blood vessel production, protein polysaccharides, and collagen deposition, thereby representing a new type of cellular therapy. At present, there is little research on the application of exosomes in pharyngocutaneous fistula regeneration after total laryngectomy. In this review, we summarize the biological characteristics of exosomes and their application in biomedical science, and highlight their application prospects in pharyngocutaneous fistula regeneration after total laryngectomy.

Urethrocutaneous fistula following VMMC: a case series from March 2013 to October 2019 in ZAZIC's voluntary medical male circumcision program in Zimbabwe.

BACKGROUND: Urethrocutaneous fistula (subsequently, fistula) is a rare adverse event (AE) in voluntary medical male circumcision (VMMC) programs. Global fistula rates of 0.19 and 0.28 per 100,000 VMMCs were reported. Management of fistula can be complex and requires expert skills. We describe seven cases of fistula in our large-scale VMMC program in Zimbabwe. We present fistula rates; provide an overview of initial management, surgical interventions, and patient outcomes; discuss causes; and suggest future prevention efforts. RESULTS: Case details are presented on fistulas identified between March 2013 and October 2019. Among the seven fistula clients, ages ranged from 10 to 22 years; 6 cases were among boys under 15 years of age. All clients received surgical VMMC by trained providers in an outreach setting. Clients presented with fistulae 2-42 days after VMMC. Secondary infection was identified in 6 of 7 cases. Six cases were managed through surgical repair. The number of repair attempts ranged from 1 to 10. One case healed spontaneously with conservative management. Fistula rates are presented as cases/100,000 VMMCs. CONCLUSION: Fistula is an uncommon but severe AE that requires clinical expertise for successful management and repair. High-quality AE surveillance should identify fistula promptly and include consultation with experienced urologists. Strengthening provider surgical skills and establishment of standard protocols for fistula management would aid future prevention efforts in VMMC programs.

Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.

Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery.

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.

Diagnóstico y tratamiento de las fístulas cutáneas odontogénicas: revisión sistemática / Diagnosis and treatment of odontogenic cutaneous sinus tracts: a systematic review

Se realizó una revisión sistemática de la literatura científica en relación con las variantes de tratamien-to que recibieron las piezas dentarias permanentes asociadas a la presencia de una fístula cutánea. Se incluyeron reportes de casos clínicos en inglés, pu-blicados en los últimos diez años. Se obtuvieron 481 artículos, 359 excluidos por escasez de datos en títu-lo e incumplimiento de criterios de selección. Se ex-cluyeron 89 por carecer de tratamiento. Se incluye-ron 33 artículos. Se analizaron fístulas de 45 piezas dentarias, superiores e inferiores, anteriores y pos-teriores. En base a los resultados obtenidos se llegó a la conclusión de que las fístulas cutáneas faciales de origen odontogénico se diagnostican de manera errónea; esto conduce a un tratamiento inadecuado y secuela estéticas. Realizar un correcto diagnóstico y adecuado plan de tratamiento permite una curación rápida y predecible. Los hallazgos obtenidos estable-cen que realizar un correcto tratamiento endodóntico en la pieza afectada, es la terapéutica adecuada para lograr el cierre definitivo de la fístula, sin necesidad de tratar quirúrgicamente la misma (AU)

A systematic review of the scientific literature was carried out in relation to the variants of treatment received by permanent teeth associated with the presence of a cutaneous sinus tract. Clinical case reports in English, published in the last ten years, were included. A total of 481 articles were obtained, 359 were excluded due to lack of title data and non-compliance with selection criteria. 89 were excluded due to lack of treatment. 33 articles were included Cutaneous sinus tracts of 45 teeth, upper and lower, anterior and posterior, were analyzed. Based on the results obtained, it was concluded that facial cutaneous sinus tracts of odontogenic origin are misdiagnosed, leading to inadequate treatment and aesthetic sequelae. Carrying out a correct diagnosis and adequate treatment plan allows a quick and predictable healing. The findings obtained establish that performing a correct endodontic treatment in the affected piece is the appropriate therapy to achieve the definitive closure of the cutaneous sinus tract, without the need to surgically treatment (AU)

Combined internal and external negative pressure wound therapy: breakthrough treatment for lymphocutaneous intractable fistula.

PURPOSE: Lymphocutaneous fistula after lymph node dissection is intractable, yet there is no established treatment strategy. This study demonstrates the wound closure time achieved by a new method of combined internal and external negative pressure wound therapy (CIEN) in patients with lymphocutaneous fistula. METHODS: The subjects of this study were six consecutive patients with lymphocutaneous fistula after lymphatic surgery, who were treated with CIEN between 2018 and 2020. The CIEN technique can be summarized as follows: first, internal foam is inserted into the fistula from the opening of the fenestration. Next, a slightly larger area of external foam is applied above the fistula flap outside the external margin of the foam-filled fistula. After bridging the internal foam and external foam, negative-pressure wound therapy is carried out on this bridging foam block. RESULTS: CIEN led to rapid and complete wound healing in all six patients. Fistula flap margin ischemia developed in one patient, but adjusting the mode and pressure settings resulted in improvement. Three patients suffered contact dermatitis. There were no signs of tumor or fistula recurrence in any patients after at least 3 months of follow-up. CONCLUSION: CIEN is an effective and less invasive treatment modality than the conventional method of managing lymphocutaneous fistula.

Unusual Left Periclavicular Cutaneous Lymphatic Fistula After Port Explantation Without Lymph Vessel Injury: Imaging and Interventional Treatment.

Complex oncological treatment can be associated with lymphatic vascular injury that is burdened by considerable morbidity. Lymphatic imaging and interventional techniques offer new minimally invasive treatment options. We report the case of a 59-year-old woman with an unusual lympho-veno-cutaneous fistula, diagnosed by magnetic resonance lymphangiography and treated by minimally invasive embolization therapy and venous recanalization.

Modified vacuum-assisted closure (EndoVAC) therapy for treatment of pharyngocutaneous fistula: Case series and a review of the literature.

BACKGROUND: Pharyngocutaneous fistula is a potential life-threatening complication following head and neck surgery. There is only limited evidence about the efficacy of vacuum-assisted closure (VAC) therapy and endoscopic vacuum-assisted closure (EndoVAC) therapy for the treatment of pharyngocutaneous fistulas. METHODS: In this article, we report on a consecutive case series of six male patients with pharyngocutaneous fistula treated with a modified outside-in EndoVAC technique. We also present a review of the current related literature. RESULTS: EndoVAC therapy alone was successful in five of the six patients (83.3%) with a median duration of EndoVAC therapy of 18.5 days (range: 7 to 32 days) and a median number of EndoVAC sponge changes of 4 (range: 1 to 9 changes). One patient needed additional reconstructive surgery after prior radiochemotherapy and jejunal transfer. No treatment-related complications were observed. CONCLUSION: EndoVAC therapy is an easy-to-perform, safe procedure for the treatment of pharyngocutaneous fistulae.

Management of postreconstructive head and neck salivary fistulae: A review of current practices.

BACKGROUND: Salivary fistulas are common complications after reconstructive head and neck surgery with significant morbidity. Yet, there are no established guidelines for their management. METHOD: A comprehensive search of PubMed was performed from 01/01/2000 to 06/31/2019 to evaluate all treatment options in postreconstructive head and neck fistulas. RESULTS: Nineteen articles with 132 patients were included. Thirty-nine of 132(30%) patients were treated with conventional wound care. All fistulas closed after 51.6±54.0 days with no refistulations. Thirty-eight of 132(29%) patients were treated with negative pressure wound therapy (NPWT). Thirty-eight of 40(95%) fistula closed after 14.7±12.0 days with no refistulations. The reduced healing time was statistically significant as compared to patients on conventional wound care (p < 0.001). Fifty-three of 132(40%) patients received surgical management. Forty-four of 53(83%) patients had complete fistula closure without postoperative complications. A pedicled flap was used in 60% of cases (n = 32). CONCLUSION: Most salivary fistulas close with conservative management. NPWT potentially shortens fistula healing time while it achieves similar closure rates as conventional wound care. In the absence of contraindications, NPWT should be trialed on all salivary fistulas. Surgical management should be reserved for large, chronic, high-risk fistulas or those not responding to a trial of conservative treatment. Secondary reconstruction should be kept as simple as possible.

Mistaken identity: an unexpected case of spontaneous cholecystocutaneous fistula formation.

We describe the case of a 78-year-old woman who presented to the emergency department with a 2-week history of a superficially developing mass in the lower right abdominal wall, fluctuant and non-tender with overlaying erythematous skin changes. Though resembling an abdominal wall abscess and initially listed for a simple incision and drainage, diagnostic uncertainty encouraged further investigation. CT and ultrasound confirmed the mass appeared to be in continuity with the gallbladder fossa, with the lumen also containing small bowel medially. While awaiting a multidisciplinary team discussion, the patient re-presented with concern over discharge appearing at the site of the mass. On inspection, we noted black flecks and small stones. This case describes the unusual and rare presentation of a cholecystocutaneous fistula. The patient was managed conservatively and remains clinically well.

Reconstructive Options During Nonfunctional Laryngectomy.

OBJECTIVE: A paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability. METHOD: We performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed. RESULTS: A total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty-four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube-dependent (P = < .0001). CONCLUSION: Herein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long-term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1510-E1513, 2021.

Enhancing digestive fistula healing by the off-label use of a thermoresponsive vessel occluder polymer associated with esophageal stent placement: A case report.

This case report relates to the first-in-man use of a vessel occluder gel medical device as a fistula occluder in a repurposing strategy. A patient with chronic colocutaneous fistula received an off-label treatment with a thermoresponsive Poloxamer 407 gel (20%) via percutaneous administration and injected under endoscopic control. Treatment consisted in the association of esophageal stent placement and gel injection. The product was administered just after the stent placement at<20°C in its liquid form, gelling at body temperature to form a fistula plug. However, the stent was removed at day 26 because of major pain and the fistula was still present. Treatment was continued a total of 14 administrations of thermoresponsive Poloxamer 407 gel during 7 weeks via the external fistula orifice. The treatment reduced fistula orifice diameter from 4.0±0.5 to 1mm and fistula daily output decreased from 425±65 to 23±4mL, when comparing the months before and after treatment. Gel administration was not associated with any toxic effects. The therapeutic outcome remained stable 1 year after treatment. The external fistula diameter and the fistula output were similar to what was observed after the last Poloxamer 407 gel administration.

Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options.

INTRODUCTION AND AIMS: PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs. METHODS: Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed. RESULTS: In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery. CONCLUSION: GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

Spontaneous cholecystocutaneous fistula: an uncommon complication of acute cholecystitis.

A 78-year-old man presented to the hospital with acute right upper quadrant pain, fever and nausea. A focused abdominal ultrasound and abdominal CT scan were performed demonstrating an acute calculous cholecystitis with gallbladder perforation. Although a CT-guided cholecystostomy was performed and a pericholecystic abscess was relieved promptly, the patient developed a cholecystocutaneous fistula in the right hypochondriac region. A cholecystocutaneous fistula is an extremely rare complication that may occur in patients with acute calculous or acalculous cholecystitis, chronic gallstone disease, gallbladder carcinoma or prior hepatobiliary surgery.