Comparison of a Fistulectomy and a Fistulotomy with Marsupialization in the Management of a Simple Anal Fistula: A Randomized, Controlled Pilot Trial

PURPOSE: This randomized clinical trial was conducted to compare a fistulectomy and a fistulotomy with marsupialization in the management of a simple anal fistula. METHODS: Forty patients with simple anal fistula were randomized into two groups. Fistulous tracts were managed by using a fistulectomy (group A) while a fistulotomy with marsupialization was performed in group B. The primary outcome measure was wound healing time while secondary outcome measures were operating time, postoperative wound size, postoperative pain, wound infection, anal incontinence, recurrence and patient satisfaction. RESULTS: Postoperative wounds in group B healed earlier in comparison to group A wounds (4.85 +/- 1.39 weeks vs. 6.75 +/- 1.83 weeks, P = 0.035). No significant differences existed between the operating times (28.00 +/- 6.35 minutes vs. 28.20 +/- 6.57 minutes, P = 0.925) and visual analogue scale scores for postoperative pain on the first postoperative day (4.05 +/- 1.47 vs. 4.50 +/- 1.32, P = 0.221) for the two groups. Postoperative wounds were larger in group A than in group B (2.07 +/- 0.1.90 cm2 vs. 1.23 +/- 0.87 cm2), however this difference did not reach statistical significance (P = 0.192). Wound discharge was observed for a significantly longer duration in group A than in group B (4.10 +/- 1.91 weeks vs. 2.75 +/- 1.71 weeks, P = 0.035). There were no differences in social and sexual activities after surgery between the patients of the two groups. No patient developed anal incontinence or recurrence during the follow-up period of twelve weeks. CONCLUSION: In comparison to a fistulectomy, a fistulotomy with marsupialization results in faster healing and a shorter duration of wound discharge without increasing the operating time.

Simultaneous Non-Traumatic Perforation of the Right Hepatic Duct and Gallbladder: An Atypical Occurrence

Simultaneous non-traumatic perforation of the extrahepatic bile duct and the gallbladder is an uncommon occurrence that has been infrequently reported. We describe a patient with a spontaneous perforation of both the extrahepatic bile duct and the gallbladder. A contrast-enhanced computed tomography (CECT) scan of the abdomen and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a perforation of the gallbladder and a free leak from the right hepatic duct, respectively. Endoscopic biliary drainage following a sphincterotomy and biliary stent placement led to a dramatic improvement in the patient’s general condition. He was subsequently scheduled to undergo an elective cholecystectomy. Repeat ERCP performed at 4 weeks after the initial stenting showed a normal cholangiogram and a distally migrated stent, which was there after removed. However, early stent removal led to re-perforation of hepatic duct and gallbladder. A repeat endoscopic biliary drainage did not help, and the patient developed biliary peritonitis. Surgical exploration revealed a perforation at the fundus of the gallbladder, 400 ml of biliopurulent collection and a frozen Calot’s triangle. A subtotal cholecystectomy, gall stone removal, and a thorough peritoneal lavage were undertaken. The patient improved postoperatively. The second biliary stent was removed after 4 months. This case report highlights the role of endoscopic biliary drainage in the management of an extrahepatic bile duct perforation and warns against the early removal of a biliary stent.

Fat poor angiomyolipoma with lymphadenopathy: diagnostic dilemma

A 24-year-old lady presented with left flank pain of 3 months duration. She had stigmata of tuberous sclerosis complex in the form of angiofibromas on face, ash-leaf macules on back and right upper limb and shagreen patches over back. Computed tomography scan of the abdomen showed 6.5 cm x 5.0 cm x 4.4 cm lobulated intensely enhancing exophytic mass lesion in mid pole of left kidney with significant para-aortic lymphadenopathy with no evidence of fat in the mass. She underwent radical left nephrectomy with a provisional diagnosis of renal cell carcinoma. Histopathological examination showed multicenteric angiomyolipoma involving kidney and para-aortic lymph nodes. This case report underscores the need for further research to differentiate fat-poor angiomyolipoma and lymphadenopathy from renal cell carcinoma

Five patients with emphysematous pyelonephritis

Emphysematous pyelonephritis is an acute necrotizing infection of the renal parenchyma, resulting in presence of gas within either in the collecting system or perinephric space. We herein report our experience with 5 cases of emphysematous pyelonephritis in 2 men and 3 women managed by broad spectrum antibiotics, supportive measures including hemodialysis [2 patients], ureteral stenting [2 patients], surgical drainage of perinephric collection [1 patient], and control of diabetes mellitus [4 patients]. Four patients were discharged after a mean hospital stay of 18 days. A nondiabetic male patient with a nonobstructed kidney died on the second postoperative day due to persistent septicemia despite nephrectomy. Emphysematous pyelonephritis is a potentially fatal disease requiring careful and prompt diagnosis, and individualized rational therapy. Ureteropelvic stenting should be used for drainage of pent-up collections as a lifesaving measure through relieving the obstruction. Perinephric fluid collection should be drained either percutaneously or surgically