Pressão arterial divergente de causa rara: múltiplas fístulas coronário ­ cavitárias / Rare divergent blood pressure: multiple coronary-cavitary fistulas

A Fístula Coronário Cavitaria (FCC) é a comunicação entre uma artéria coronária e uma veia ou câmara cardíaca. A incidência é cerca de 0,002% na população geral e até 0,25% dos pacientes submetidos a cineangiocoronariografia. As fístulas para ventrículo esquerdo são muito mais raras, com incidência de cerca de 3%. CASO: Paciente masculino, 75 anos, hipertenso e tabagista, com relato de dispneia aos moderados esforços e pressão arterial (PA) divergente (200/70mmHg). O Médico da unidade básica de saúde solicitou cintilografia miocárdica que evidenciou hipoperfusão persistente na parede ínfero lateral do ventrículo esquerdo e função ventricular global preservada. O eletrocardiograma não evidenciou área eletricamente inativa (contrastando com a cintilografia). Ao ecocardiograma observou-se artérias coronárias com ectasia (troncos principais com 9 e 7mm de diâmetro), múltiplas imagens sugestivas de fluxo diastólico direcionado da parede para dentro do ventrículo esquerdo. O VE tinha discreta dilatação, com fração de ejeção no limite inferior da normalidade e strain global longitudinal reduzido. Sem evidência de insuficiência aórtica ou de outras causas de roubo de fluxo. A cineangiocoronariografia mostrou coronárias com ectasia, isentas de processo ateromatoso, com imagem sugestiva de FCC tanto da coronária esquerda quanto direita. CONCLUSÃO: A maioria dos casos de FCC é assintomática e diagnosticada incidentalmente. No caso do nosso paciente, a presença de PA divergente direcionou o exame para patologias com roubo de fluxo. Excluímos as mais frequentes e obvias, e o achado de fluxo diastólico da parede para o VE ajudou no diagnóstico de FCC, confirmado por coronariografia. Devido baixa casuística relatada, o diagnóstico desses pacientes é ainda um desafio para a prática clínica do ecocardiografista. Também é um desafio terapêutico, dessa forma, mais estudos precisam ser realizados para que esta condição seja cada vez mais suspeitada, diagnosticada e tratada.

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.

Pharyngeal mucosal closure in total laryngectomy: comparison between vertical and T-shaped closure.

Objective: The objective of this study was to compare the outcomes vertical and T-shaped pharyngoplasty closure techniques after total laryngectomy (TL) and to evaluate the factors associated with the development of pharyngocutaneous fistula. Materials and methods: We performed a retrospective study that included patients with a histopathological diagnosis of laryngeal cancer that underwent TL between 2009 and 2021. Results: Fifty-seven patients were included in the study. A total of 14 patients underwent a vertical closure of the neopharynx (24.6%), while 43 patients underwent a T-shaped closure (74.4%). Pharyngocutaneous fistula was the most common complication, observed in 40.4% of cases (n = 23). No difference in the rate of complications was observed between groups, with the exception of tracheal dehiscence which was reduced in patients with T-shaped closure (n = 2, 4.7% vs. n = 5, 35.7%, p = 0.002). Diabetes mellitus was more frequently observed in patients withthe development of pharyngocutaneous fistula (n = 7, 30.4% vs. n = 3, 8.8%, p = 0.03). Conclusions: Although complicationswere lower in the T-shaped closure group, we could not establish the superiority of either technique.

Objetivo: Evaluar los desenlaces de la técnica vertical en comparación con la técnica en T para el cierre de faringoplastia posterior a una laringectomía total, y evaluar los factores asociados con el desarrollo de fístula faringocutánea. Método: Estudio retrospectivo de pacientes con diagnóstico de cancer de laringe a quienes se realizó laringectomía total como tratamiento, de 2009 a 2021. Resultados: Se incluyeron 57 pacientes. A 14 (24.6%) se les realizó una faringoplastia con cierre en T y a 43 (74.4%) un cierre vertical. La fístula faringocutánea fue la complicación más frecuente, presente en el 40.4% de los casos (n = 23). No se observaron diferencias en el desarrollo de complicaciones entre grupos, con excepción de la dehiscencia traqueal, la cual fue menos frecuente en el grupo de cierre en T (n = 2, 4.7% vs. n = 5, 35.7%; p = 0.002). La diabetes mellitus se asoció con el desarrollo de fístula faringocutánea (n = 7, 30.4% vs. n = 3, 8.8%; p = 0.03). Conclusiones: Aunque se observó una tendencia a una disminución de las complicaciones en el grupo de cierre en T, no se encontró superioridad de una técnica sobre otra.

Effects of upper limbs' neuromuscular electrical stimulation (NMES) superimposed to voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise, in muscle strength, functional capacity and quality of life of adult patients with CKD: a randomized clinical trial protocol.

OBJECTIVE: To investigate the effects of unilateral upper limbs' (ULM) neuromuscular electrical stimulation (NMES) superimposed on a voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise on muscle strength, functional capacity and quality of life of adult patients with chronic kidney disease (CKD). METHODS: This randomized controlled clinical trial will be carried out at a Brazilian University Hospital. The patients will be evaluated and randomly allocated to an intervention group (i.e., unilateral NMES on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min) or a control group (i.e., unilateral NMES-Sham on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min). The patients will be treated for 8 weeks, with three weekly treatment sessions totaling 24 sessions. MEASUREMENTS: ULM muscle strength, functional capacity, quality of life and also the feasibility, safety and patient adherence to the exercise protocol. All physical measurements will be collected by trained researchers before treatment (week 0) and at the end of treatment (week 9), always in the second hemodialysis session of the week. It will be used in an intention-to-treat analysis. RESULTS/CONCLUSIONS: The outcomes of this clinical trial protocol may help to know the possible benefits of unilateral ULM' NMES superimposed on a voluntary contraction added to a protocol of leg cycle ergometer for patients with CKD and to aid clinical decisions about future implementation or not of this technique (NMES) in intradialytic physical training programs.

Ventriculo-gallbladder shunt: case series and literature review.

BACKGROUND: The ventriculoperitoneal shunt (VPS) is the gold-standard surgical technique to treat hypertensive hydrocephalus; however, it may fail in 20 to 70% of cases. The present study shows an alternative for patients with contraindications to VPS. METHODS: A case series of nine patients. The medical records of all patients under 17 years of age who underwent ventriculo-gallbladder (VGB) shunt at a pediatric hospital from January 2014 to October 2022 were reviewed. RESULTS: There were 6 (66.7%) males and 3 (33.3%) females. The average age of 73.6 months or 6.1 years at the time of surgery. They had undergone, on average, 5.1 VPS reviews before the VGB shunt. Five (55.5%) had complications of VGB shunt: infection (11.1%), atony (11.1%), hypodrainage (11.1%), and ventriculoenteric fistula (22.2%); all these patients got better at surgical reapproach, and in two of them, the VGB shunt was re-implanted. CONCLUSION: This case series shows a lower risk of death and a similar risk of complications compared to other alternative shunts. This article spotlighted VGB as a viable alternative when VPS fails or has contraindications.

Update on Ultrasound Diagnostic Criteria and New Ultrasound Severity and Activity Scorings of Hidradenitis Suppurativa: Modified SOS-HS and US-HSA.

Hidradenitis suppurativa (HS) is a devasting autoimmune cutaneous disease that affects the hair follicles and can clinically present palpable nodules, abscesses, and tunnels (fistulas), usually in the intertriginous regions. It has been widely reported that color Doppler ultrasound can detect subclinical abnormalities and stage the severity of the disease more accurately. Nevertheless, the ultrasound diagnostic criteria were reported with 15 MHz 10 years ago, and now it is possible to detect early anatomical abnormalities in HS using 70 MHz. Thus, an update of the ultrasonographic diagnostic criteria is needed. The most widely used sonographic staging of severity of HS (SOS-HS) includes the number of affected regions, besides counting the number of key lesions like pseudocysts, fluid collections, and tunnels; however, the total number of affected regions may fit better in an activity scoring. Furthermore, a high number of tunnels or communicated tunnels can complicate the management and may indicate an even more urgent treatment, which should be considered in the severity classification. To date, no hidradenitis scoring of activity has been reported in the literature, making it difficult to track the degree of inflammation under treatment objectively. Therefore, two new scorings are proposed. The first is an updated sonographic scoring of severity called modified SOS-HS (mSOS-HS), and the second is an activity ultrasound scoring of HS called US-HSA. Both staging systems can provide better anatomical information for discriminating the categories and, therefore, selecting more appropriate treatments and supporting research and clinical trials by giving more objective anatomical tools in real-world settings.

Ureterovaginal fistula: a case report and review of an unexpected contemporary complication secondary to transvaginal ultrasound-guided oocyte retrieval.

Despite the widespread use of transvaginal ultrasound-guided oocyte retrieval in assisted reproductive technology procedures, there is a lack of systematic data on the incidence and nature of its complications. This makes it difficult for healthcare providers to fully understand and manage the risks associated with the procedure, and for patients to make informed decisions about their care. Ureteral injuries and other complications during oocyte retrieval are important to consider and manage appropriately. Early ureterovaginal fistula is a rare but serious complication that can occur after oocyte collection by transvaginal ultrasound. It is important for medical professionals to be aware of this potential complication and to take appropriate measures to prevent and manage it. Minimally invasive treatments for ureterovaginal fistula can be effective in resolving the condition and minimize the risk of further complications. However, early diagnosis and prompt intervention are critical in achieving a successful outcome.

A Stent Misplaced in the Septal Perforating Artery: Right Ventricular Fistula, Interventricular Septal Hematoma, and Right Ventricular Outflow Tract Obstruction. / Um Stent Mal Colocado na Artéria Septal Perfurante: Fístula Ventricular Direita, Hematoma do Septo Interventricular e Obstrução da Via de Saída do Ventrículo Direito.

Coronary-cameral fistulas, though mostly regarded as congenital entities, have also been encountered as complications of major traumas and percutaneous coronary interventions (PCIs).1 On the other hand, interventricular septal (IVS) hematoma might potentially arise mostly during retrograde chronic total occlusion (CTO) interventions and has a benign course in this context.2 Herein, we describe a challenging PCI complication (and its management strategy) presenting with IVS hematoma, right ventricular fistula, and right ventricular outflow tract (RVOT) obstruction due to a misimplanted coronary stent in the septal perforating artery (SPA).

As fístulas coronário-camerais, embora consideradas em sua maioria como entidades congênitas, também têm sido encontradas como complicações de grandes traumas e intervenções coronárias percutâneas (ICPs).1 Por outro lado, o hematoma do septo interventricular (SIV) pode potencialmente surgir principalmente durante intervenções de oclusão total crônica retrógrada (OTC) e tem um curso benigno nesse contexto.2 Aqui, descrevemos uma complicação desafiadora da ICP (e sua estratégia de manejo) apresentando hematoma do SIV, fístula ventricular direita e obstrução da via de saída do ventrículo direito (VSVD) devido a um stent coronário mal implantado na artéria septal perfurante (ASP).

Aortoenteric fistulae and their multidisciplinary approach.

Aortoenteric fistula is an uncommun life-threatening condition which remains associated with significant morbidity and mortality. It can be primary (aneurysm, neoplasms, radiation therapy, infection) or secondary to vascular prosthesis. Early diagnosis and aggressive surgical treatment are very important to achieve optimal outcomes in these patients. The aim of this article is to highlight the importance of early diagnosis and multidisciplinary approach of aortoenteric fistula through the presentation of a clinical case.

La fístula aortoentérica es una patología poco frecuente, pero de riesgo vital, asociada a alta morbimortalidad. Puede ser primaria (aneurisma, neoplasia, radioterapia, infección) o secundaria a prótesis vascular. El diagnóstico precoz y el tratamiento quirúrgico agresivo son los pilares fundamentales para lograr buenos resultados en estos pacientes. El objetivo de este trabajo es destacar la importancia del diagnóstico precoz de la fístula aortoentérica y su manejo multidisciplinar, mediante la presentación de un caso clínico.

Cirugía de fosa posterior y fístula de líquido cefalorraquídeo: una revisión de cómo prevenirla y tratarla / Posterior fossa surgery and Cerebro Spinal Fluid Leak: Review of How to Prevent and Treatment

Introducción: La fístula de Líquido Cefalorraquídeo (LCR) es una complicación frecuente de las cirugías de fosa posterior. Objetivo: Realizar una revisión bibliográfica de la prevención de la fístula mediante diferentes técnicas de reparación del defecto dural y analizar factores de riesgo en el manejo de la fistula postoperatoria. Materiales y Métodos: Realizamos una búsqueda bibliográfica de las bases de datos de Medline, Cochrane y Embase. Resultados: Se hallaron 413 estudios inicialmente, 367 fueron descartados y 46 fueron seleccionados. Conclusión: Concluimos que no existen selladores durales superiores a otros. Recomendamos el uso de autoinjertos por su facilidad, bajo costo y mayor efectividad, particularmente el pericráneo, combinado con parches durales como Duragen® o Selladores durales como DuraSeal®. En abordajes suboccipitales otra opción es fascia cervical. Sí no es posible obtener un autoinjerto, los parches durales de colágeno presentan mayor eficacia en combinación con Selladores de Polietilenglicol. En caso de producida la fístula, para el manejo terapéutico es necesario el uso de medidas conservadoras más Drenaje Lumbar Externo (DLE) de forma temprana ya que aumenta su eficacia(AU)

Background: Cerebrospinal fluid (CSF) leakage is a frequent complication of posterior fossa surgery. Objectives: To study a bibliographic review of fistula prevention through different dural defect repair techniques and analyze risk factors in the management of postoperative fistula. Methods: A bibliographic search was performed using Medline, Cochrane and Embase. Results: 413 studies were considered at the beginning, 367 were discarded and 46 were selected. Conclusion: To conclude that there is not an ideal dural sealant. We recommend the use of autografts due to their relative ease, low cost and high effectivity, particularly pericranium, combined with dural sealants like Duragen® or DuraSeal®. In the suboccipital approach cervical fascia is another option. If not technically possible the use of an autologous graft, collagen matrix have higher efficiency combined with Polietilenglicol Sealants. If CSF leakage appears, for the management is necessary the use of conservative actions associated with External Lumbar Drainage (ELD) as quickly as possible because it increases efficacy(AU)

Rupture of sinus of Valsalva aneurysm to the right atrium resolved with interventionism.

We present a case of a ruptured right sinus of Valsalva aneurysm to the right atrium that developed global heart failure over the course of three months, and which was completely resolved through cardiac catheterism, placing an occlusive device at the site of the fistula. Its ethology is discussed, as well as the guidelines for clinical diagnosis and treatment.

Se presenta un caso de aneurisma del seno de Valsalva derecho roto a la aurícula derecha, que en el transcurso de tres meses desarrolló insuficiencia cardiaca global y fue resuelto del todo por medio de intervencionismo, colocando un dispositivo oclusor en el sitio de la fístula. Se discute su etología, así como las pautas para el diagnóstico clínico y el tratamiento.

[E-VAC therapy as treatment of complications in gastrointestinal surgery in a gastroenterology reference center in Colombia: Case series]. / Terapia E-VAC como tratamiento de complicaciones en cirugía gastrointestinal en centro de referencia de gastroenterología en Colombia: Serie de casos.

Gastrointestinal postoperative anastomotic leaks and fistulas occur frequently and many are managed surgically; however, endoscopic interventions have shown to improve healing outcomes and length of hospital stay. The experience of vacuum-assisted closure therapy (E-VAC) is described, in complications such as fistulas and postoperative anastomotic leaks, in a gastrointestinal reference center in Colombia. A case series study was carried out in patients with anastomotic leaks and fistulas at different levels of the digestive tract, treated by E-VAC, by the Gastroenterology Service in Colombia, during a period from February 2019 to November 2021. Sociodemographic, clinical and surgical variables were described. 6 cases are described, 4 from lower digestive tract and 2 from upper digestive tract. 83% were men; the mean age was 51.8 years (+/-17.5). The indication for E-VAC was colorectal anastomotic fistula in 66%; the most frequent anatomical location was near the anal region (66%), less frequently at the level of the cardia (16%) and esophagus (16%). The size of the defect was described between 20 and 80% in patients undergoing E-VAC therapy, with an average hospitalization length of stay of 22.5 days, with an average number of exchanges of seven per patient. Anastomotic leaks and fistulas are potentially fatal complications in gastrointestinal surgery. E-VAC therapy has shown to be effective and safe, promoting defect closure and drainage of collections present, also decreasing the length of hospital stay.

Fístula nasal de líquido cefalorraquídeo post-traumática. Resultados de la implementación de un protocolo de trabajo / Post-traumatic cerebrospinal fluid nasal leak. Results of the implementation of a work protocol

Introducción: Los pacientes con fracturas de base de cráneo anterior post traumatismo encéfalo-craneano tienen alto riesgo de fístula de líquido céfalo-raquídeo por las fosas nasales. Es importante el manejo oportuno y apropiado, evitando así complicaciones; razón por la cual se desarrolló el "protocolo HP" para su tratamiento quirúrgico. Objetivo: Comunicar la utilidad del "protocolo HP" en el manejo de la fístula de líquido céfalo-raquídeo de la base de cráneo anterior. Materiales y métodos: Estudio transversal retrospectivo con pacientes ≥ 15 años con diagnóstico de fístula de líquido céfalo-raquídeo nasal post traumatismo encéfalo-craneano, desde 1/1/2016 hasta 31/8/2021 que ingresaron al hospital y requirieron cirugía de reparación, con 28 pacientes incluidos, el valor p ˂0,05 (estadísticamente significativo). Resultados: 96,4% hombres, mayoría adultos jóvenes con traumatismo encéfalo-craneano leve; 82,1% presentó fístula de líquido céfalo-raquídeo temprana. Todos requirieron reparación transcraneal frontal, en 67,9% fue bilateral. La reparación antes de los 7 días fue en el 39,3%, 7-21 días en 46,4% y después de 21 días en 14,3% de los casos. Uso de drenaje lumbar continuo: preoperatorio 10,7%, intraoperatorio 60,7%, postoperatorio 46,4%. En el 89,3% la ubicación de la fístula de líquido céfalo-raquídeo intra-quirúrgica fue congruente con la tomografía. Desde el 2020 se sistematizó el manejo de las fístula de líquido céfalo-raquídeo. La recurrencia fue de 10,7% antes del 2020 (posteriormente fue de 0%), asociándose con Glasgow bajo e inicio de fístula de líquido céfalo-raquídeo 7 días post traumatismo encéfalo-craneano (p˂0,05). Complicaciones encontradas: meningitis 28,6%, convulsión 25%, anosmia 14,3%, neumoencéfalo a tensión 7,1% y absceso 3,6%. Mortalidad por fístula de líquido céfalo-raquídeo: 3,6%. Curación 96,4%. Conclusiones: La aplicación del "Protocolo HP" tuvo resultados satisfactorios. La tasa de recurrencia postoperatoria de fístula de líquido céfalo-raquídeo nasal post traumatismo encéfalo-craneano fue 0%(AU)

Background: Patients with anterior skull base fractures after traumatic brain injury have a high risk of cerebrospinal fluid leak through the nostrils. Timely and appropriate management is important, avoiding complications. The "HP protocol" for surgical treatment was developed. Objectives: To communicate the utility of the "HP protocol" in the management of the anterior skull base cerebrospinal fluid leak. Methods: Retrospective cross-sectional study; patients ≥ 15 years old with a diagnosis of nasal cerebrospinal fluid leak after traumatic brain injury, who were admitted at the hospital from 1/1/2016 to 8/31/2021 and required surgery. Included 28 patients, p value ˂0.05 (statistically significant). Results: 96.4% men, mostly young adults with mild traumatic brain injury; 82.1% presented early cerebrospinal fluid leak. All required frontal transcranial repair, in 67.9% it was bilateral. Repair before 7 days was in 39.3%, 7-21 days in 46.4%, and after 21 days in 14.3%. Use of continuous lumbar drainage: preoperative 10.7%, intraoperative 60.7%, postoperative 46.4%. In 89.3%, the location of the intraoperative cerebrospinal fluid leak was consistent with the CT scan. Since 2020, the management of the cerebrospinal fluid leak was systematized. The recurrence was 10.7% before 2020; after it was 0% and associated with low Glasgow and onset of cerebrospinal fluid leak 7 days after traumatic brain injury (p<0.05). Complications: meningitis 28.6%, seizure 25%, anosmia 14.3%, high tension pneumocephalus 7.1% and abscess 3.6%. Cerebrospinal fluid leak mortality: 3.6%. Cure 96.4%. Conclusions: The application of the "HP Protocol" had satisfactory results. The post traumatic brain injury nasal cerebrospinal fluid leak recurrence rate was 0%