Surviving a Rare Case: Successful Endovascular Treatment for Multiple Dural Venous Sinus Thrombosis With Dural Arteriovenous Fistula.

Vascular anomalies known as dural arteriovenous fistulas (DAVFs) occur when arteries that emerge from carotid or vertebral artery branches empty straight into the dural venous sinuses. A 16-year-old male patient at the center of this case study initially arrived at the hospital with symptoms of generalized tonic-clonic seizures and headaches accompanied by vomiting, followed by right-sided hemiparesis and subsequently left-sided hemiparesis. An MRI brain with MR angiography was performed, revealing an abnormal fistulous connection between the sigmoid and transverse sinus and the branches of the bilateral external carotid and right internal carotid artery. Embolization was performed using a mixture of glue and lipoid to address the issue.

Impacted Ectopic Maxillary Incisor at the Margins of an Oronasal Palatal Fistula.

An oronasal fistula is one of the most common complications that can occur after cleft palate surgeries. Some of the reasons for the failure of repair are the closure of palatal flaps under tension, vascular compromise, and infection. We present a case of a 10-year-old patient who experienced nasal regurgitation during feeding, four years after undergoing a redo palatoplasty. The reason was identified as an impacted maxillary incisor located at the fistula site. The patient was managed with the closure of the oronasal palatal fistula, with a two-layered repair technique using bilateral mucoperiosteal flaps after the removal of the impacted tooth.

The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy.

Objectives: Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial. Methods: We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF. Results: Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status. Conclusion: PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Clinical course of five patients definitively diagnosed with idiopathic perilymphatic fistula treated with transcanal endoscopic ear surgery.

Objectives: An idiopathic perilymphatic fistula (PLF) can be difficult to diagnose because patients present with sudden sensorineural hearing loss (SSHL) and/or vestibular symptoms without any preceding events. In such cases, we currently test for cochlin-tomoprotein (CTP) to confirm the diagnosis of idiopathic PLF because CTP is only detected in the perilymph. In this study, we report the clinical course of five patients definitively diagnosed with idiopathic PLF who underwent PLF repair surgery using transcanal endoscopic ear surgery (TEES). Patients and methods: Five patients were initially treated with intratympanic dexamethasone for SSHL, at which time a CTP test was also performed (preoperative CTP test). Due to refractory hearing loss and/or fluctuating disequilibrium, PLF repair surgery using TEES was performed to seal the oval and round windows using connective tissue and fibrin glue. These patients were diagnosed with definite idiopathic PLF based on pre- or intra-operative CTP test results (negative, < 0.4 ng/mL; intermediate, 0.4-< 0.8 ng/mL; and positive, > 0.8 ng/mL). We evaluated pre- and intra-operative CTP values, intraoperative surgical findings via a magnified endoscopic view, and pre- and post-operative changes in averaged hearing level and vestibular symptoms. Results: Pre- and intra-operative CTP values were positive and intermediate in three patients, positive and negative in one patient, and negative and positive in one patient. None of the patients had intraoperative findings consistent with a fistula between the inner and middle ears or leakage of perilymph. Only two patients showed a slight postoperative recovery in hearing. Four patients complained of disequilibrium preoperatively, of whom two had resolution of disequilibrium postoperatively. Conclusion: A positive CTP test confirms PLF in patients without obvious intraoperative findings. The CTP test is considered more sensitive than endoscopic fistula confirmation. We consider that CTP test results are important indicators to decide the surgical indication for idiopathic PLF repair surgery. In our experience with the five cases, two of them showed improvements in both hearing and vestibular symptoms.

Lipectomy as an alternative for superficialization of autologous AVF in obese patients: experience of a referral center in Amazon.

Background: The preferred vascular access for hemodialysis is a native arteriovenous fistula (AVF) because it offers the best results in the short and long terms, lower morbidity and mortality, and has additional advantages in relation to central venous catheters or arteriovenous grafts. However, obesity can present an additional challenge because of the barrier of subcutaneous cellular tissue covering the surface of the vein to be punctured. Objectives: The authors review their experience with excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients. Methods: Consecutive vascular access patients undergoing lipectomy for cannulation with difficult access because of vein depth were reviewed. Cephalic vein depth was measured by ultrasound in all cases. Results: Twenty-two patients were reviewed (15 men and 7 women), with a mean body mass index of 34.0 kg/m2 (range: 28-40 kg/m2). Mean age was 58.4 years. The mean preoperative vein depth of 7.9 mm (range: 7.0-10.0 mm) was reduced to 4.7 mm (range: 3.0-6.0 mm) (P 0.01). The mean follow-up period for patients was 13.2 months. Four patients were lost to follow-up and four died during the period due to causes unrelated to vascular access. Conclusions: Obesity should not be a limiting factor to creation of a native AVF, since lipectomy is a relatively simple option for superficialization, enabling functioning native and deep arteriovenous fistulas in obese patients.

Acute Suppurative Thyroiditis in Childhood: An Atypical Presentation.

Neck stiffness is a common clinical sign in children presenting to the emergency department that may indicate a wide variety of diagnoses. Acute suppurative thyroiditis (AST) is an infection of the thyroid gland caused by a bacterium, virus, or, less commonly, fungus. It presents as an acute or subacute development of an anterior cervical mass, with associated inflammatory signs. The pressure upon neck muscles may be reflected as a limitation of cervical mobility. AST is often preceded by an upper respiratory tract infection, and pyriform sinus fistula is the most common predisposing factor. It is particularly uncommon in the pediatric age, with limited cases reported in the literature. Therefore, a heightened suspicion is required for proper diagnosis and timely intervention, due to its high mortality. Prompt treatment with broad-spectrum parenteral antibiotic therapy and drainage is mandatory to prevent the numerous complications associated, namely, mediastinitis and sepsis. We report the case of a two-year-old female child admitted with a two-week history of intermittent high-grade fever and sore throat, followed by prostration and limitation in neck movement on admission. Examination revealed neck stiffness with positive Kernig and Brudzinski signs. The laboratory tests showed elevated inflammatory parameters. Cranial computed tomography (CT) scan and lumbar puncture were normal. On day 2 after admission, an anterior cervical mass with slight signs of fluctuation was detected. Ultrasound was compatible with a hemorrhagic/overinfected thyroid nodule, and the patient was started on broad-spectrum antibiotics. Due to clinical worsening, a cervical CT scan was performed, which documented a thyroid abscess with extension into the retropharyngeal space. She underwent surgical drainage, and Streptococcus anginosus and mixed anaerobes were isolated, sensitive to ongoing antibiotherapy. On multidisciplinary follow-up, an esophageal barium study, laryngoscopy, and cervical magnetic resonance imaging (MRI) were performed, revealing no anatomical defects. AST is a rare disease in children, but potentially fatal, so its early recognition and treatment are essential. We aim to draw attention to this disease and its differential diagnosis to reduce the associated morbimortality.

Arteriovenous Fistula Histology, Hemodynamics, and Wall Mechanics: A Case Report of Successful and Failed Access in a Single Patient.

The low 1-year patency rate of mature arteriovenous fistulas (AVFs) remains a significant clinical problem. Although vessel properties and biomechanics have been suggested to affect AVF function, understanding their roles in AVF patency failure is challenging owing to the heterogeneity within the patient population, including demographics and comorbid conditions. In this study, we present a case of a patient with 2 upper-arm AVFs with different 1-year patency outcomes and investigate whether they had different histologic features before the AVF creation surgery and biomechanics at 1 day and 6 weeks after the AVF creation surgery using magnetic resonance imaging-based fluid structure interaction simulations. Despite both AVFs being in the upper arm, created <1 year apart by the same surgeon, and having similar preoperative vessel diameters, the 1-year patent AVF had less preoperative intimal collagen and higher wall shear stress 1 day after AVF creation, when compared with the AVF that failed by 1 year. Thus, a low intimal collagen content before the AVF surgery and higher wall shear stress immediately after the AVF creation surgery may be important for long-term AVF patency and should be investigated with larger cohorts.

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

An 11-year-old male neutered English 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 guarded prognosis and critical condition. Pathological examination confirmed presence of bicuspid aortic valve, aorto-left atrial fistula, and aortic infective endocarditis. Antemortem blood culture revealed two unusual organisms: Achromobacter xylosoxidans and Fusobacterium mortiferum.

Experiential Narratives of Factors Limiting and Boosting Access to Support Services for Women with Obstetric Fistula in Southeast Nigeria.

PURPOSE: Obstetric fistula is a chronic health condition that leaves affected women battered and traumatized, thereby exposing them to social recluse life as a result of associated discomfort and odor. Support services to those with challenging health conditions are reputed to help cushion the adverse effects on them; thus women with fistula and other chronic diseases receiving adequate support will help them to cope and recuperate from such illnesses. This study explores the factors limiting and boosting access to support services for those with obstetric fistulainNigeria. MATERIALS AND METHOD: Focus Group Discussions and In-depth Interviews were employed to obtain data from 44 participants. The thematic data analysis method was deployed in analyzing the data collected. RESULTS: Factors like the limited number of fistula specialist doctors, poor funding, withdrawal from seeking help, long distance, and discrimination limit patients' access to support services and adequate fistula care. The study highlighted that community involvement in fistula care, adequate funding, training, and retraining of professionals will boost support services for fistula patients. CONCLUSION: The study recommends the adoption of a multidisciplinary approach in the management of obstetric fistula patients including the involvement of not only medical personnel but also social workers, families, groups, and community leaders.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate.

INTRODUCTION: Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees. METHODS: A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club. RESULTS: Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training. CONCLUSIONS: Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate.

INTRODUCTION: Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees. METHODS: A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club. RESULTS: Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training. CONCLUSIONS: Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae.

OBJECTIVES: Some studies suggest that regional (RA) provides better patency for arteriovenous fistula (AVF) for hemodialysis (HD) access as compared to Local (LA) and General Anesthesia (GA). This study evaluates the impact of anesthetic modality on long term fistula function at 12 months. METHODS: A retrospective review of patients undergoing cephalic vein-based HD access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic based lower forearm and wrist versus upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months. RESULTS: There were 818 cephalic based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (p=0.009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (p=0.343). Multivariate regression analysis identified that history of AVF/AVG (OR 0.24, p=0.007), receiving intraoperative systemic anticoagulation (OR 2.49, p<0.001), and vein diameter (OR 1.85, p=0.039) as independently associated with AVF functional patency at 12 months. CONCLUSION: There was no association between anesthetic modality and functional patency of cephalic based-AVF at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

One-staged brachial-basilic vein transposition versus arm straight arteriovenous graft for hemodialysis.

OBJECTIVES: After forearm and arm cephalic veins are no longer available as options, the choices of arm vascular access between one-staged brachial-basilic vein transposition (BBAVF) and arm straight arteriovenous graft (AS-AVG) for hemodialysis are controversial. This study aims to compare outcomes between groups. METHODS: All one-staged BBAVF and AS-AVG from August 2014 to December 2019 were reviewed. In cases of suitable basilic vein of 3 mm or more present from cubital crease to axilla, one-staged BBAVF was preferred. AS-AVG was performed for patients who need timely functioning access or have no suitable basilic vein. RESULTS: Twenty-eight one-staged BBAVF and 74 AS-AVG were included. Baseline characteristics were not significantly different, except AS-AVG had less previous ipsilateral access (9% vs 39%; p < .001). Postoperative complications were not different. With six loss follow-ups (3 in BBAVF and 3 in AS-AVG), 24 (96%) and 64 (90%) matured after one-staged BBAVF and AS-AVG, respectively (p = .676). BBAVF took about 30 days (95% CI: 10, 51) longer time to first successful cannulation. Primary patency was significantly better for one-staged BBAVF (hazard ratio (HR) of 3.0 (95%CI: 1.2, 7.7)), whereas secondary patency was not different. The total access failure (i.e. failure to mature combined with any thrombosis or intervention to maintain patency) significantly favored BBAVF (HR 2.7 (95%CI: 1.1, 6.6)). CONCLUSIONS: Provided a suitable arm basilic vein is available, one-staged BBAVF is preferred over AS-AVG when forearm AVF, forearm AVG, and arm cephalic veins are out. However, it requires a longer time to start cannulating than AS-AVG.

Clinical Analysis of 76 Cases of Second Branchial Cleft Fistula.

Objective: To provide the experience of diagnosis and treatment of second branchial cleft fistula in children. Methods: The clinical data of 76 children with second branchial cleft fistulas admitted to Beijing Children's Hospital affiliated with Capital Medical University from January 2016 to December 2020 were retrospectively analyzed. All patients underwent cervical ultrasonography and resection of the second branchial cleft fistula, and their clinical manifestations, surgical methods, complications, recurrence condition, and lesion appearance of the patients were analyzed. Results: Among the 76 cases, the lesions of 43 cases were on the right side, 20 were on the left side, and 13 were bilateral, for a total of 89 lesions. There were 49 type I lesions, 28 type II lesions, 8 type III lesions, and 4 type IV lesions. Type I and type II cases underwent complete excision of the fistula through a small incision in the neck; 2 cases of type III branchial cleft fistulas were treated with trapezoidal incision; 2 cases of type III branchial cleft fistulas underwent single transverse incisions; single small incision-assisted endoscopic resection was adopted in 4 cases of type III and 4 cases of type IV branchial cleft fistulas. During the follow-up period of 6 to 60 months, only 3 cases developed postoperative infection, the others had no postoperative complications, and no cases had recurrence during postoperative follow-up. Conclusion: The incision of the second branchial fistula should be selected according to imaging examination to achieve removal of the fistula while maintaining esthetics.

A modified pancreaticojejunostomy anastomotic technique using double U-sutures for laparoscopic pancreaticoduodenectomy.

Although recent advances in laparoscopic technology have popularized laparoscopic pancreatoduodenectomy (LPD), laparoscopic pancreaticojejunostomy anastomosis (PJA) still presents a major technical challenge. From February 2021 to January 2023, 42 patients underwent LPD with modified double U-suture PJA. Data on the demographic characteristics and clinical results of these patients were investigated. The median operation time was 316 min (249-596 min). The median PJA time was 32 min (25-40 min). The median intraoperative blood loss was 150 mL (50-500 mL). The median postoperative stay was 12 days (7-30 days). Complications occurred in 10 (23.8%) patients, including two cases (4.8%) of delayed gastric emptying and nine cases (21.4%) of postoperative pancreatic fistula (POPF). One patient presented delayed gastric emptying and POPF. Eight patients (19.0%) experienced biochemical leakage, and one patient (2.4%) had grade B POPF. Laparoscopic double U-suture PJA is a feasible and safe technique for performing LPD.

Enhanced adsorption of phenolic compounds using biomass-derived high surface area activated carbon: Isotherms, kinetics and thermodynamics.

The progress of industrial and agricultural pursuits, along with the release of inadequately treated effluents especially phenolic pollutant, has amplified the pollution load on environment. These organic compounds pose considerable challenges in both drinking water and wastewater systems, given their toxicity, demanding high oxygen and limited biodegradability. Thus, developing an eco-friendly, low-cost and highly efficient adsorbent to treat the organic pollutants has become an important task. The present investigation highlights development of a novel adsorbent (CFPAC) by activation of Cassia fistula pod shell for the purpose of removing phenol and 2,4-dichlorophnenol (2,4-DCP). The significant operational factors (dosage, pH, concentration, temperature, speed) were also investigated. The factors such as pH = 2 and T = 20°C were found to be significant at 1.6 g/L and 0.6 g/L dosage for phenol and 2,4-DCP respectively. Batch experiments were further conducted to study isotherms, kinetic and thermodynamics studies for the removal of phenol and 2,4-DCP. The activated carbon was characterised as mesoporous (specific surface area 1146 m2/g, pore volume = 0.8628 cc/g), amorphous and pHPZC = 6.4. At optimum conditions, the maximum sorption capacity for phenol and 2,4-DCP were 183.79 mg/g and 374.4 mg/g respectively. The adsorption isotherm was better conformed to Redlich Peterson isotherm (phenol) and Langmuir isotherm (2,4-DCP). The kinetic study obeyed pseudo-second-order type behaviour for both the pollutants with R2 > 0.999. The thermodynamic studies and the value of isosteric heat of adsorption for both the pollutants suggested that the adsorption reaction was dominated by physical adsorption (ΔHx < 80 kJ/mol). Further, the whole process was feasible, exothermic and spontaneous in nature. The overall studies suggested that the activated carbon synthesised from Cassia fistula pods can be a promising adsorbent for phenolic compounds.

Left dural carotid cavernous fistula mimicking an inflammatory process: A case report.

A female in her 70s presented with altered mental status, left eye pain, ophthalmalgia, and diplopia following a fall. Brain MRI demonstrated contrast-enhancing left peri-insular T2 hyperintense changes that was read as possible herpes simplex encephalitis by neuroradiology. Cerebral angiogram revealed a Barrow Type D left sided carotid cavernous fistula. The patient was subsequently treated with endovascular transvenous coil embolization of the left cavernous sinus resulting in complete occlusion of the fistula. The goal of this case is to present a unique case of a carotid cavernous fistula radiologically mimicking herpes simplex encephalitis. Early recognition of carotid cavernous fistula on neuroimaging is important for prompt treatment of symptoms.

Optimizing prediction models for pancreatic fistula after pancreatectomy: Current status and future perspectives.

Postoperative pancreatic fistula (POPF) is a frequent complication after pancreatectomy, leading to increased morbidity and mortality. Optimizing prediction models for POPF has emerged as a critical focus in surgical research. Although over sixty models following pancreaticoduodenectomy, predominantly reliant on a variety of clinical, surgical, and radiological parameters, have been documented, their predictive accuracy remains suboptimal in external validation and across diverse populations. As models after distal pancreatectomy continue to be progressively reported, their external validation is eagerly anticipated. Conversely, POPF prediction after central pancreatectomy is in its nascent stage, warranting urgent need for further development and validation. The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance. Moreover, there is potential for the development of personalized prediction models based on patient- or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF. In the future, prospective multicenter studies and the integration of novel imaging technologies, such as artificial intelligence-based radiomics, may further refine predictive models. Addressing these issues is anticipated to revolutionize risk stratification, clinical decision-making, and postoperative management in patients undergoing pancreatectomy.