Epidemiological, anatomoclinical, and therapeutic profile of obstetric fistula in the Democratic Republic of the Congo: About 1267 patients.

OBJECTIVE: Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC). METHODOLOGY: This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic. RESULTS: The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito-digestive fistulas. Urethro-vaginal (26.2%) and vesico-uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%). CONCLUSION: In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro-genital obstetric fistulas are the most frequent with predominance of urethro-vaginal and vesico-uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result.

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

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

Long-term Outcomes and Factors Predicting Outcome of IPAA When Used Intentionally for Well-Defined Crohn's Disease.

BACKGROUND: Crohn's disease is considered a contraindication for IPAA. In our prior study, when IPAA was used intentionally for well-defined Crohn's disease, we found a high incidence of recurrent disease with a low incidence of pouch failure. OBJECTIVE: This study aimed to replicate these findings in a larger cohort over a longer period. DESIGN: Retrospective review of a prospective IBD registry. SETTINGS: Large IBD referral center. PATIENTS: Patients with preoperative colorectal Crohn's disease requiring surgery were included in the study. INTERVENTION: IPAA. MAIN OUTCOME MEASURES: Long-term Crohn's disease recurrence, pouch failure, and pouch function. RESULTS: Forty-six patients were identified. Crohn's disease was diagnosed on the basis of perianal disease (n = 18; 39%), small-bowel disease (n = 16; 35%), noncaseating granuloma (n = 10; 22%), and discontinuous inflammation (colorectal skip lesions) (n = 11; 24%). After a median follow-up of 93 (7-291) months, 22 patients (48%) developed recurrent Crohn's disease based on afferent limb disease (n = 14; 30%) or pouch fistulizing disease (n = 8; 18%). Only 4 patients (9%) developed pouch failure. No clinical factor was associated with Crohn's disease recurrence. Young age at the time of surgery and short duration of disease before IPAA were associated with pouch fistula recurrence ( p = 0.003 and p = 0.03, respectively). Most patients (86%) reported excellent continence, with no urgency (67%) and median stool frequency of 6 (range, 3-9) per day. LIMITATION: Retrospective nature and relatively small sample size. CONCLUSION: This largest reported series examining the intentional use of IPAA in Crohn's disease showed a high (48%) incidence of postoperative Crohn's disease with a low (9%) incidence of pouch failure. Young age and short disease course before surgery were risk factors for poor outcomes. Highly motivated patients with colorectal Crohn's disease may consider IPAA and avoid a definitive ileostomy. See Video Abstract at http://links.lww.com/DCR/C171 . RESULTADOS A LARGO PLAZO Y FACTORES PREDICTORES DE RESULTADOS DE LA ANASTOMOSIS ILEOANAL CON RESERVORIO CUANDO SE USA INTENCIONALMENTE PARA LA ENFERMEDAD DE CROHN BIEN DEFINIDA: ANTECEDENTES: La enfermedad de Crohn (EC) se considera una contraindicación para la anastomosis ileoanal con reservorio (IPAA). Nuestro estudio previo de IPAA cuando fue usada intencionalmente para EC bien definida mostró una alta incidencia de enfermedad recurrente con una baja incidencia de falla del reservorio.OBJETIVO: Replicar estos hallazgos en una cohorte más grande durante un período más largo.DISEÑO: Revisión retrospectiva de una base de datos prospectiva de enfermedad inflamatoria intestinal.ESCENARIO: Un centro grande de referencia de EII.PACIENTES: EC colorrectal preoperatoria con necesidad de tratamiento quirúrgico.INTERVENCIÓN: Anastomosis ileoanal con reservorio.RESULTADOS PRINCIPALES: Recurrencia de EC a largo plazo, falla del reservorio y función del reservorio.RESULTADOS: Cuarenta y seis pacientes fueron identificados. El diagnóstico de EC se basó en enfermedad perianal (n = 18; 39%), enfermedad del intestino delgado (n = 16; 35%), granuloma no caseificante (n = 10; 22%) e inflamación discontinua (lesiones salteadas colorrectales) (n = 11; 24%). Después de una mediana de seguimiento de 93 (7-291) meses, 22 (48 %) pacientes desarrollaron EC recurrente debido a enfermedad del asa aferente (n = 14; 30%) o enfermedad fistulizante del reservorio (n = 8; 18%). Solo 4 (9%) pacientes desarrollaron falla del reservorio. Ningún factor clínico se asoció con la recurrencia de EC. La edad joven en el momento de la cirugía y la corta duración de la enfermedad antes de IPAA se asociaron con la recurrencia de la fístula del reservorio ( p = 0.003 y p = 0.03, respectivamente). El recuento de plaquetas preoperatorio más alto fue la única característica clínica significativamente asociada con el fracaso del reservorio ( p = 0.02). La mayoría de los pacientes (86%) reportaron una continencia excelente, sin urgencia (67%) y una mediana de frecuencia evacuatoria de 6 (rango, 3-9) por día.LIMITACIONES: Naturaleza retrospectiva y tamaño de muestra relativamente pequeño.CONCLUSIÓN: Esta serie, la más grande reportada que examina el uso intencional de IPAA en la EC mostró una incidencia alta (48Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy%) de EC posoperatoria con una incidencia baja (9%) de falla del reservorio. La edad joven y el curso corto de la enfermedad antes de la cirugía fueron factores de riesgo para pobres resultados. Pacientes altamente motivados con EC colorrectal pueden considerar una IPAA y evitar una ileostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/C171 . (Traducción-Dr. Jorge Silva Velazco ).

Facial canal dehiscence, dural exposure, and labyrinthine fistula in middle ear cholesteatoma and mastoiditis.

PURPOSE: To analyze the prevalence and associations of facial canal dehiscence (FCD), dural exposure, and labyrinthine fistula in chronic otitis media (COM) with and without cholesteatoma. METHODS: This was a retrospective study performed in an academic medical center. Patients who received tympanoplasty with mastoidectomy for COM with and without cholesteatoma were included. The prevalence of FCD, dural exposure, and labyrinthine fistula in COM with and without cholesteatoma (mastoiditis) and their relationships were analyzed. RESULTS: A total of 189 patients, including 107 (56.6%) females and 82 (43.4%) males, with 191 ears were included. There were 149 cases (78.0%) of cholesteatoma and 42 patients (22.0%) with mastoiditis. FCD was noted in 27.5% of patients with cholesteatoma and 9.5% of patients with mastoiditis. Dural exposure was found in 21 patients (14.1%) with cholesteatoma and 4 patients (9.5%) with mastoiditis. Eleven patients (7.4%) with cholesteatoma and 1 patient (2.4%) with mastoiditis had labyrinthine fistula. Patients with a labyrinthine fistula had nearly a fivefold greater chance (OR = 4.924, 95% CI = 1.355-17.896, p = 0.015) of having FCD than those without a fistula. There was a positive correlation between dural exposure and labyrinthine fistula (P = 0.011, Fisher's exact test). CONCLUSION: FCD, dural exposure, and labyrinthine fistula are common complications in COM. These complications are more frequently observed in patients with cholesteatoma than in patients with mastoiditis. Surgeons should pay more attention to the treatment of COM.

Gastrointestinal/genitourinary perforation and fistula formation with or without bevacizumab in patients with previously irradiated recurrent cervical cancer: a Korean multicenter retrospective study of the Gynecologic Oncology Research Investigators Collaboration (GORILLA) group (GORILLA-1001).

BACKGROUND: This study aims to evaluate the incidence of and identify risk factors for gastrointestinal (GI) and genitourinary (GU) fistula or perforation formation with or without bevacizumab in patients with recurrent cervical cancer who underwent pelvic radiation therapy (RT). METHODS: Medical records of patients with recurrent cervical cancer who previously underwent pelvic RT between 2007 and 2020 were retrospectively reviewed. Clinicopathological factors were compared between groups that are stratified according to: 1) fistula/perforation (+) versus (-); and 2) bevacizumab plus conventional chemotherapy (BC) versus chemotherapy alone (C). Univariate and multivariate regression analyses were performed to identify risk factors for fistula/perforation. Overall survival (OS) was compared between the different groups. RESULTS: Of 219 participants, fistula/perforation of any grade occurred in 36 patients (16.4%); 27 fistulas and 9 perforations. Bevacizumab was more frequently used in Bevacizumab was more frequently used ( +) group than fistula/perforation (-) group (p = 0.015). Multivariate analysis showed that bevacizumab administration was the only independent risk factor for fistula or perforation (HR, 3.27; 95% CI, 1.18-9.10; P = 0.023). F/P was observed more frequently in women receiving BC (n = 144) than those receiving C (n = 75) (20.8% vs. 8.0%; P = 0.019). During median follow-up of 33.7 months (1.2-185.6 months), no significant OS difference was observed between fistula/perforation ( +) vs. (-) (hazards ratio [HR], 1.78; median 84.2 months [95% CI, 59.3-109.0] vs. 129.5 months [95% CI, 114.1-144.9]; P = 0.065) or BC vs. C (HR, 1.03; median 119.8 months [95% CI, 97.3-142.3] vs. 115.7 months [95% CI, 96.0-135.4]; P = 0.928). CONCLUSIONS: This study suggests that incorporation of bevacizumab in chemotherapy regimens for treating recurrent cervical cancer in patients who underwent pelvic RT incurs considerable risk for GI/GU fistula or perforation. There were no other independent risk factors for developing GI/GU fistula or perforation in this study population.

Mesenteric Excision and Exclusion for Ileocolic Crohn's Disease: Feasibility and Safety of an Innovative, Combined Surgical Approach With Extended Mesenteric Excision and Kono-S Anastomosis.

INTRODUCTION: Ileocolic resection for Crohn's disease traditionally does not include a high ligation of the ileocolic pedicle, and most commonly is performed with a stapled side-to-side ileocolic anastomosis. The mesentery has recently been implicated in the pathophysiology of Crohn's disease. Two techniques have been developed and are associated with reduced postoperative recurrence: the Kono-S anastomosis that excludes diseased mesentery and extended mesenteric excision that resects diseased mesentery. We aimed to assess the technical feasibility and safety of a novel combination of techniques: mesenteric excision and exclusion. TECHNIQUES: This initial report is a single-center descriptive study of consecutive adults who underwent mesenteric excision and exclusion for primary or recurrent ileocolic Crohn's disease from September 2020 to June 2021. Medication exposure and endoscopic balloon dilation before surgery were recorded. Phenotype was classified using the Montreal Classification. Thirty-day outcomes were reported. A video of the mesenteric excision and exclusion including the Kono-S anastomosis is presented. RESULTS: Twenty-two patients with ileocolic Crohn's disease underwent mesenteric excision and exclusion: 100% had strictures, 59% had fistulas, 81% were on biologics, and 27% had previous ileocolic resection(s). Seventy-two percent underwent laparoscopic procedures, a mesenteric defect was closed in 86%, omental flaps were fashioned in 77%, and 3 patients were diverted. Median operative time was 175 minutes. Median postoperative stay was 4 days. At 30 days, there were 2 readmissions for reintervention: 1 seton placement and 1 percutaneous drainage of a sterile collection. There were no cases of intra-abdominal sepsis or anastomotic leak. CONCLUSIONS: Mesenteric excision and exclusion represents an innovative, progressive, and promising approach that appears to be highly feasible and safe. Further study is warranted to determine if mesenteric excision and exclusion is associated with reduced postoperative recurrence of ileocolic Crohn's disease.

Knowledge of obstetric fistula and its associated factors among women of reproductive age in Northwestern Ethiopia: a community-based cross-sectional study.

BACKGROUND: Obstetric fistula has been a major maternal health challenges in low and middle-income countries, especially in Ethiopia, due to high child marriage and poor access to healthcare. Obstetric fistula is common among teenage mothers that results in a vast social, economic and cultural sequel. In Ethiopia, there is a paucity of research evidence on women's knowledge about obstetric fistula. Therefore, this study aimed to assess women's knowledge about obstetric fistula and its associated factors at Banja District, Northwestern Ethiopia. METHODS: A community-based cross-sectional study design was conducted from 1st -21th July 2021. Systematic sampling method was used to recruit 784 women in the reproductive age from six rural and one urban sub-districts. Two days of training was given to research assistants regarding the objective of the study, inclusion and exclusion criteria, checking completeness and ways of protecting confidentiality. Data were collected using face-to-face interview method. Collected data were entered into EpiData and exported into SPSS version 24 for cleaning and analysis. Descriptive statistics, binary and multivariable logistic regression analysis were performed to identify associated factors. Adjusted odds ratio (AOR) at 95% CI with p < 0.05 was used to declare significant association with women's knowledge of obstetric fistula. RESULTS: A total of 773 women gave a complete response with response rate of 98.6% (773/784). One-third (36.4%; 95%CI: 32.9-39.7%) had good knowledge about obstetric fistula. Women who had completed primary education (AOR:3.47, 95%CI:2.01-5.98), secondary and above (AOR:3.30, 95%CI:1.88-5.80), being a student (AOR: 6.78, 95%CI:3.88-11.86), get counseling about obstetric fistula (AOR:6.22, 95%CI: 3.78-10.24), participated in pregnant women's discussion forum (AOR:3.36, 95%CI: 1.99-5.66), had antenatal care follow-up (AOR: 2.40, 95% CI: 1.39-4.13), being an urban resident (AOR: 3.19, 95% CI: 1.33-7.66), and having access to Television/Radio (AOR:1.68, 95%CI:1.10-2.60) were significantly associated with women's good knowledge about obstetric fistula. CONCLUSION: Women's knowledge about obstetric fistula is unacceptably low. Therefore, concerned stakeholders should enhance awareness creation programs, strengthen antenatal care, counselling and women's discussion forum that could substantially optimize women's knowledge about obstetric fistula and its risk factors of obstetric fistula.

Incidence of fistula occurrence in patients with cervical cancer treated with bevacizumab: data from real-world clinical practice.

BACKGROUND: This study aimed to determine the incidence of pelvic fistulas in cervical cancer patients treated with bevacizumab in Japanese clinical practice. METHODS: A post-marketing surveillance (PMS) study was conducted between June 2016 and February 2018 to survey physicians who treated advanced or recurrent cervical cancer patients with bevacizumab (according to the product label). The clinical/treatment status of patients with pelvic fistulas was assessed in an additional retrospective case series study. RESULTS: 142 patients were included in the PMS study (median age 51 years; 66.9% squamous cell carcinoma; 66.2% recurrent cervical cancer; 64.1% previous radiotherapy). Patients received a median of seven bevacizumab doses. Six patients, all of whom had a history of pelvic irradiation, developed seven fistulas (4.2%; 95% confidence interval, 1.56-8.96), and five patients had also undergone pelvic surgery. The case series study of the patients who developed fistulas indicated that three patients had high cumulative bladder and rectal doses of radiation, and two of them had undergone salvage re-irradiation for pelvic recurrence. The other three patients underwent both radical hysterectomy and adjuvant radiotherapy, but did not receive an excessive radiation dose to the bladder or rectum. CONCLUSIONS: This study found that the upper limit of the 95% confidence interval for pelvic fistula incidence did not exceed the incidence reported in the GOG 240 study. To ensure an adequate benefit-risk assessment of bevacizumab in cervical cancer patients, a comprehensive evaluation of prior treatment is essential and the possibility of unexpected fistulas, even after careful evaluation, should be considered.

Prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia: a multilevel fixed effects analysis.

BACKGROUND: An obstetric fistula is an inappropriate connection between the vagina, rectum, or bladder that results in faecal or urine incontinence. Young women from rural areas with poor socioeconomic situations and education are the majority of victims, which restricts their access to high-quality healthcare. Obstetric fistulas can have devastating effects on the physical health of affected women if they are not promptly treated. Inadequate awareness of the symptoms delays recognition of the problem, prompt reporting, and treatment. Women with poor awareness of the disorder are also more likely to develop complications, including mental health issues. Using data from a nationally representative survey, this study investigated the prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia. METHODS: This study used population-based cross-sectional data from the 2019-2020 Gambia Demographic and Health survey. A total of 11823 reproductive-aged women were sampled for this study. Stata software version 16.0 was used for all statistical analyses. Obstetric fistula awareness was the outcome variable. Multilevel logistic regression models were fitted, and the results were presented as adjusted odds ratios (aOR) with statistical significance set at p < 0.05. RESULTS: The prevalence of obstetric fistula awareness was 12.81% (95%CI: 11.69, 14.12). Women aged 45-49 years (aOR = 2.17, 95%CI [1.54, 3.06]), married women (aOR = 1.39, 95%CI [1.04, 1.87]), those with higher education (aOR = 2.80, 95%CI [2.08, 3.79]), and women who worked as professionals or occupied managerial positions (aOR = 2.32, 95%CI [1.74, 3.10]) had higher odds of obstetric fistula awareness. Women who had ever terminated pregnancy (aOR = 1.224, 95%CI [1.06, 1.42]), those who listened to radio at least once a week (aOR = 1.20, 95%CI [1.02, 1.41]), ownership of a mobile phone (aOR = 1.20, 95%CI [1.01, 1.42]) and those who were within the richest wealth index (aOR = 1.39, 95%CI [1.03, 1.86]) had higher odds of obstetric fistula awareness. CONCLUSION: Our findings have revealed inadequate awareness of obstetric fistula among women of reproductive-age in The Gambia. Obstetric fistulas can be mitigated by implementing well-planned public awareness initiatives at the institutional and community levels. We, therefore, recommend reproductive health education on obstetric fistula beyond the hospital setting to raise reproductive-age women's awareness.

CTA analysis of 482 cases of coronary artery fistula: A large-scale imaging study.

OBJECTIVE: The prevalence of coronary artery fistula (CAF) based on coronary angiography has been reported. However, with the popularity of coronary computerized tomography angiography (CTA), CAFs have been found more and more by chance. The purpose of this study was to determine the prevalence and types of CAFs detected by coronary CTA, and to explore the differences in the size of fistulas, the number of complicated aneurysms, and fistulas among different types. MATERIALS AND METHODS: From January 2016 to December 2020, 96,037 patients underwent coronary CTA in our hospital. The prevalence of CAF was retrospectively evaluated, The origin, course, and drainage site of CAF and coexisting abnormalities were analysed. The conventional treatments and follow-up DSCT images were also evaluated. Analyze the difference between the coronary-pulmonary artery fistula (CPAFs) group (380) and the coronary-cameral fistula (CCF) group (99). RESULTS: Among 96,037 patients, 482 (0.5%) patients (male 232 and 250 female) had CAF. The types of CAF detected. The pulmonary artery was the most common site of drainage (380/482, 78.8%). Of the 99 CCFs, coronary to the left ventricle is the most common pattern in CCF (34/482, 7.0%). Single origins are more common in CAF (n = 361, 74.9%), multiple origins are more common in CPAFs than in CCF. There were statistically significant differences in the stoma diameter (2.4 ± 1.1 mm vs. 5.4 ± 4.3 mm p < .05), aneurysm complicated (85 cases [85/380] vs. 50 cases [50/99]), the size of aneurysm (8.8 ± 5.7 mm vs. 19.1 ± 11.6 mm, p < .05), and single fistula (261 [261/380] vs. 96 [96/99], p < .05). Most of the 380 CPAFs patients received conservative treatment (350/380, 92.1%), While the 59 CCF patients (59/93, 63.4%) were treated. CONCLUSIONS: Different from previous reports, the prevalence of CAF in coronary CTA is 0.5%, the incidence of CPAFs is the highest, and the incidence of the left ventricular fistula is higher in CCF. Compared with CPAFs, CCF fistulas were more likely to be associated with a larger diameter of draining, larger aneurysms, single fistula pattern. Coronary artery CTA is a useful and noninvasive imaging method to detect CAF, which is of great significance for the detection of small fistulas and the surgical guidance of complex CAF.

Management and prevention of brachial plexus injury caused by surgical suture of neck dissection induced chylous fistula.

BACKGROUND: The complication of brachial plexus injury (BPI) after surgical suture of chylous fistula caused by neck dissection is extremely rare. For the first time, we investigated the treatment and prevention strategy of BPI caused by surgical suture of neck dissection induced chylous fistula. METHODS: Forty-two patients undergoing surgical suture of neck dissection induced chylous fistula were identified between January 2015 to March 2022 at a single tertiary academic center. All patients were divided into two groups, medial anterior scalene muscle (MASM) group (24 patients) and lateral anterior scalene muscle (LASM) group (18 patients), according to the location of fistula regarding scalene muscle described in the surgical records. The incidence of BPI between the two groups after surgical suture was summarized and compared. RESULTS: There was significant difference in the incidence of different degrees of BPI between the two groups. In the MASM group, the incidence of BPI was 0 % (0/24), while in the LASM group, 6 cases suffered different degrees of BPI immediately after operation and the incidence of BPI was 33.3 % (6/18) (p < 0.05). The neurological function of all BPI cases recovered within 1-3 months after the suture was removed in time. CONCLUSION: The incidence of BPI in patients of LASM group was significantly higher than that of MASM group. When suturing this kind of fistula, the depth of the needle should be properly controlled to avoid BPI. In case of BPI, the suture should be removed as soon as possible to promote the recovery of neurological function.

Long-Term Follow-up of Unilateral Cleft lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation.

OBJECTIVE: The ideal surgical protocol and technique for primary closure of unilateral cleft lip and palate (UCLP) are unclear, and the development of velopharyngeal insufficiency and fistulae following primary repair is common. This study aimed to determine the long-term surgical burden of care in terms of secondary surgeries, defined as speech-correcting surgeries (SCSs) and fistula repair, in a UCLP population, and to compare outcomes of various surgical protocols. DESIGN: Retrospective, single-center review. PARTICIPANTS: The study comprised 290 nonsyndromic children with complete UCLP. Different surgical protocols entailing both single-stage and 2-stage approaches were compared, and the surgical outcome was analyzed at the time of alveolar bone grafting (ABG) and post ABG. RESULTS: Altogether 110 children (37.9%) underwent secondary surgery by the time of ABG. Of the total population 25.9% (n = 75) had undergone SCS and 17.2% (n = 50) had undergone fistula repair. The respective incidences at follow-up (post ABG) were 30.3% (n = 88) and 18.9% (n = 55). Median age at ABG was 9.8 years and at follow-up was 16.3 years. No significant difference emerged in terms of secondary surgeries between the techniques and protocols applied at primary repair. However, some differences occurred regarding the location of fistulae; the single-stage procedure had more anterior fistula repairs, particularly connected to a perialveolar fistula. CONCLUSIONS: Although the outcome differences between the surgical protocols were small, indicating that none of the treatment protocols was clearly superior to another, attention was drawn to the favorable outcomes of the single-stage protocol.

A cover flap reduces the rate of fistula after urethroplasty whatever the severity of hypospadias.

OBJECTIVE: To determine which patients should benefit from the interposition of a well-vascularized flap between the neourethra and the penile skin and if it should be performed even in mild hypospadias. PATIENTS AND METHODS: A retrospective study on patients with a primary hypospadias repair was performed (2003-2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. Univariate analysis and adjusted logistic regression were used to evaluate the relation between postoperative complications, the severity of hypospadias, the use of flap and patients' characteristics. RESULTS: Three-hundred and seventy-six patients were included with anterior (59.3%), midshaft (27.4%) and posterior hypospadias (13.3%). The median follow-up was 54 months (24 months-17 years). The overall rate of fistula was 11.7% (n = 44). Comparing the outcome in children with flap (n = 217) to controls (n = 159) showed that the use of a flap reduces the rate of fistula (6.5 vs 18.9%, p < 0.001). Stratification of the study according to the phenotype reveals that the more severe the hypospadias, the more protective was the flap (OR = 2.6 for anterior, 5.5 for midpenile, 7.1 for posterior hypospadias). The flap remains nevertheless significantly effective whatever the phenotype (p < 0.05 for anterior, p = 0.01 for midpenile, p = 0.02 for posterior hypospadias). CONCLUSIONS: The more severe the hypospadias, the more effective is the cover flap to avoid fistula. It remains nevertheless suitable even in anterior hypospadias and the use of a cover flap should not be limited to the surgery of severe phenotypes.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review.

BACKGROUND: Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure. OBJECTIVE: This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease. DATA SOURCES: A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews. STUDY SELECTION: The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected. INTERVENTION: Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology. MAIN OUTCOMES MEASURES: The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate. RESULTS: Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified. LIMITATIONS: This investigation was limited by the small number of studies with significant study heterogeneity. CONCLUSION: In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Meta-analysis on the rate of pharyngocutaneous fistula in early oral feeding in laryngectomy patients.

BACKGROUND: Laryngectomy remains a common operation in head and neck units. The operation holds significant risk of post-operative morbidity including swallowing dysfunction. The most significant post-operative concern is the formation of a pharyngocutaneous fistula [PCF], the reported incidence of which is between 3% and 65%. The purpose of this systematic review and meta-analysis was to assess the safety of initiating early oral feeding following laryngectomy and the risk of PCF formation. METHODS: A literature search was conducted through online databases: MEDLINE, EMBASE and PubMed. Eligible studies were included which contained cohorts of patients who had undergone laryngectomy, with early oral feeding commencing within seven days compared to late oral feeding. The primary outcome assessed was the incidence of PCF. Studies were excluded if cohorts had not included laryngectomy or if no comment was made on PCF formation. Meta-analysis was used to examine associations between oral feeding and PCF formation using Fixed Effect models. RESULTS: Twelve studies and 1883 patients were included after systematic review. Six studies were non-interventional whereas the remaining were randomized clinical trials. Exposure included those with early oral feeding (before seven days) or late feeding oral feeding (after seven days) and the outcome assessed was the risk of PCF formation. Results from observational studies showed a higher risk of PCF formation for early feeders compared to late feeders [RR = 1.56, 95% CI: 1.15, 2.11]. Higher risk was also observed for RCT but was not significant [RR = 1.40, 95% CI: 0.85, 2.30]. Overall, there was a 50% greater risk of PCF formation for early oral feeding compared to late oral feeding [RR = 1.51, 95% CI: 1.17, 1.96]. CONCLUSION: While early oral feeding can reduce post-laryngectomy patients' hospital stay and improve psychological wellbeing, there is a significant relative risk of PCF development within this group. However, this must be taken in context of the significant heterogeneity that exists within the literature.

Complications following secondary voice prosthesis insertion and impact of previous irradiation on their appearance.

OBJECTIVE: The aim of this study was to analyze the complications following secondary voice prosthesis insertion and impact of previous irradiation on their appearance. METHODS: This study included 106 totally laryngectomized patients who underwent secondary Provox 2 voice prosthesis insertion. Among them, 79 (74.5%) were irradiated. Surgery, prosthesis, fistula, and voice-related complications were analyzed and presented. RESULTS: Complications occurred in 23 (22%) patients. Fifteen of them were previously irradiated. There were no surgery-related complications. In the group of prosthesis-related complications, one patient had increased negative pressure during swallowing with extremely short prosthesis life time. There were 17 complications in the group of fistula related ones; 3 patients had excessive granulation tissue around the fistula and 14 patients experienced prosthesis displacement (7 had closed esophageal end of the fistula, 5 had the prosthesis turned sideways in an open fistula, one patient inhaled and one ingested the prosthesis). Tracheoesophageal voice was not established in 5 patients. Previous irradiation had no statistically significant influence on the complication rate (P = 0,251). CONCLUSIONS: The majority of complications following secondary voice prosthesis insertion are fistula-related ones, among which, displacement of the voice prosthesis is the most common. Previous irradiation does not significantly increase the risk of developing complications.

Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time?

BACKGROUND: Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points. OBJECTIVE: The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss. DESIGN: This was a retrospective study from an institutional database. SETTINGS: The study was conducted at the Cleveland Clinic Foundation. PATIENTS: Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included. MAIN OUTCOME MEASURES: Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years. RESULTS: A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula. LIMITATIONS: This was a retrospective, single-institution study. CONCLUSIONS: Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).

Transabdominal Pouch Salvage for Failed Minimally Invasive Versus Open IPAA: A Case-Matched Study.

BACKGROUND: Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo IPAA outcomes. OBJECTIVE: This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA. DESIGN: This was a retrospective cohort study. SETTINGS: This investigation was based on a single-surgeon experience on redo IPAA. PATIENTS: Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included. MAIN OUTCOME MEASURES: Short-term complications and long-term outcomes were compared between 2 groups. RESULTS: A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable. LIMITATIONS: This study was limited by its retrospective, nonrandomized nature and relatively low patient number. CONCLUSIONS: A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMÓTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creación de modalidades e índices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados después de rehacer la cirugía de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningún estudio que evalúe los efectos de la modalidad de creación de índices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugía transabdominal redo RIA en casos de fracaso por via mínimamente invasiva (MI-RIA) o por la vía abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigación basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operación transabdominal y re-confección de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con índice fallido de MI-RIA fueron emparejados con 42 homólogos con índice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fué más corto en pacientes que tenían MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un muñón rectal largo (> 2 cm) fue más común después de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron más comúnmente con engrampadoras en el grupo Minimalmente Invasivo en comparación con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparición de abscesos (7% frente a 24%, p = 0.035) fue más frecuente en pacientes que tenían RIA con técnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, también fué comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el número relativamente bajo de pacientes.Un muñon rectal largo después de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad técnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA están asociadas con un mayor riesgo de formación de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.

Redo IPAA After a Failed Pouch In Patients With Crohn's Disease: Is It Worth Trying?

BACKGROUND: In selected patients with ulcerative colitis and pelvic pouch failure, redo pouch is an option. However, it is unknown whether selected patients with Crohn's disease should be offered a chance to avoid permanent diversion after failure of IPAA. OBJECTIVE: The objective was to compare the outcomes of redo pouch for ulcerative colitis and Crohn's disease. DESIGN: This was a retrospective analysis of a prospectively maintained pouch database (1983-2017). SETTINGS: The setting was the Cleveland Clinic. PATIENTS: This study included patients who underwent redo pouch with a primary surgical specimen diagnosis of ulcerative or Crohn's colitis at the time of initial pouch. MAIN OUTCOME MEASURES: Pouch failure was defined as either pouch excision or indefinite pouch diversion. Patient characteristics, perioperative and functional outcomes, pouch survival, and quality of life were compared according to the diagnosis. RESULTS: Of 422 patients, 392 had ulcerative colitis and 30 had Crohn's disease. Age and sex were comparable. The most common indications for redo pouch included anastomotic separation and fistulas (220 (56.1%) in ulcerative colitis and 21 (70%) in Crohn's disease). The majority of redo pouches required mucosectomy with handsewn anastomosis (310 (79%) in ulcerative colitis and 30 (100%) in Crohn's disease; p = 0.23). A new pouch was constructed in 160 patients (41%) with ulcerative colitis and repair of old pouch in 231 patients (59%) compared with 25 (83%) in Crohn's disease, who had creation of new pouch; only in 5 (17%) was the old pouch re-anastomosed. Stool frequency, seepage, and fecal urgency were comparable between groups. Cumulative 5-year pouch survival was longer in ulcerative colitis versus Crohn's disease (88% vs 55%; p = 0.008). Major causes of redo failure in Crohn's disease were pouch fistulas and/or strictures occurring after ileostomy closure. These were more common in Crohn's disease than in ulcerative colitis (p < 0.001). LIMITATIONS: This was a retrospective design. CONCLUSIONS: Redo pouch can be offered to selected patients with colonic Crohn's disease diagnosed at the time of their primary pouch. See Video Abstract at http://links.lww.com/DCR/B206. REHACER LA ANASTOMOSIS ILEOANAL CON RESERVORIO DESPUéS DE UN RESERVORIO ILEAL FALLIDO EN PACIENTES CON ENFERMEDAD DE CROHN: ¿VALE LA PENA INTENTARLO?: En pacientes seleccionados con colitis ulcerativa y falla del reservorio pélvico, rehacer el reservorio es una opción. Sin embargo, se desconoce si en los pacientes seleccionados con enfermedad de Crohn se debería ofrecer la oportunidad de evitar la derivación permanente después de la falla de la anastomosis ileoanal con reservorio ileal.El objetivo fue comparar los resultados de reservorios re-hechos en colitis ulcerosa y la enfermedad de Crohn.El escenario fue la Cleveland Clinic.Análisis retrospectivo de una base de datos de reservorios ileales mantenida prospectivamente (1983-2017).Este estudio incluyó a pacientes que se sometieron a cirugía para rehacer el reservorio ileal con un diagnóstico en el espécimen quirúrgico primario de colitis ulcerosa o de Crohn en el momento del reservorio inicial.La falla del reservorio se definió como la escisión del reservorio o la derivación indefinida del reservorio. Las características del paciente, los resultados perioperatorios y funcionales, la supervivencia del reservorio y la calidad de vida se compararon de acuerdo con el diagnóstico.De 422 pacientes, 392 tenían colitis ulcerativa y 30 tenían enfermedad de Crohn. La edad y el género fueron comparables. Las indicaciones más comunes para rehacer el reservorio incluyeron dehiscencia anastomótica y fístulas [220 (56,1%) en colitis ulcerosa y 21 (70%) en la enfermedad de Crohn]. La mayoría de los reservorios rehechos requirieron mucosectomía con anastomosis manual [310 (79%) en colitis ulcerosa y 30 (100%) en la enfermedad de Crohn, p = 0.23]. Se construyó un nuevo reservorio en 160 (41%) pacientes con colitis ulcerativa y se reparó el reservorio antiguo en 231 (59%) pacientes, en comparación con 25 (83%) en la enfermedad de Crohn, que requirieron creación de un nuevo reservorio, y solo 5 (17%) donde el reservorio antiguo se volvió a anastomosar. La frecuencia de las evacuaciones, el manchado fecal y la urgencia fecal fueron comparables entre grupos. La supervivencia acumulada del reservorio a 5 años fue mayor en la colitis ulcerativa frente a la enfermedad de Crohn (88% frente a 55%, p = 0.008). Las principales causas de falla del reservorio rehecho en la enfermedad de Crohn fueron las fístulas del reservorio y / o las estenosis que ocurrieron después del cierre de ileostomía. Estas fueron más comunes en la enfermedad de Crohn que en la colitis ulcerativa (p <0.001).Este fue un diseño retrospectivo.Rehacer el reservorio ileal se puede ofrecer a pacientes seleccionados con enfermedad de Crohn colónica diagnosticada en el momento de su reservorio primario. Consulte Video Resumen en http://links.lww.com/DCR/B206. (Traducción-Dr Jorge Silva Velazco).

Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India.

BACKGROUND: The study was conducted to estimate the prevalence and risk factors of obstetric fistula in the rural area of the south eastern community of India and the training of community health workers for its prevention. METHODS: A population-based cross-sectional analytical study was conducted in the south eastern rural community of India. A total of 3939 women were included in the study and Probability proportional to size sampling was used in the study. Frequency distribution and logistic regression were computed to analyse the data using STATA version 11.2. RESULTS: Out of 3939 participants interviewed, 23.7% women reported obstetric fistula symptoms whereas after clinical diagnosis and speculum examination the obstetric morbidity pattern was: Obstetric fistula 0.3%, stress urinary incontinence 20.0%, pelvic inflammatory diseases 1.2%, uterine prolapse 1.4% and urinary tract infection 3.8%. The awareness level of the rural women regarding the obstetric fistula was assessed by a structured knowledge questionnaire and found to be very poor, hence community based fistula training was implemented among community health workers as a health system based strategy for its prevention. Obstetric fistula found to be more prevalent among women of poor educational level, low socioeconomic status, less no of antenatal visits, delay in accessing the emergency obstetric care and prolonged labour (p ≤ 0.05). CONCLUSION: Finding of the study indicated that the prevalence and risk of developing obstetric fistula was associated with less number of antenatal visits, prolonged labour, delay in timely intervention, delay in accessing emergency obstetric care and more number of movements from home to the delivery place. Finally, our study suggests that emphasis needs to be placed on training of community health workers to facilitate early screening for identification and referral of women with obstetric fistula.