Fístula pleurocutánea secundaria a empiema

RESUMEN Introducción: La fístula pleurocutánea es una rara entidad que aparece como complicación de traumatismos torácicos, de la cirugía pleuro pulmonar o procesos infecciosos que afectan el espacio pleural tales como el empiema. Objetivo: Describir hallazgos clínico imagenológicos de un paciente con fístula pleurocutánea secundaria a empiema. Caso clínico: Paciente masculino de 56 años de edad, blanco, de procedencia rural, fumador inveterado y consumidor habitual de bebidas alcohólicas, con antecedentes patológicos personales de neumonías extrahospitalarias que requirieron hospitalización por aparición de complicaciones pleurales. Acudió al servicio de medicina interna del Hospital "Vladimir Ilich Lenin" porque desde hacía dos meses notó un agujero debajo de la axila derecha, por el cual drenaba líquido fétido. Los estudios imagenológicos realizados incluyeron fistulografía y tomografía axial computarizada. El diagnóstico clínico imagenológico fue fístula pleurocutánea. El paciente ingresó en el servicio de Medicina para cumplir tratamiento antimicrobiano; se le realizaron procederes intervencionistas diagnósticos y terapéuticos; evolucionó con complicaciones y falleció. La fístula pleurocutánea es una complicación de difícil manejo para el médico de asistencia, pues no siempre suelen resolver con los métodos tradicionales de tratamiento y requiere períodos prolongados de curación. Conclusiones: La fístula pleurocutánea es infrecuente y de difícil manejo. El diagnóstico de certeza se realiza a través de la fistulografía.

ABSTRACT Introduction: Pleurocutaneous fistula is a rare entity that appears as a complication of thoracic trauma, pleuro-pulmonary surgery or infectious processes that affect the pleural space such as empyema. Objective: To describe clinical imaging findings of a patient with pleurocutaneous fistula secondary to empyema. Clinical case: 56-year-old white male patient of rural origin, inveterate smoker and habitual consumer of alcoholic beverages, with a personal pathological history of community-acquired pneumonia that required hospitalization due to the onset of pleural complications. He went to the internal medicine service of the "Vladimir Ilyich Lenin" Hospital because for two months he had noticed a hole under his right armpit, through which he was draining foul-smelling fluid. The imaging studies included fistulography and computerized axial tomography. The clinical imaging diagnosis was pleurocutaneous fistula. The patient was admitted to the Medicine service for antimicrobial treatment; diagnostic and therapeutic interventionist procedures were performed; he evolved with complications and passed away. Pleurocutaneous fistula is a complication difficult to manage for the attending physician, as it does not always usually resolve with traditional methods of treatment and requires prolonged healing periods. Conclusions: Pleurocutaneous fistula is rare and difficult to manage. The certainty diagnosis is made through fistulography.

Magnetic resonance imaging of perianal fistulas in clinically symptomatic patients and the correlation among plain, contrast, and post jelly MRI fistulography

Abstract Objectives To evaluate different types of perianal fistulas and their complications on magnetic resonance imaging (MRI) and to compare plain, contrast, and jelly magnetic resonance fistulography findings. Materials and Methods This prospective study was performed in 30 patients who presented with perianal pus discharge or external fistulous opening. Magnetic resonance imaging of the perianal region before and after giving intravenous contrast and after injecting jelly through a percutaneous opening was performed on a 3T scanner and the results were correlated. Results The mean age of the patients was 40.13±13.88 years (range 19-75 years). The male to female ratio was 14:1. The most common type of fistula was St. James classification type I, which was seen in 13 patients (43%), followed by type IV in 30%, type III in 16%, type II in 6.66%, and type V in 3.33% of the patients. Using agreement analysis, we compared the number of primary and secondary tracts, internal openings, and horseshoe tracts and found a significant agreement between plain and post Jelly MRI fistulography (kappa statistic close to 1).When comparing plain and contrast MRI, there was significant agreement in the primary and secondary tracts, while statistically insignificant results were obtained (p>0.05) for the horseshoe tract and internal openings. Contrast injection was helpful in 7 subjects (23.3%) as peripheral enhancement of abscesses were better delineated. Conclusion Magnetic resonance imaging is the one stop diagnostic modality for perianal fistulas. Acquisition of axial (Ax) T2, axial T2 FS, coronal T2 and coronal T2 FS sequences without administering intravenous contrast or jelly is usually sufficient for the diagnosis of fistulas and their complications.

Seno del segundo arco branquial en un paciente adulto / Bilateral second branchial cleft cysts in an adult patient

Resumen El seno del segundo arco branquial es una alteración secundaria a un desarrollo anormal de los arcos branquiales. Las anomalías de los arcos branquiales incluyen quistes, fístulas, senos y glándulas ectópicas. Deben ser consideradas en el diagnóstico diferencial de las masas en cuello de pacientes adultos o pediátricos. El seno del arco branquial supone alrededor del 30 % de las masas congénitas del cuello y suele ser diagnosticado en la segunda a tercera década de la vida, siendo más comunes las del segundo arco. Se presenta con síntomas inespecíficos. Los estudios de imágenes son esenciales para su diagnóstico, clasificación y manejo quirúrgico. Se presenta el caso de un paciente de 67 años con historia clínica y examen físico de seno del segundo arco branquial, quien requirió de fistulografía y tomografía computarizada para una adecuada caracterización. El paciente fue intervenido quirúrgicamente sin complicaciones posteriormente.

Abstract The sinus of the second branchial arch is a secondary alteration of an abnormal development of the branchial arches. The anomalies of the branchial arches include cysts, fistulas, sinuses and ectopic glands. They should be considered in the differential diagnosis of neck masses in adult or pediatric patients. The sinus of the branchial arch accounts for about 30 % of the congenital masses of the neck and is usually diagnosed in the second to third decade of life, with those of the second arch being more common. It presents with nonspecific symptoms. Imaging studies are essential for the diagnosis, classification and surgical management. We present the case of a 67-year-old patient with a clinical history and physical examination of second branchial arch sinus, who required fistulography and computed tomography for adequate characterization. The patient underwent surgery without complications.

Fístula útero-cutánea posterior a cesárea. Reporte de caso / Uterocutaneous fistula following cesarean section. A case report

Resumen ANTECEDENTES: El mecanismo más frecuente por el que se originan las fístulas útero-cutáneas es la cesárea, con una incidencia no mayor a 0.4%. El sangrado menstrual a través de la herida quirúrgica es un dato patognomónico. El diagnóstico puede establecerse mediante fistulografía, inyección transcervical de azul de metileno, tomografía computada contrastada, resonancia magnética o histerosalpingografía. En la actualidad el tratamiento de elección es la escisión quirúrgica del trayecto fistuloso, con o sin histerectomía. CASO CLÍNICO: Paciente de 25 años, con antecedente de tres cesáreas; la última en febrero de 2018. Hallazgo transoperatorio: útero fácilmente sangrante y friable, con drenaje tipo Penrose en la fosa iliaca izquierda, que se retiró a las 72 horas. Acudió a consulta debido a un padecimiento de 22 días de evolución caracterizado por hipertermia, dolor pélvico y secreción fétida a través de la herida del drenaje previo. Durante el sangrado menstrual advirtió descarga por el sitio de la herida quirúrgica. En la exploración se observaron: cicatriz de drenaje del Penrose de aspecto granulomatoso y exudado purulento. Debido a que se sospechó un trayecto fistuloso útero-cutáneo se realizó una fistulografía con medio de contraste yodado no iónico y una tomografía. Se practicó fistulectomía con histerectomía. La paciente tuvo evolución clínica favorable. CONCLUSIÓN: A pesar de que la fístula útero-cutánea es un problema realmente excepcional, aun así, debe considerarse después de la cesárea. El dato clínico patognomónico es el sangrado menstrual a través de la herida quirúrgica. El diagnóstico certero es preciso, con la demostración del trayecto de la fístula mediante fistulografía, inyección transcervical de azul de metileno, tomografía computada contrastada, resonancia magnética o histerosalpingografía.

Abstract BACKGROUND: Fistula is an abnormal communication between two epithelialized surfaces. Caesarean section is the most frequent cause of uterine-cutaneous fistula, with an incidence of no more than 0.4%. Menstrual bleeding through the surgical wound is an almost pathognomonic finding. The diagnosis can be made using fistulography, transcervical injection of methylene blue, computerized tomography with contrast, as well as magnetic resonance or hysterosalpingography. Currently, the treatment of choice continues to be the surgical excision of the fistulous tract with or without hysterectomy. CLINICAL CASE: Female patient of 25 years of age with a history of three caesarean sections;; last in February 2018. As transoperative finding: uterus easily bleeding and friable leaving Penrose drainage to the left iliac fossa, which is removed 72 hours later. He came to the clinic for a condition of 22 days of evolution characterized by hyperthermia, pelvic pain and foul-smelling discharge through a previous drainage wound. When presenting menstrual bleeding, she sees discharge by surgical wound site. On examination: Penrose drainage scar of granulomatous appearance and purulent exudate, suspecting cutaneous uterus fistulous tract, so fistulography is performed with iodinated non-ionic contrast medium and tomography. We proceed to fistulectomy with hysterectomy. He is currently a patient with favorable clinical evolution. CONCLUSION: Although the uterine-cutaneous fistula is a really exceptional problem, even so, it should be considered after the cesarean section. The pathognomonic clinical data is menstrual bleeding through the surgical wound. The accurate diagnosis is precise, with the demonstration of the path of the fistula by means of fistulography, transcervical injection of methylene blue, contrasted computed tomography, magnetic resonance or hysterosalpingography.

Imaging of Anal Fistulas: Comparison of Computed Tomographic Fistulography and Magnetic Resonance Imaging

The primary importance of magnetic resonance (MR) imaging in evaluating anal fistulas lies in its ability to demonstrate hidden areas of sepsis and secondary extensions in patients with fistula in ano. MR imaging is relatively expensive, so there are many healthcare systems worldwide where access to MR imaging remains restricted. Until recently, computed tomography (CT) has played a limited role in imaging fistula in ano, largely owing to its poor resolution of soft tissue. In this article, the different imaging features of the CT and MRI are compared to demonstrate the relative accuracy of CT fistulography for the preoperative assessment of fistula in ano. CT fistulography and MR imaging have their own advantages for preoperative evaluation of perianal fistula, and can be applied to complement one another when necessary.

Ecofistulografía como herramienta diagnóstica en el tratamiento de la fístula perianal / Fistulography as diagnostic tool in the treatment of anal fistulas

Demostrar la utilidad de la ecofistulografía en la identificación de la fístula perianal. Estudio realizado en el Servicio de Cirugía 2 del Hospital Domingo Luciani, IVSS. Caracas. Estudio descriptivo, prospectivo y transversal de todos los pacientes que consultaron por secreción perianal en el período comprendido entre octubre de 2008 y junlio de 2009. Para la ecofistulografía se utilizó un equipo de ultrasonografía tridimensional Profocus Blue de BK Medical®, con transductor 2050 de 360°. Todos los estudios fueron realizados por el mismo explorador. Se incluyeron 41 pacientes, 37 hombres y 4 mujeres, en edades comprendidas entre 20 y 70 años, encontrando 7 fístulas interesfintéricas, 10 fístulas transesfintéricas, 2 fístulas extraesfintéricas, 1 fístula supraesfintérica; 2 fístulas en herradura. En 4 fístulas se observó un trayecto secundario. En 5 estudios se observó 1 o más cavidades de absceso y en 23 pacientes se evidenció la localización del orificio interno. En 23 pacientes se pudo realizar la medición del trayecto, y en 27 de los casos se describió su relación con el complejo esfinteriano. La ultrasonografía transrrecta tridimensional se considera un instrumento de gran importancia en el manejo de la fístula perianal orientando la búsqueda de hallazgo quirúrgico, siendo de ayuda para decidir la conducta, disminuir el índice de recidivas y complicaciones; por ser un método diagnóstico rápido, de bajo costo, con posibilidad de utilización en nuestro medio y bien tolerado por los pacientes.

To demostrate the effectiveness of fistulography in the identification of anal fistulas. Study performed at the General Surgery Service 2 of the Hospital Domingo Luciani, Caracas. This is a prospective, descriptive and transversal study of all the patients consulting with perianal discharge, in a period between October 2008 and July 2009. For fistulography it was used a tridimentional ultrasonographic Profocus Blue of BK Medical®, with a 2050 of 360º transductor. All the studies were done by the same explorer. There were included 41 patients, 37 males, and 4 females; with ages between 20 and 70 years old. We found 7 inter-sphinteric fistulas, 10 trans-sphinteric, 2 extra-sphinteric, 1 supra-sphinteric and 2 horseshoe fistulas. In 4 patients, secondary tracks were identified. In 5 studies we found one or more abscesses cavities and internal opening was demostrated in 23 patients, and tracks were measured. The relationships with sphinteric complex was described in 27 patients. Tridimentional trans-anal sonography is considered a very important diagnostic tool in the management of anal fistula. It helps to decide the surgical strategy. With this method we can decrease the number of recidivies and complications, also is an economic, fast and well tolerated study.

Estenosis de colédoco: reporte de caso / Choledocho stenosis: clinic case

Se reporta el caso de una paciente de sexo femenino de 24 años de edad que presentó estenosis de colédoco, cuyo cuadro clínico evoluciona durante siete meses a raíz de intervención quirúrgica por colecistectomía. La fistulografía demostró dilatación de las vías biliares intra y extrahepáticas y obstrucción del colédoco. Las estenosis benignas de los conductos biliares ocurren en el 97% de los casos, por lesión accidental durante actos quirúrgicos. En 1 de 400 colecistectomías convencionales, y en 1 de 200 colecistectomías laparoscópicas, se produce un daño a la vía biliar que provoca el desarrollo de la estrechez de la misma.

Report the case a female patient, with 24 years old that present choledocho stenosis, which clinic development for seven month since the surgery for cholecystectomy. The fistulography show a dilation pf intra and extrahepatic biliar tract and choledoco obstruction. The benign stenosis of the biliar tracts present in 97% of the cases by accidental damage during surgical procedure. In 1 of 400 conventional cholecystectomies and 1 of 200 laparoscopies cholecistectomy, produce a damage of biliar tract that cause a growth of the narrowness

Clinical Significance of Routine Fistulography at Postoperative 1 Month in Patients Receiving Native Arteriovenous Fistula / 대한신장학회잡지

BACKGROUND: Fistulography is simple and accurate method detecting vascular access dysfunction. This study was performed to evaluate clinical significance of routine fistulography at postoperative 1 month in hemodialysis (HD) patients receiving native arteriovenous fistula (AVF). METHODS: This study enrolled 28 HD patients receiving native AVF operation who performed routine fistulography at postoperative 1 month before the first needling through the AVF. We investigated fistulographic findings and performed percutaneous angioplasty (PTA) in patients having severe stenosis more than 50 % of normal internal diameter. RESULTS: Of the total 28 patients, 8 patients showed normal findings and 20 patients showed stenosis in which 8 patients had severe stenosis requiring radiological or surgical correction. Of the 20 patients with stenosis, 12 patients had multiple lesions. Stenotic lesions were observed in AVF anastomosis site (n=6), proximal vein (n=5), artery near the AVF anastomosis site, and mixed lesions (n=6). PTA was performed in 5 of the 8 patients with severe stenosis and all stenostic lesions were completely corrected. CONCLUSION: Routine fistulography performed at postoperative 1 month is effective in detecting early native AVF and deciding treatment modalities.

Clinical Significance of Fistulography by Brachial Artery Approach in Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Fistulography is usually performed through transvenous approach in hemodialysis patients. We preformed this study to evaluate the clinical significance of the brachial arterial approach for the fistulography from the hemodialysis patients. METHODS: This study included 13 cases from 12 hemodialysis patients who had the fistulogram or percutaneous transluminal angioplasty through brachial arterial approach between November 2003 and June 2005. We investigated the indication, the radiologic finding, the complication and the outcome of the fistulography and the percutaneous transluminal angioplasty. RESULTS: Indication of transbrachial artery approach was immaturation of the arteriovenous fistula or poor visualization of venous route. The brachial artery puncture was successfully performed in all patients. For 10 cases, the stenoses or occlusions were observed in the arteriovenous anastomosis site, distal radial artery or proximal cephalic vein. Four patients had severe arterial stenosis. Additionally, the percutaneous transluminal angioplasty were performed in 8 cases of 13 cases. The procedure-related complication demonstrated focal pseudoaneurysm formation at brachial artery puncture site, resulting in transient radial nerve palsy in only one case. CONCLUSION: Tranbrachial artery approach is considered as effective in the immaturation of hemodialysis arteriovenous fistulas or arterial vascular problem. However, we should give attention to the brachial arterial approach because of its significant complication.