Ligadura del trayecto fistuloso interesfinteriano. Nuestros resultados / Ligation of the intersphincteric fistulatract. Our results

Introducción: existen varias técnicas para el tratamiento quirúrgico de las fístulas anales, con variables resultados. La técnica de ligadura del trayecto fistuloso interesfinteriano (LIFT) consiste en la disección del espacio entre ambos esfínteres para localizar el trayecto fistuloso y proceder a su ligadura y sección. Objetivo: evaluar nuestros resultados con la técnica de LIFT para del tratamiento de las fístulas anales transesfinterianas. Diseño: retrospectivo, observacional de corte transversal. Materiales y métodos: Se incluyeron todos los pacientes con fístulas transesfinterianas tratados con LIFT desde enero de 2013 a diciembre 2020. El seguimiento postoperatorio se realizó hasta los 2 años. Resultados: se operaron 62 pacientes. El sexo predominante fue masculino. Hubo 47 pacientes con fístulas transesfinterianas bajas y 15 con fístulas transesfinterianas altas. En todos se identificó el trayecto fistuloso realizándose ligadura de ambos cabos del trayecto interesfinteriano y se procedió a un curetaje del trayecto a través del orificio externo. Cinco pacientes (8%) presentaron dehiscencia de piel a nivel de la incisión del espacio interesfinteriano, manejado en forma conservadora. Este grupo tuvo una cicatrización mas retardada de 4 semanas. Ocurrió recidiva en 22 (35,5%) pacientes. Conclusión: La técnica de LIFT parece una alternativa eficaz y segura para el tratamiento de las fístulas transesfinterianas bajas y altas ya que no altera la anatomía ni la continencia. (AU)

Introduction: there are various techniques for the surgical treatment of anal fistulas, with variable results. The ligation procedure of the intersphincteric fistulous tract (LIFT) consists of dissecting the space between both sphincters to locate the fistulous tract and proceed to its ligation and section. Objective: to evaluate our results with the LIFT procedure for the treatment of transsphincteric anal fistulas. Design: retrospective, cross-sectional observational study. Material and methods: all patients with transsphincteric fistulas treated with LIFT from January 2013 to December 2020 were included. Postoperative follow-up was carried out for up to 2 years. Results: sixty-two patients underwent surgery. The predominant sex was male. There were 47 patients with low transsphincteric fistulas and 15 with high transsphincteric fistulas. After identifying the fistulous tract in the intersphincteric groove, both ends were ligated and the tract was cut. Finally, curettage of the tract through the external orifice was performed. Five patients (8%) presented skin dehiscence at the level of the intersphincteric groove incision, managed conservatively. This group had a longer healing time of four weeks. Recurrence occurred in 22 (35.5%) patients. Conclusion: the LIFT procedure appears to be an effective and safe alternative for the treatment of low and high transsphincteric fistulas, since it does not alter the anatomy or continence. (AU)

Caracterización de las fístulas enterocutáneas posoperatorias / Characterization of Postoperative Enterocutaneous Fistulas

Introducción: Las fístulas enterocutáneas representan una enfermedad grave que deben afrontar un gran número de cirujanos durante el ejercicio de la profesión. El tratamiento suele ser extremadamente complejo y siempre requiere de una intervención multidisciplinaria adaptada para cada caso en particular. Objetivo: Evaluar las características clínico-epidemiológicas y terapéuticas de las fístulas enterocutáneas posoperatorias. Métodos: Se realizó un estudio observacional, descriptivo, con recogida prospectiva de datos en el quinquenio 2013-2017. El universo fue de 28 pacientes diagnosticados con fístula enterocutánea posoperatoria y se usaron las variables: edad, sexo, carácter de la intervención, diagnóstico operatorio, tipo de fístula, tratamiento definitivo, complicaciones y pilares de tratamiento. Resultados: La edad media fue de 49 años. Las fístulas fueron más frecuentes en el sexo femenino (53,57 por ciento). El 78,57 por ciento de los pacientes fueron intervenidos con carácter de urgencia, y el 25 por ciento tuvieron un diagnóstico operatorio de oclusión intestinal mecánica por bridas seguida de la oclusión intestinal por tumor de colon izquierdo (17,86 por ciento). La hemicolectomía izquierda con anastomosis término-terminal (21,43 por ciento) y la resección intestinal con anastomosis término-terminal (17,86 por ciento) fueron los principales procedimientos quirúrgicos realizados. Conclusiones: Las fístulas de tipo II y de bajo gasto prevalecieron en la serie de casos en una media de tiempo que se corresponde con lo reportado en la literatura. La infección del sitio quirúrgico fue la complicación más observada y los pilares del tratamiento fueron cumplidos en la mayoría de los pacientes prevaleciendo el cierre espontáneo como tratamiento definitivo(AU)

Introduction: Enterocutaneous fistulas are a serious disease that a large number of surgeons must face during the practice of their profession. Their treatment is usually extremely complex and always requires a multidisciplinary intervention adapted to each particular case. Objective: To evaluate the clinical-epidemiological and therapeutic characteristics of postoperative enterocutaneous fistulas. Methods: An observational and descriptive study was performed, with prospective data collection, in the five-year period 2013-2017. The study universe was 28 patients diagnosed with postoperative enterocutaneous fistula. The following variables were used: age, sex, nature of the intervention, operative diagnosis, type of fistula, definitive treatment, complications and treatment cornerstones. Results: The mean age was 49 years. Fistulas were more frequent in the female sex (53.57 percent). 78.57 percent of the patients underwent emergency surgery, while 25 percent had an operative diagnosis of mechanical intestinal occlusion due to adherences, followed by intestinal occlusion due to left colon tumor (17.86 percent). Left hemicolectomy with end-to-end anastomosis (21.43 percent) and intestinal resection with end-to-end anastomosis (17.86 percent) were the main surgical procedures. Conclusions: Type II and low-output fistulas prevailed in the case series at a mean time that corresponds to that reported in the literature. Surgical site infection was the most frequently observed complication, while the treatment cornerstones were fulfilled in most patients, with spontaneous closure prevailing as a definitive treatment(AU)

Tomographic sarcopenia predicts anastomotic leaks and long-term survival in gastric cancer patients operated with curative intent / Sarcopenia tomográfica prevê fístulas de anastomoses e sobrevida a longo prazo em pacientes com câncer gástrico operados com intenção curativa

ABSTRACT BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

RESUMO RACIONAL: O estado nutricional pré-operatório tem valor prognóstico pós-operatório. A densidade tomográfica e a área do músculo psoas é uma ferramenta validada para o estado nutricional. Existem poucos estudos avaliando a utilidade da tomografia de estadiamento em pacientes com câncer gástrico neste campo. OBJETIVOS: Determinar a influência da sarcopenia, medida por tomografia computadorizada de estadiamento pré-operatório, na morbimortalidade pós-operatória e sobrevida em longo prazo em pacientes operados de câncer gástrico com intenção curativa. MÉTODOS: Estudo retrospectivo de 2007 a 2013. A definição de sarcopenia radiológica foi pela medida da área (PA) e densidade do músculo psoas (PD) a nível de L3 (Terceira vertebra lombar), em um corte axial de tomografia computadorizada abdominopélvica (na seleção sem meio de contraste intravascular). O Software utilizado foi o OsirixX v 10.0.2, com a ferramenta "propagar segmentação", ajustando manualmente todos os músculos vistos na imagem. RESULTADOS: Foram incluídos 70 pacientes, 77% homens, PA média em L3: 16,6 cm2 (desvio padrão+6,1), PD média em L3: 36,1 mean muscle density (desvio padrão+7,1). Os cânceres avançados foram de 86, 28,6% tinham células em anel de sinete, 78,6% necessitaram de gastrectomia total, a morbidade e mortalidade cirúrgica pós-operatória foi de 22,8 e 2,8%, respectivamente, a sobrevida global de 5 anos a longo prazo (SV5) foi de 57,1%. Na análise multivariada, PA falhou em prever morbidade cirúrgica (p=0,4) e sobrevida global de 5 anos (p=0,34), enquanto PD foi capaz de prever fístulas anastomóticas (p=0,009; OR 0,86; IC95% 0,76-0,96) e SV5 (p=0,04; OR 2,9; IC95% 1,04-8,15). CONCLUSÕES: O diagnóstico tomográfico de sarcopenia por desvio padrão é capaz de predizer fístulas anastomóticas e sobrevida a longo prazo em pacientes com câncer gástrico tratados com intenção curativa.

Malformaciones arteriovenosas pulmonares: presentación de un caso clínico pediátrico y revisión de la literatura / Pulmonary arteriovenous malformations: presentation of a pediatric case and review of the literature

Las malformaciones arteriovenosas pulmonares (MAVP) consisten en comunicaciones directas entre el sistema arterial y el sistema venoso pulmonar, sin paso de la sangre por el lecho capilar, produciéndose un cortocircuito de derecha a izquierda extracardíaco, pueden ser congénitas o adquiridas. Algunos casos pueden ser asintomáticos, en cambio en otros pueden ocasionar diversas manifestaciones clínicas y se pueden asociar a complicaciones severas. En niños se observa una baja incidencia y son más frecuentes las formas congénitas. La MAVP se debe sospechar por las manifestaciones clínicas y las imágenes de la radiografía de tórax (RxTx) y su confirmación se realiza mediante una AngioTomografía Computada (TC) de tórax. La embolización endovascular es actualmente el tratamiento de elección, con excelentes resultados, aunque requiere de un seguimiento posterior y de un operador experimentado. Reportamos el caso de una niña que ingresó con clínica muy sugerente, incluyendo: disnea, acropaquia, cianosis periférica, e hipoxemia refractaria. Sin embargo, inicialmente el cuadro clínico fue confundido con una crisis asmática. La Angio-TC de tórax confirmó el diagnóstico y el tratamiento mediante embolización endovascular resultó exitoso.

Pulmonary arteriovenous malformations (PAVM) are communications between the arterial and the pulmonary venous system, without passage of blood through the capillary bed, causing a left to right extracardiac shunt. Some cases may be asymptomatic, while others may cause various clinical manifestations and may be associated with severe complications. In children a low incidence is observed, and congenital forms are more frequent. PAVM should be suspected by clinical manifestations and chest x-ray imaging and confirmed by chest Computed Tomography Angiography (CTA). Endovascular embolization is currently the treatment of choice, with excellent results, although it requires subsequent follow-up. We report a patient who was admitted with a very suggestive clinical history, including: dyspnea, clubbing, peripheral cyanosis, and severe hypoxemia, refractory to oxygen therapy. However, initially the clinical picture was confounded with an asthmatic crisis. CTA confirmed the diagnosis and treatment by endovascular embolization was successful.

Prevalence of Tinnitus in Patients Diagnosed with Cerebral Arteriovenous Fistula Treated with Endovascular Technique

Abstract Introduction Tinnitus is characterized as the conscious and involuntary perception of sound, and it affects ~ 30% of the population. Despite careful physical examination, the etiology of tinnitus can be established for only 30% of patients. Tinnitus is a common symptom of cerebral arteriovenous fistulas and results from increased blood flow through the dural venous sinuses, leading to turbulent arterial flow, mainly related to sigmoid and transverse sinus lesions. Objectives To analyze the frequency of tinnitus, patient profile, and endovascular treatment characteristics in individuals diagnosed with cerebral arteriovenous fistulas. Methods A retrospective and observational study based on reviewed data from medical records on the PHILIPS Tasy system (Philips Healthcare, Cambridge, MA, USA) at the neurosurgery and interventional neuroradiology service of Hospital Santa Isabel in Blumenau-state of Santa Catarina, Brazil. Results The profile of 68 individuals diagnosed with cerebral arteriovenous fistula who underwent endovascular treatment were analyzed. Most patients were female, aged 31 to 60. Tinnitus affected 18 individuals. Dural fistulas were the most prevalent in the sample, and computed tomography alone was the most used diagnostic method for initial investigation. Conclusion The prevalence of this symptom in patients diagnosed with cerebral arteriovenous fistula was found in 26.5% of this sample, mainly in women with associated comorbidities. Tinnitus remission was observed in all patients who underwent endovascular treatment to correct cerebral fistula.

Stents metálicos autoexpandibles para el manejo endoscópico de las fístulas esofagogástricas / Self-expanding metal stents for endoscopic management of esophageal and gastric fistulas

Resumen Objetivos: mostrar la eficacia y seguridad de los stents metálicos autoexpandibles para el manejo endoscópico de las fístulas esofágicas. Materiales y métodos: se evalúo una serie de casos de manera retrospectiva entre el 2007 y el 2017, en los que se manejaron a 11 pacientes con un stent metálico autoexpandible para el manejo de fístula esofágica, en quienes se realizó el diagnóstico por clínica, endoscopia digestiva alta o estudios radiológicos en la unidad de gastroenterología del Hospital Universitario San Ignacio (HUSI) de Bogotá D. C., Colombia. Resultados: el principal síntoma inicial fue la disnea en 27,3 % de los casos, seguido por tos en un 18,2 %. El hallazgo más frecuentemente encontrado durante el seguimiento fue el derrame pleural en el 36,4 %, se realizó el diagnóstico de fístula en el 45,5 % con esofagograma y el tipo de lesión más reportada fue la fuga en la anastomosis esofagoentérica, con un 45,5 %, seguida de la esofagopleural, con un 36,4 %; y estos pacientes fueron manejados con un stent metálico autoexpandible. En el 100 % hubo éxito técnico y la resolución del defecto se evidenció en el 72,7 % de los casos. La única complicación reportada fue el desplazamiento del stent en el 27,3 %, y en un paciente se requirió el cambio del stent en 3 oportunidades. El promedio de estancia hospitalaria fue de 41,5 días. Conclusiones: el manejo endoscópico de las fístulas esofagogástricas con stents metálicos autoexpandibles es efectivo y seguro, con una baja tasa de complicaciones.

Abstract Objective: To demonstrate the efficacy and safety of self-expanding metal stents for endoscopic management of esophageal fistulas. Materials and methods: Retrospective case series between 2007 and 2017. A total of 11 patients were treated with self-expanding metal stents for esophageal fistula management, after being diagnosed based on symptoms, upper endoscopy, and/or radiological studies in the gastroenterology unit of the Hospital Universitario San Ignacio (HUSI) in Bogotá D.C, Colombia. Results: The most common initial symptom was dyspnea in 27.3% of cases, followed by cough in 18.2%. The most frequent finding during follow-up was pleural effusion in 36.4% of the cases, of which 45.5% received a diagnosis of fistula through esophagogram. The most reported lesion was esophagoenteric anastomotic leak with 45.5%, followed by esophagopleural injury with 36.4%; these patients were those who received self-expanding metal stent management. Technical success was achieved in 100% of the cases, and the defect was resolved in in 72.7% of them. The only complication reported was stent migration in 27.3%, requiring 3 changes in 1 patient. The average hospital stay was 41.5 days. Conclusions: Endoscopic management of esophagogastric fistulas with self-expanding metal stents is effective and safe, with a low complication rate.

Funcionabilidad y durabilidad de fístulas arterio-venosas para hemodiálisis en pacientes no diabéticos / Functionability and durability of arterio-venous fistulas for haemodialysis in non-diabetic patients

Introducción: Existe un incremento anual de pacientes con insuficiencia renal crónica tributarios a hemodiálisis. Para la realización de esta se requiere de la correcta inserción de accesos vasculares que sean duraderos y funcionales. Objetivo: Caracterizar la durabilidad y funcionabilidad de las fístulas arterio-venosas en pacientes no diabéticos con enfermedad renal crónica. Métodos: Se realizó un estudio ambispectivo en 60 pacientes no diabéticos, con enfermedad renal crónica, portadores de una fístula arterio-venosa interna autóloga. Se describieron las variables: edad, sexo, grado de la enfermedad, lugar de confección, durabilidad, funcionabilidad, intentos, superficialización, uso de prótesis de poli-tetra-fluoro-etileno y complicaciones. Resultados: La edad media de los pacientes fue de 55,7 ± 12,7 años y la mitad estuvo entre 40 y 59 años. Los del sexo masculino ocuparon el 71,7 por ciento. Las fístulas duraderas (66,7 por ciento) y las funcionales (71,7 por ciento) se mostraron como las de mayor aparición. Los pacientes con la enfermedad en grado 4 ocuparon el 51,7 por ciento. Las fístulas en zonas radio-cefálica (43,3 por ciento) y húmero-cefálica (45 por ciento) primaron. Solo el 71,7 por ciento tuvo un intento de cirugía. Únicamente en el 20 por ciento se realizó superficialización y cuatro pacientes (6,4 por ciento) recibieron prótesis de poli-tetra-fluoro-etileno. La trombosis representó la complicación más frecuente (25 por ciento). Conclusiones: La durabilidad y la funcionabilidad de las fístulas elaboradas se asociaron con factores como el grado de la enfermedad, el número de intentos, el uso de prótesis vasculares y las complicaciones(AU)

Introduction: There is an annual increase of patients with chronic renal impairment who need haemodialysis. The correct insertion of vascular accesses that are durable and functional is required to perform haemodialysis. Objective: Characterize the durability and functionability of arterio-venous fistulas in non-diabetic patients with chronic kidney disease. Methods: An ambispective study was conducted in 60 non-diabetic patients, with chronic kidney disease carrying an autologous internal arterio-venous fistula. The described variables were: age, sex, stage of the disease, place of manufacture, durability, workability, attempts, superficialization, use of polytetrafluoroethylene prostheses, and complications. Results: The average age of patients was 55.7 ± 12.7 years and half were between 40 and 59 years old. Males were 71.7 percent. Durable (66.7 percent) and functional (71.7 percent) fistulas were shown as the most common ones. Patients with a grade 4 disease represented the 51.7 percent. Fistulas in radio-cephalic zones (43.3 percent) and humerus-cephalic zone (45 percent) prevailed. Only 71.7 percent had an attempt of surgery. Only 20 percent had superficialization and four patients (6.4 percent) received polytetrafluoroethylene prostheses. Thrombosis was the most common complication (25 percent). Conclusions: The durability and functionability of the prepared fistulas were associated with factors such as the stage of the disease, the number of attempts, the use of vascular prostheses, and the complications(AU)

Profile of Crohn's disease patients who underwent anorectal examination under anesthesia

Introduction: Crohn's disease (CD) is an inflammatory bowel disease, and in ~ 30% of cases it is associated with perianalmanifestations. To identify the extent of the damage and to implement an appropriate treatment, anorectal examination under anesthesia (EUA) is fundamental. Objective: To describe the profile of patients who underwent anorectal EUA in university and private hospitals in the state of Bahia, Brazil. Methodology: A retrospective, descriptive study with 46 patients who underwent anorectal EUA between March, 2016 and November, 2019. Results: A total of 62 anorectal EUAs were performed in 46 patients. With an average age of 36.8 years, the female gender was predominant (52.2%) among these patients. Anal fistulas were the most frequent findings (83.8%), and in most cases they were treated with a seton placement (69.4%). The main recommended surgical indication was a proper evaluation and identification of perianal disease, followed by drainage of the abscess and therefore immunobiological therapy (59.6%). Conclusion: In the present study, the profile of CD patients was similar to those found in the literature, with a high rate of complex anal fistulas. Additional studies are still necessary to further comprehend and treat this particular and debilitating manifestation of the disease. (AU)

Trans gastric sinus stent placement and drainage in management of persistent external pancreatic fistula / 中华肝胆外科杂志

Objective:To study the use of trans gastric sinus stent placement and drainage in management of persistent external pancreatic fistula.Methods:The clinical data of 12 patients who developed persistent external pancreatic fistulae after severe acute pancreatitis, pancreatic trauma or pancreatic surgery who were treated at the First Medical Center of Chinese PLA General Hospital from August 2018 to December 2020 were retrospectively analyzed. There were 10 males and 2 females, aged 30 to 65 years, median 43.5 years. These patients underwent trans gastric sinus stent placement and drainage, and were followed-up to study persistence of pancreatic fistula, new pancreatic fluid accumulation, complications and death.Results:In this study, there were 9 patients who developed persistent external pancreatic fistulae after severe acute pancreatitis, 2 patients after pancreatic trauma, and 1 patient after pancreatic surgery. The median operation time was 47 min (range 38-54 min). The technical success rate was 100.0% (12/12). The median follow-up was 22.5 months (range 2-29 months). Seven days after stenting, the percutaneous drainage tubes (urinary catheters) of all the patients were removed. One patient (8.3%) developed recurrence of pancreatic fistula 17 days after treatment. The same procedure of placing another stent was done and the patient recovered. Six months after treatment, 2 patients (16.7%) lost their stents, and 1 patient developed a pseudocyst (recurrence of pancreatic fistula). The maximum diameter of this pseudocyst increased gradually to 7cm after 9 months. A double pigtail drainage tube was placed under endoscopy in this patient, and the patients recovered. All the other patients did not develop recurrence of pancreatic fistula or pseudocyst. During the follow-up period, no patient developed any new complications including pancreatic fluid accumulation, fever, bleeding, infection and organ dysfunction, and no patients died.Conclusion:It was safe and efficacious to use trans gastric sinus stent placement for treatment of persistent external pancreatic fistula. However, the long-term outcomes require further studies.

Caracterización de los pacientes con fístulas arterio-venosas para hemodiálisis / Description of patients with arterio-venous fistulas for haemodialysis

Introducción: La fístula arterio-venosa para hemodiálisis es el acceso vascular utilizado con mayor frecuencia. De su adecuada funcionalidad depende la calidad de vida de los pacientes con enfermedad renal crónica. Objetivo: Caracterizar a los pacientes a los que se les confeccionó fístulas arterio-venosas para hemodiálisis. Métodos: Se realizó un estudio descriptivo retrospectivo en 73 pacientes, a los que se les confeccionó una fístula arterio-venosa para hemodiálisis. Las variables de estudio fueron: edad, sexo, tipo de fístula arterio-venosa, localización, complicaciones y tratamiento quirúrgico de las complicaciones. Resultados: Se encontró un predominio del sexo masculino y del grupo etario entre 51 y 60 años. El 94,6 por ciento de las fístulas realizadas fueron autólogas; y, de estas, el 44,1 por ciento, radio-cefálicas. El 27,3 por ciento de las autólogas y el 20 por ciento de las protésicas se presentó trombosis, y el 18,2 por ciento y el 40 por ciento presentaron hipertensión venosa para las autólogas y protésicas, respectivamente. El 43,5 por ciento de los tratamientos realizados frente a las complicaciones resultó la confección de una nueva fístula. Conclusiones: Los pacientes a los que se les confeccionó fístulas arterio-venosas eran predominantemente adultos mayores del sexo masculino y las fístulas más realizadas fueron las autólogas radio-cefálicas. Como principal complicación de las fístulas se encontró la trombosis y se realizaron escasos procederes para el rescate de estas(AU)

Introduction: Arterio-venous fistula for haemodialysis is the most commonly used vascular access. Its proper functionality depends on the quality of life of patients with chronic kidney disease. Objective: Describe patients to whom were made arterio-venous fistulas for haemodialysis. Methods: A retrospective descriptive study was conducted in 73 patients to whom were made an arterio-venous fistula for haemodialysis. The study variables were: age, sex, type of arterio-venous fistula, location, complications and surgical treatment of complications. Results: It was found a predominance of male sex and the age group of 51 to 60 years. 94.6 percent of the fistulas made were autologous; and, of these, 44.1 percent were radio-cephalic. 27.3 percent of the autologous fistulas and 20 percent of the prosthetics ones developed thrombosis, and 18.2 percent and 40 percent showed venous hypertension for autologous and prosthetic fistulas, respectively. 43.5 percent of the treatments performed to face complications resulted in the making of a new fistula. Conclusions: The patients to whom were made arterio-venous fistulas were predominantly older adults of the male sex and the most performed fistulas were the radio-cephalic autologous. As the main complication of fistulas, thrombosis was found and a few practices were performed to rescue them(AU)

A case of recto-vaginal obstetrical fistula treated by the Martius lamp, seen at Befelatanana Madagascar

The rectovaginal fistulas are a pathological epithelialized communication between the vagina and the rectum, its frequency is 10 to 30%, and it is a disabling pathology because of the social repercussion. Many flap techniques have been described but the aim is to present a simple procedure according to a particular technique called Martius. This is a case of woman presenting a low rectovaginal fistula on obstetrical trauma. The surgical technique consists of a repair according to the technique of Martius. The operative follow-up was simple and the patient was able to resume sexual activity and normal anal sphincter function. It is a simple technique, easy to achieve for the technical platform in Madagascar whose evaluation of the results for a larger population should be considered. This technique therefore deserves to be known and widely used.

Role of seton versus conventional techniques in the management of anorectal fistulas

Background: This study was conducted to compare the use of different setons with conventional management like fistulotomy and fistulectomy in terms of healing (after 1 and 3 months), recurrence and incontinence.Methods: This was a retrospective non-randomized study conducted at JNMCH, Aligarh from January 2018 to June 2019. Patients included- patients (males and females) of age group 18-70 years, patients giving consent. Patients excluded- fistula secondary to- Crohn’s disease, tuberculosis, malignancy, recurrent fistula, pregnant females, immuno-suppressed patients.Results: After 1 month, 17 out of 24 patients (70.8%) of fistulotomy, 48 out of 68 patients (70.6%) of seton group and 21 out of 32 patients (65.6%) of fistulectomy group had their wounds healed (p=0.8693). After 3 months, 19 out of 24 (79.2%) patients of fistulotomy, 61 out of 68 (89.7%) of seton, and 24 out of 32 patients (75%) with fistulectomy had their wound healed (p=0.1374). Recurrence was observed in 5 out of 24 patients of fistulotomy, 10 out of 68 patients of seton use and 5 out of 32 patients with fistulectomy (p=0.7788). 6 out of 24 patients (25%) had incontinence after fistulotomy, 7 out of 68 (10.3%) of seton group and 8 out of 24 (25%) after fistulectomy (p=0.0944). Healing was higher in patients of non-cutting setons as compared to cutting seton (p=0.0252). After 3 months, no difference was observed (p=0.1245). Recurrence higher in cutting setons as compared to non-cutting setons (p=0.0187).Conclusions: Setons are safe, low-cost, less invasive, precise, and cost-effective option for treating simple and complex fistula-in-ano.

Fístulas arteriovenosas pulmonares en un paciente pediátrico: un reporte de caso / Pulmonary arteriovenous fistulas in a pediatric patient: a case report

Las fístulas arteriovenosas pulmonares son malformaciones congénitas dadas por la comunicación directa anómala entre arterias y venas, con una incidencia mundial de 2-3 : 100 000 habitantes. La presentación es, en general, única, asintomática, y aparecen en forma incidental como hallazgo imagenológico en la adultez, y su tratamiento de elección es la embolización endovascular.Se describe la inusual presentación clínica en una paciente de 10 años, que ingresó por disnea, tos, cianosis central y cefalea. Se encontró hipoxemia persistente, hipocratismo digital, nódulos parahiliares pulmonares, gases arteriales con gradiente alvéolo-arterial aumentado. La tomografía axial computarizada de tórax de alta resolución confirmó la presencia de una malformación arteriovenosa pulmonar en la región parahiliar derecha, la cual no se asociaba con la enfermedad de Rendu-Osler-Weber. La paciente fue tratada con embolización endovascular transcutánea. Tras 1,5 años de seguimiento, no hubo recaídas. Son pocos los casos reportados de estas fístulas en la edad pediátrica

Pulmonary arteriovenous fistulas are congenital malformations due to anomalous direct communication between arteries and veins; the incidence is 2-3 : 100,000 inhabitants. This condition is usually asymptomatic and incidentally appearing in adult imaging findings. Transcutaneous endovascular embolization is the technique of choice for treatment. The unusual presentation in a 10-year-old patient is described; she was presented to the Emergency Department with dyspnea, cough, central cyanosis and headache. The examination revealed persistent hypoxemia and digital clubbing; chest X-ray with images suggestive of parahilar nodules, arterial blood gases with increased alveolar arterial gradient. The high resolution computed tomography of the thorax revealed pulmonary arteriovenous malformation in the right parahilar region not associated with Rendu-Osler-Weber disease. The patient was treated with transcutaneous endovascular embolization, and after a year and a half of follow-up there were no relapses. There are few reported cases of pulmonary arteriovenous fistulas in the pediatric age.

Long-term efficacy of bioprosthetic anal fistula plug in the treatment of transsphincteric anal fistula / 中华胃肠外科杂志

Objective@#To evaluate the long-term healing rate of transsphincteric anal fistula treated with anal fistula plug procedure and the risk factors affecting the healing of anal fistula.@*Methods@#A retrospective case-control study was conducted to analyze the clinical data of 207 patients with transsphincteric anal fistulas who received anal fistula plug procedure at the Department of General Surgery, Beijing Chaoyang Hospital of Capital Medical University from August 2008 to September 2012. Inclusion criteria: (1) consistent with the diagnosis of transsphincteric anal fistula: the anal fistula passed through the internal and external sphincter; (2) complete data; (3) initial treatment with anal fistula plug procedure. Exclusion criteria: (1) acute rectal or perianal infection or poorly controlled focal infection; (2) recent incision and drainage of perianal abscess or spontaneous rupture of abscess; (3) patients with malignant tumor; (4) patients with Crohn′s disease or ulcerative colitis; (5) patients with heart, liver, brain, lung or renal insufficiency; (6) cachexia due to various chronic wasting diseases; (7) patients could not tolerate surgery. Patients were followed up for anal fistula healing. The cumulative healing rate of patients with transsphincteric anal fistula was plotted using the Kaplan-Meier method, and the factors affecting anal fistula healing were explored by univariate and multivariate logistic regression analysis.@*Results@#There were 186 males and 21 females with age of 15 to 69 (mean 38) years. The duration of anal fistula was 3-60 (mean 15) months. Three patients had a history of previous episodes of perianal abscess and underwent incision and drainage of perianal abscess (all more than 3 months). During follow-up ending on October 31, 2018, 72 patients (34.8%) were lost to follow-up. Among 135 patients who were successfully followed up, the average follow-up period was 96 (75-124) months. Seventy-five patients had anal fistula healing, with healing rate of 55.6%. Kaplan-Meier survival curve showed that the healing time of anal fistula was prolonged and finally stabilized at 55.6%. In the patients who failed initial treatment with anal fistula plug packing, there were 6 cases whose anal fistula healed spontaneously without other treatment. Among them, 3 cases healed spontaneously 2 years and 3 cases 3 years after operation without recurrence. From 2008 to 2012, the annual healing rates of anal fistula plug treatment were 3/6, 61.5% (24/39), 42.1% (24/57), 12/15 and 12/18, respectively. Multivariate logistic regression analysis showed that the duration of anal fistula≥6 months (OR=3.187, 95% CI: 1.361-7.466, P=0.008) was an independent risk factor for anal fistula healing after treatment with anal fistula plug.@*Conclusion@#The long-term efficacy of anal fistula plug procedure in the treatment of transsphincteric anal fistula is positive, and this procedure should be implemented as soon as possible.

Fístulas colónicas de origen diverticular / Colonic fistulas of diverticular origin

INTRODUCCIÓN: La enfermedad diverticular de colon sigmoides representa la principal causa de fistulización del colon a órganos vecinos. OBJETIVO: Describir variables clínicas y terapia quirúrgica de esta entidad. MATERIALES Y MÉTODO: Revisión retrospectiva de los casos de fístulas colónicas de origen diverticular (FCD) operados en forma electiva en un centro terciario. RESULTADOS: En un periodo de 30 años se realizó cirugía resectiva por una FCD en 49 pacientes. Los órganos más afectados fueron la vejiga en 33 casos (68%) y la vagina en 6 (12%). La cirugía efectuada fue la sigmoidectomía en 48 casos (5 con una ileostomía de protección) y una operación de Hartmann. La vía de abordaje fue laparoscópica en 4 pacientes y la morbilidad global de la serie fue 20%, sin mortalidad. Con un seguimiento promedio de 87 meses (extremos 16-178) no hubo casos de recidiva de la fístula. CONCLUSIONES: La FCD representa el 26% de los casos intervenidos por una enfermedad diverticular de colon sigmoides, lo que probablemente refleja un diagnóstico tardío. La fístula colovesical (FCV) es la fístula más común por esta causa y en la mitad de los casos tienen una presentación silenciosa. Las fístulas colovaginales ocurren en mujeres histerectomizadas. La cirugía resectiva del colon en pacientes con riesgo normal es la cirugía estándar con buenos resultados a corto y largo plazo. La cirugía laparoscópica es factible y segura especialmente en los casos de FCV.

BACKGROUND: Fistula formation is a well-known complication of diverticular disease (FCD). AIM: Determine the clinical presentation and surgical management of this kind of fistulas. MATERIALS AND METHODS: Retrospective revision of all consecutive scheduled cases operated on in a terciary public centre in a thirty-years period. RESULTS: Forty-nine patients with a segmental resection of sigmoid colon were analized. Colovesical fistulas were the most common type (n = 33), followed by colovaginal (n = 6). Resection with anastomosis was performed in 48 cases and Hartmann type operation in one. Laparoscopic procedure was made in 4 cases without conversion. Complication rate was 20% and two patients were reoperated on, without mortality in this series. Follow up showed no case of recurrence. CONCLUSIONS: FDC represent 26% of cases operated on in our series. Colovesical fistula is the most common type, followed by colovaginal fistula in histerectomized women. Resection and primary anastomosis should be the treatment of choice in average risk patients with acceptable morbidity and good long-term results. Laparoscopic approach is safe, specifically in patients with colovesical fistulas.

Experiencia inicial en la adaptación del instrumental del tratamiento video asistido modificado de las fistulas perianales complejas (VAMAFT) / Initial experience in the adaptation of the instruments of the modified assisted video treatment of complex perianal fistulas (VAMAFT)

Introducción: Las fístulas perianales tienen dos problemas fundamentales, la tasa de recurrencia y de incontinencia fecal postoperatoria, complicaciones que varían en frecuencia dependiendo de varios factores como el tipo de fistula, la técnica quirúrgica usada y la experiencia del cirujano. Debido a esto existen técnicas quirúrgicas no conservadoras y conservadoras de esfínteres donde se incluye el tratamiento video asistido que aparece desde el año 2006 y en la cual se utiliza un sistema de video endoscopio sofisticado y de alto valor económico el cual hemos adaptado a nuestro medio. Pacientes y método: De septiembre del 2015 al 2017 en la Unidad de Coloproctología del Hospital Domingo Luciani IVSS se realizó un estudio prospectivo experimental, donde se incluyeron 18 pacientes con fístulas perianales complejas diagnosticadas previamente con Ecofistulografía 3D y los cuales se operaron con un sistema adaptado usando citoscopio pediátrico de 4 mm y energía láser. Se evaluaron parámetros referentes a la técnica así como la tasa de éxito y riesgo de incontinencia. Resultados: Tiempo quirúrgico de 40 a 80 minutos, con tasa de éxito de 89%, recidiva en 2 pacientes, con tiempo de seguimiento entre 12 a 36 meses y sin cambios en la escala de incontinencia pre y post quirúrgica. Conclusión: El tratamiento video asistido modificado para fistulas anales (VAMAFT) es una técnica innovadora y factible de realizar al adaptar algunos instrumentos, con una tasa de éxito adecuada y sin riesgo de incontinencia, pero más trabajos aleatorizados con mayor números de pacientes deben ser realizados.

Introduction: Anal fistulas have two basic problems, rate of recurrence and postoperative anal incontinence. These complications vary according to several factors such as type of anal fistula, surgical technique and the surgeon´s experience. For each cases there are different surgical techniques with and without conservation of anal sphincters like conservative video assisted anal fistula treatment, described in 2006, this technique uses a sophisticated and expensive endoscope system but that we modified to use in our hospitals. Patients and method: Between September 2015 to 2017 in the Unit of Coloproctology of Domingo Luciani Hospital, was perfomed a prospective and experimental trial in 18 patients with anal complex fistulas previously diagnosed using tridimensional anal ultrasound and operated with a modified system consisting of pediatric cystoscope of 4 mm and laser energy. Some parameters were evaluated including surgical technique, recurrence and anal incontinence rate. Results: Surgical times were between 40 to 80 minutes, success rate of 89%, recurrence in two patients with follow up of 12 to 36 months and no changes in pre and post surgical anal incontinence scale. Conclusion: Video assited modified anal fistula treatment (VAMAFT) is an innovative and feasible surgical technique to do adapting some instruments, with suitable success rate and without anal incontinence risk but many randomized research with more patients have to be perfomed.

Acceso venoso para hemodiálisis y repercusión crónica en el sistema cardiovascular / Hemodialysis venous access and chronic impact on cardiovascular system

En el tratamiento de enfermos renales en fase terminal, se realizan accesos vasculares para hemodiálisis. Son hechos habitualmente, en las venas de los miembros superiores, especialmente la técnica de Brecia y Cimino (fístula arteriovenosa latero lateral de la cefálica y la radial en la muñeca). La mayor complicación, directamente relacionada con un flujo excesivo por la fístula arteriovenosa, es la insuficiencia cardíaca congestiva. Se presenta el caso de un paciente con una fístula arteriovenosa (iatrogénica) que causó una insuficiencia cardiaca congestiva. El paciente, hipertenso conocido, tuvo un acceso venoso de más de 10 años de evolución (por un aparente diagnóstico y para una futura hemodiálisis que nunca fue efectuada). Acudió a consulta con disnea y edemas periféricos. Al examen físico se encontró la tensión arterial en 160 y 100 mm Hg, signos clínicos de cardiomegalia, edemas periféricos, ingurgitación yugular y hepatomegalia. Se palpó un thrill sistodiastólico en la muñeca izquierda, donde presentaba una cicatriz. Pudo observarse marcada dilatación y endurecimiento de todas las venas superficiales del plexo braquial de ese lado, (arterialización del árbol venoso del miembro superior izquierdo hasta las venas superficiales del hemitórax). Se diagnosticó una insuficiencia cardiaca de gasto alto, mejoró con el tratamiento habitual, pero continuó con la malformación venosa adquirida. Fue un caso muy llamativo, que muestra una complicación poco frecuente de los accesos venosos para hemodiálisis y también una causa mencionada, pero escasamente vista, de insuficiencia cardiaca de gasto elevado(AU)

In the treatment of renal patients in terminal phase. Vascular accesses are used for hemodialysis. They are usually performed in the veins of the upper limbs, especially using Brecia and Cimino technique (lateral arteriovenous fistula of the cephalic and radial at the wrist). The major complication, directly related to an excessive flow of arteriovenous fistula, is congestive heart failure. We present the case of a patient with an arteriovenous (iatrogenic) fistula that caused a congestive heart failure. He is hypertensive and had venous access for over 10 years of evolution (for an apparent diagnosis and for future hemodialysis, which was never performed). He went to the clinic with dyspnea and peripheral edema. Physical examination revealed blood pressure of 160 and 100 mm Hg, clinical signs of cardiomegaly, peripheral edema, jugular engorgement and hepatomegaly. We found a systodiastolic thrill on his left wrist, where there is a scar. A marked dilation and hardening of all the superficial veins of the brachial plexus on that side was observed, that is arterialization of the venous tree of the left upper limb to the superficial veins of hemitorax. The diagnosis was high output heart failure. He improved with the usual treatment, but the acquired venous malformation continued in an iatrogenic manner. It was a very striking case because of the infrequent complication of venous accesses for hemodialysis and because for rarely seen elevated heart failure(AU)

Comparative analysis of MR imaging findings of perianal fistulas in patients with and without Crohn disease / 中华放射学杂志

Objective To investigate the differences in magnetic resonance imaging characteristics between perianal?fistulas of Crohn disease (P?FCD) and perianal?fistulas of non?Crohn disease (P?FNCD). Methods A retrospective analysis was made of 109 patients with perianal fistula who were confirmed by clinical examinations and surgery and had complete preoperative pelvic MRI data from sir run run shaw hospital affiliated to Zhejiang University from June 2015 to March 2017. Patients were divided into P?FCD and P?FNCD groups according to whether the patient was clinically diagnosed with Crohn disease (CD). There were 59 cases in group P?FCD and 50 cases in group P?FNCD. All patients underwent pelvic MRI plain scan and enhanced scan. the classifications of perianal fistula (St. James University Hospital classification and improved Parks classification) were evaluated. The number of branches, the number of abscesses, the number of internal opening, the height of the internal opening were measured and recorded. The incidence of proctitis and anal inflammation were recorded. Van Assche score was evaluated. Measured data between patients in the P?FCD and P?FNCD groups were compared using independent sample t test (normal distribution) or non?parametric test (skewed distribution).The quantitative data were compared using cross?sectional Pearson χ2 test. Results There were significant differences in the number of branches, the number of abscesses, the number of internal opening, the height of the internal opening, the positive rate of proctitis, the positive rate of anal canalitis, and the Van Assche score between the P?FCD group and the P?FNCD group (all P<0.05). There was no significant difference in the modified Parks classification between the P?FCD group and the P?FNCD group (P>0.05).There was significant difference in the classification of St. James University Hospital between the P?FCD group and the P?FNCD group (P<0.05). Conclusions P?FCD is mainly composed of high complex anal fistula, which is significantly different from P?FNCD. We used St. James University Hospital classification and Van Assche score to diagnose perianal fistula in combination with clinical examinations, which was helpful for the diagnosis of P?FCD.

An Anatomical Study Of Gracilis Muscle & Its Role In Clinical Reconstruction Surgeries

Introduction: It is the most superficial of the adductor group of muscles. Gracilis muscle is used oftenly inreconstructive plastic surgery,because ofits reliable vascular and neurological pedicles and the minimal donorsite morbidity.Materials and Methods: The present study was conducted on 40 cadaveric lower limbs (22 males and 18 females)in the Deptartment of Anatomy of VIMS&RC.Metrical and non-metrical characteristics of gracilis muscle andvascular pedicles were analyzed.Results: All the parameter were more in males compared to females. distal tendon length was more than proximaltendon length. P value was significant in all the measurements. The ratios between various components ofmuscle remain fairly constant. Main vascular primary pedicle was arising from profund femoral artery in 60 %& 40% from Medial circumflex femoral artery .Presence of proximal secondary pedicle was only in 30% of thespecimens arising from profunda femoral artery or Medial circumflex femoral artery. Distal secondary pediclesarising from 5% of femoral artery.Conclusion: These parameters will help the reconstructive surgeon in assessing the length of muscle belly ortendon available for reparative procedures before undertaking surgery like Anterior Cruciate Ligament graft,Restoration of sphincteric function in anogenital area, Repair of ano-vaginal or recto-vaginal fistulas, Facialrehabilitation, Upper limb and lower limb defects, Groin wounds and autologous breast reconstruction.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center

PURPOSE: Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation. METHODS: We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses. RESULTS: Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%. CONCLUSION: The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.