Botulinum Neurotoxin A in the Treatment of Pharyngocutaneous Fistula after Salvage Surgery in Head and Neck Cancer Patients: Our Preliminary Results.

Objective: To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods: A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results: Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7-18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different (p < 0.05). Conclusions: BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Relationship between clinical remission of perianal fistulas in Crohn's disease and serum adalimumab concentrations: A multi-center cross-sectional study.

BACKGROUND: Crohn's disease (CD) is complicated by perianal fistulas in approximately 20% of patients. Achieving permanent fistula closure remains a challenge for physicians. An association between serum anti-tumor necrosis factor-α concentrations and clinical outcomes in patients with CD has been demonstrated; however, little information is available on serum adalimumab (ADA) concentrations and remission of perianal fistulas in such patients. AIM: To study the relationship between serum ADA concentrations and clinical remission of CD-associated perianal fistulas. METHODS: This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018. At the time of each serum ADA concentration measurement, we collected information about the patients and their fistulas. The primary study endpoint was clinical remission of fistulas defined as the absence of drainage (in accordance with Present's criteria), with a PDAI ≤ 4, absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center. We also assessed fistula healing [defined as being in clinical and radiological (magnetic resonance imaging, MRI) remission] and adverse events. RESULTS: The study cohort comprised 34 patients who underwent 56 evaluations (patients had between one and four evaluations). Fifteen patients had clinical remissions (44%), four of whom had healed fistulas on MRI. Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not [14 (10-16) vs 10 (2-15) µg/mL, P = 0.01]. Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas [11 (7-14) vs 10 (4-16) µg/mL, P = 0.69]. The adverse event rate did not differ between different serum ADA concentrations. CONCLUSION: We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas.

Intralesional Triamcinolone for Fistulous Tracts in Hidradenitis Suppurativa: An Uncontrolled Prospective Trial with Clinical and Ultrasonographic Follow-Up.

BACKGROUND: There is little evidence on the use of intralesional triamcinolone (ILT) for managing fistulous tracts in hidradenitis suppurativa (HS). OBJECTIVE: To assess the clinical and ultrasound response to ILT for single fistulous lesions in HS patients. METHODS: A prospective open-label study was conducted to assess response to ILT (40 mg/mL) for fistulous tracts in HS. Consecutive patients (Hurley II stage exclusively) presenting to our department were recruited from August 2016 to August 2018. They received a single injection of ILT as the sole treatment. Lesions were assessed clinically and by ultrasound at baseline and 90 days. RESULTS: Of the 53 included HS patients with fistulous tracts, 36 (67.9%) were women, 30 (56.6%) were smokers, and 36 (67.9%) were obese or overweight (body mass index ≥25). Median Sartorius score was 9.0 (IQR 9.0-36.0), and median duration of the lesion treated was 6 months (IQR 3.0-12.0). Fistulous tracts were injected with 0.5 mL triamcinolone 40 mg/mL. Seven patients were lost to follow-up. At 90 days, 20 (43.5%) lesions showed clinical and ultrasound resolution, 13 (28.3%) showed only clinical resolution while persisting on ultrasound, and 13 (28.3%) persisted both clinically and on ultrasound. Mean clinical size decreased from 17.0 to 5.1 mm (p < 0.0001), while mean length on ultrasound decreased from 16.0 to 8.6 mm (p < 0.0001). LIMITATIONS: Small sample size and no control group. CONCLUSIONS: Our study suggests that ILT is beneficial for small fistulous tracts in HS.

Staged surgical treatment for infection of total disc arthroplasty: three cases and a narrative review of the literature.

Although total disc arthroplasty (TDA) is a common procedure for selected cases of degenerative disc disease, until today there are only two cases of TDA infections reported in the literature. We report three cases of postoperative TDA infections, two developed cutaneous fistulas. To eradicate the infectious site, a staged removal of the device, resolute debridement, and stabilization plus fusion is proposed. Surgeons are challenged by (1) major retroperitoneal vessels adherent to the device, (2) surrounding scar tissue, (3) accompanying retroperitoneal abscess, and (4) technical issues when removing and replacing the implant. A staged multidisciplinary team approach involving vascular and plastic surgery as well as spine specialists is mandatory to achieve good results.

A Functional Approach to Posttraumatic Salivary Fistula Treatment: The Use of Botulinum Toxin.

This manuscript highlights key aspects regarding the practical use of botulinum toxin for the conservative nonsurgical treatment of a rarely encountered, but significant posttraumatic complication-the parotid salivary fistula. It adds information to the scarce existing literature on the subject. The authors outline the main differences between postoperative and trauma-related parotid injury regarding salivary fistula treatment. A total of 6 patients with trauma-related salivary fistulas have been treated by Abobotulinum toxin A injections over the course of 5 years. The technique is detailed, describing the doses used in the presence of parenchyma and duct injuries, the location and number of injection points in relation to the wound pattern. The results were favorable, leading to the healing of the salivary fistulas in all patients, with 1 injection session, without additional conservative treatment. In our experience, the use of botulinum toxin is of great benefit for treating salivary fistulas in a traumatic context.

[Congenital cysts and fistulas on the neck in adults]. / Kystes et fistules congenitaux du cou chez l'adulte.

Cervical congenital malformations are relatively common in children. They can also be found in adults. The embryological development of the cervical region is closely related to the branchial clefts. This must be a diagnosis made by elimination; a cervical tumor must evoke the diagnosis of cancer. A cutaneous fistula or a cervical tumor, chronic or recent appearance in an inflammatory context, are the clinical signs. The thyroglossal duct cysts and the second branchial clefts cysts are the most common causes of median and lateral cervical cysts, respectively. Imaging contributes greatly to the orientation and diagnostic evaluation of the extent of the lesions. Treatment is initially based on antibiotic therapy and then on complete surgical excision, away from an infectious episode, the sole guarantee for the absence of local recurrence.

Linezolid-induced black hairy tongue.

Black hairy tongue (BHT) is a self-limiting disorder characterized by abnormal hypertrophy and elongation of filiform papillae on the surface of the tongue. The exact mechanism of drug-induced BHT is unknown. Several factors have been implicated and included smoking or chewing tobacco, drinking alcohol, poor oral hygiene and antibiotics such as tetracyclines and penicillins. We report a quite uncommon case of Linezolid-induced BHT in a patient with a long-lasting history of chest wall infection.

Tubercular esophagocutaneous fistula: Rare case report.

Tubercular esophagocutaneous fistula is a rare entity with only about five cases reported so far. It can be as a result of primary involvement of esophagus by tuberculosis or due to spread of infection from adjacent structures like lungs or mediastinal lymph nodes. The fistula usually heals with initiation of antitubercular therapy and surgery is rarely required. Here we report a case of 65-year-old diabetic male who developed esophagocutaneous fistula secondary to caseation of mediastinal lymph nodes and was successfully treated with antitubercular treatment.

Tuberculosis epididymitis complicated by a cutaneous fistula.

A 63-year-old man developed scrotal swelling that became bilateral over 2 months. His symptoms persisted after treatment for epididymitis, and he developed a scrotal fistula with drainage. Mycobacterium tuberculosis grew from the urine and fistula. His symptoms resolved and fistula closed with medical therapy. His case highlights the importance of early recognition, diagnosis and treatment of this form of extrapulmonary tuberculosis.

Fístula cutánea de líquido cefalorraquídeo posterior a analgesia epidural obstétrica. A propósito de un caso / Cerebrospinal fluid cutaneous fistula following obstetric epidural analgaesia. Case report

La fístula cutánea de líquido cefalorraquídeo es una rara complicación de los bloqueos neuroaxiales. Presentamos el caso de una gestante a la que se le colocó un catéter epidural para analgesia de trabajo de parto y que 12h tras la retirada del catéter presentó abundante pérdida asintomática de líquido por la zona de punción, compatible en el análisis citoquímico con líquido cefalorraquídeo. Fue tratada con acetazolamida, compresión del orificio cutáneo de salida de líquido, profilaxis antibiótica, hidratación y reposo, evolucionando de forma satisfactoria sin ameritar parche hemático (AU)

Cutaneous fistula of cerebrospinal fluid is a rare complication of neuroaxial blockade. We report the case of a parturient in whom an epidural catheter was placed for labour analgesia and 12h after the catheter was removed, presented an abundant asymptomatic fluid leak from the puncture site, compatible in the cyto-chemical analysis with cerebrospinal fluid. She was treated with acetazolamide, compression of skin orifice of the fluid leakage, antibiotic prophylaxis, hydration and rest, and progressed satisfactorily without requiring blood patch (AU)

Cutaneous fistulization of the hydatid disease: A PRISMA-compliant systematic review.

AIM: To provide an overview of the medical literature on cutaneous fistulization in patients with hydatid disease (HD). METHODS: According to PRISMA guidelines a literature search was made in PubMed, Medline, Google Scholar, and Google databases were searched using keywords to identify articles related to cutaneous fistulization of the HD. Keywords used were hydatid disease, hydatid cyst, cutaneous fistulization, cysto-cutaneous fistulization, external rupture, and external fistulization. The literature search included case reports, review articles, original articles, and meeting presentations published until July 2016 without restrictions on language, journal, or country. Articles and abstracts containing adequate information, such as age, sex, cyst size, cyst location, clinical presentation, fistula opening location, and management, were included in the study, whereas articles with insufficient clinical and demographic data were excluded. We also present a new case of cysto-cutaneous fistulization of a liver hydatid cyst. RESULTS: The literature review included 38 articles (32 full text, 2 abstracts, and 4 unavailable) on cutaneous fistulization in patients with HD. Among the 38 articles included in the study, 22 were written in English, 13 in French, 1 in German, 1 in Italian, and 1 in Spanish. Forty patients (21 males and 19 females; mean age ±â€Šstandard deviation, 54.0 ±â€Š21.5 years; range, 7-93 years) were involved in the study. Twenty-four patients had cysto-cutaneous fistulization (Echinococcus granulosus); 10 had cutaneous fistulization (E multilocularis), 3 had cysto-cutaneo-bronchio-biliary fistulization, 2 had cysto-cutaneo-bronchial fistulization; and 1 had cutaneo-bronchial fistulization (E multilocularis). Twenty-nine patients were diagnosed with E granulosis and 11 had E multilocularis detected by clinical, radiological, and/or histopathological examinations. CONCLUSION: Cutaneous fistulization is a rare complication of HD. Complicated HD should be considered in the differential diagnosis of cases presenting with cutaneous fistulization, particularly in regions where HD is endemic.

Ustekinumab for the Treatment of Refractory Crohn's Disease: The Spanish Experience in a Large Multicentre Open-label Cohort.

BACKGROUND: Ustekinumab is a fully human monoclonal antibody against IL-12/23. Ustekinumab induced clinical response and maintained higher rate of response than placebo in patients with Crohn's disease (CD). This study aims to assess the effectiveness and safety of ustekinumab in refractory patients with CD in real-life practice. METHODS: Consecutive patients with CD who were treated with subcutaneous ustekinumab between March 2010 and December 2014 were retrospectively included in a multicenter open-label study. Clinical response was defined by Harvey-Bradshaw index score and assessed after the loading doses, 6, 12 months, and last follow-up. RESULTS: One hundred sixteen patients were included, with a median follow-up of 10 months (interquartile range: 5-21). Clinical response after loading ustekinumab was achieved in 97/116 (84%) patients. The clinical benefit at 6, 12 months, and at the end of the follow-up was 76%, 64%, and 58%, respectively. Dose escalation was effective in 8 of 11 (73%) patients. Perianal disease also improved in 11 of 18 (61%) patients with active perianal fistulae. The initial response to ustekinumab and previous use of more than 2 immunosuppressant drugs were associated with a clinical response to ustekinumab maintenance therapy. In contrast, previous bowel resection predicted a long-term failure with ustekinumab. Adverse events were reported in 11 (9.5%) patients, but none required ustekinumab withdrawal. CONCLUSIONS: Subcutaneous ustekinumab is effective and safe in a high proportion of patients with CD that were resistant to conventional immunosuppressant and antitumor necrosis factor drugs.

Radioterapia para linfoceles y fístulas linfocutáneas refractarias: tratamiento corto con bajas dosis / Radiotherapy for refractory lymphoceles and lymphocutaneous fístulas: Short treatment with low doses

INTRODUCCIÓN: Las fístulas linfocutáneas o linfoceles (LFL) tienen una baja incidencia pero a los afectados pueden disminuirles severamente la calidad de vida. OBJETIVO: Evaluar la eficacia y toxicidad de dosis bajas antiinflamatorias de radioterapia como tratamiento definitivo de LFL refractarios. MATERIAL Y MÉTODOS: Estudiamos a todos los pacientes tratados desde 2001 hasta 2012 retrospectivamente en nuestro Servicio de Oncología Radioterápica. Nuestro esquema de tratamiento fue 7,5 Gy en 5 sesiones diarias administradas en acelerador lineal mediante electrones de diferentes energías según la profundidad de la lesión. Al final, y tras un mes del tratamiento, se estudió su eficacia y toxicidad. RESULTADOS: Se trató a 9 hombres y 4 mujeres con una mediana de edad media de 66 años (23-86). De ellos, 11 presentaban fístulas linfocutáneas y 2 linfoceles. La etiología desencadenante predominante fue una cirugía vascular (8 pacientes). Previamente, todos tuvieron tratamiento conservador: uno fue reoperado y a otro se le practicaron varios drenajes. Un total de 11 pacientes recibieron 7,5 Gy, uno recibió 9 Gy y otro 12 Gy al aumentar el tiempo total de tratamiento por conmorbilidad, pero con la misma dosis biológica equivalente. La duración del tratamiento fue 5 días naturales en 6 pacientes y 7 días naturales en 4 pacientes. De los tratamientos, 7 se realizaron con electrones de 12 MeV, 5 con electrones de 9 MeV y uno con electrones de 6 MeV. Al final de la radioterapia, 11 pacientes tenían una mejoría notable de su sintomatología. Al mes, 9 pacientes presentaban una resolución completa. No se observó en ninguno de los casos toxicidad rádica aguda. CONCLUSIONES: Este tratamiento es eficaz, seguro y rápido para esta enfermedad, aun cuando otros tratamientos fracasaron

INTRODUCTION: Lymphocutaneous fístulas and/or lymphoceles (LFL) have a low incidence, but they can affect the quality of life of the patient. AIM: To value effectiveness and toxicity of low dose radiotherapy as an anti-inflammatory curative treatment of LFL when other treatments are ineffective. MATERIALS AND METHODS: Consecutive patients treated in our department from 2001 to 2012 were retrospectively studied. Treatment schedule was 7.5 Gy in 5 daily sessions with linear acceleration electrons. Patients were reviewed at the end of treatment and one month after this. RESULTS: The study included 9 men and 4 women, with a mean age of 66 (23-86) years old. There were 11 lymphocutaneous fístulas and 2 lymphoceles. Predominant aetiology: vascular surgery (8 patients). All had conservative treatment, one was also re-operated, and another was drained before radiotherapy. The total dose received by 11 patients was 7.5 Gy, in one it was 9 Gy and in another, 12 Gy. The total treatment time extension was 5 natural days in 6 patients, and 7 days in 4. Seven patients were treated with 12MeV, 5 with 9 MeV, and 1 with 6 MeV electrons. On the day of last treatment session, LFL had decreased in 11 patients, and in 9 of them it was completely resolved at one month. No radiation toxicity was observed. CONCLUSIONS: This treatment is safe, effective and fast for this condition

Therapeutic approach to Crohn disease: possible parallels with hidradenitis suppurativa. / Abordaje terapéutico de la enfermedad de Crohn: posibles paralelismos con la hidradenitis supurativa.

The current controversy in the setting of dermatology surrounding the treatment of inflammatory diseases, and specifically hidradenitis suppurativa, bears strong similarities with the debate concerning inflammatory bowel disease (IBD) that took place several years ago. That debate led to new perspectives on this disease and, in particular, its treatment after the development of biological agents.