Factores de riesgo en la aparición de fístula faringocutánea / Risk factors in the apparition of pharyngocutaneous fistula

RESUMEN Introducción: la fístula faringocutánea es la complicación postoperatoria más frecuente de la laringectomía total. Incrementa la morbimortalidad, demora la administración del tratamiento oncológico y repercute en la esfera psicológica del paciente. Objetivo: conocer el comportamiento de la fístula faringocutánea en pacientes con laringectomía total. Materiales y métodos: se realizó un estudio observacional, descriptivo, retrosprospectivo en el Hospital Universitario "Comandante Faustino Pérez", en el período comprendido entre enero 2010 a diciembre 2015. El universo lo constituyó 143 pacientes laringectomizados. Se estudiaron las variables: edad, sexo, estado nutricional previo a la cirugía, estadio del tumor, radiaciones, traqueostomía; manejo del cuello, previo a la cirugía, y evolución de la fístula. Resultados: presentó fístula postoperatoria el 28 %, predominando el sexo masculino, en un 92.3 %; y los normopesos en un 56,6 %. Se encontraban en estadio IV, el 70 %. Fueron irradiados 72,5 % y se les practicó traqueostomía, previa a la cirugía, al 95 % de los pacientes. Vaciamiento cervical se realizó al 37,5 %. En el 70 % de los pacientes, la fístula apareció entre los 8 y 14 días. Conclusiones: la incidencia de la fístula faringocutánea es mayor en el sexo masculino entre los 60-69 años. La mayor incidencia ocurrió en el año 2015. El estadio avanzado del tumor, la presencia de traqueostomía, el estado nutricional e irradiación previa, fueron los factores que más incidieron en la aparición de fístula faringocutánea. En la mayoría de los pacientes el cierre fue espontáneo con buena su evolución (AU).

ABSTRACT Introduction: pharyngocutaneous fistula is the most frequent post-surgery complication of the total laryngectomy. It increases morbimortality, delays the administration of the oncological treatment and rebounds in the patient's psychological sphere. Objective: to know the behavior of the pharyngocutaneous fistula in patients with total laryngectomy. Materials and methods: a retrospective, descriptive, observational study was carried out in the University Hospital "Comandante Faustino Pérez", in the period from January 2010 until December 2015. The universe were 143 patients who undergone a laryngectomy. The studied variables were age, sex, nutritional status before the surgery, tumor stage, radiations, tracheotomy, neck management before surgery, and fistula evolution. Results: 28 % of the patients presented post-surgery fistula, predominantly among males (92.3 %). Normal weight patients were 56.6 %; 70 % were in the IV stage. 72.5 % of the patients were irradiated and 95 % undergone tracheotomy before the surgery. 37.5 % of them undergone cervical resection. In 70 % of the patients, the fistula appeared after 8-14 days. Conclusions: the incidence of the pharyngocutaneous fistula is higher in the male sex and the 60-69 years age-group. The highest incidence occurred in 2015. The advanced stage of the tumor, the presence of tracheotomy, the nutritional status and previous irradiation were the factors that had more incidences on pharyngocutaneous fistulae. The closure of the fistula was spontaneous in most of the patients, with a good evolution (AU).

Características e diagnóstico diferencial das doenças inflamatórias intestinais / Characteristics and differential diagnosis of inflammatory bowel diseases

As doenças inflamatórias intestinais (DIIs) compreendem, principalmente, a doença de Crohn (DC) e a retocolite ulcerativa (RU), ambas idiopáticas, porém relacionadas a uma resposta imunológica anormal à microbiota bacteriana da luz intestinal. Na RU a inflamação é difusa, restrita à mucosa e inespecífica, com comprometimento contínuo da parede, principalmente do reto, enquanto na DC as lesões são descontínuas, podem comprometer todas as camadas da parede e afetar qualquer parte do trato gastrointestinal. O quadro clínico é comum e compreende diarreia, febre e dores abdominais, podendo cursar também com manifestações extraintestinais. O diagnóstico é feito através dos dados clínicos, achados radiológicos e histológicos, sem haver, no entanto, nenhuma característica que isoladamente feche o diagnóstico de DII específica.

Inflammatory bowel diseases (IBDs) comprise mainly Crohn?s disease (CD) and ulcerative colitis (UC), both are idiopathic but believed to be related to an abnormal immune response to bacterial microbiota in the intestinal lumen. In RU diffuse inflammation is restricted to the mucosa and is nonspecific, with continued commitment that stars at rectum?s wall. In DC, the injuries are discontinuous, involve all layers of the intestinal wall and can affect any part of the gastrointestinal tract. The clinical picture of both is diarrhea, fever, abdominal pain, and may present with extraintestinal manifestations. The diagnosis is made by the junction of clinical, radiological and histological findings, without having, however, a feature alone that leads to a diagnosis of a specific IBD.

Fistula enterocutanea de dificil manejo / Difficult to treat enterocutaneous fistula

Introducción. Las fistulas entero cutáneas todavía son uno de los problemas quirúrgicos más difíciles de manejar. Los pacientes frecuentemente cursan con malnutrición, infección de la pared abdominal y sepsis. Las fistulas son consecuencia de diversos factores pero por lo general se manifiestan en el posoperatorio de procedimientos para el tratamiento del intestino o cáncer, a pesar de una estrategia de manejo muy especifica desarrollada en el curso de los últimos 25 años, la tasa de mortalidad sigue siendo elevada. Presentación de caso. Se trata de un paciente con antecedente de cirugía abdominal 20 años antes, quien fue operado de emergencia por obstrucción intestinal secundaria a bridas y/o adherencias. Se efectuó un manejo médico amplio e integral, pues presentó fístulas recurrentes durante el período posoperatorio inmediato. La evolución final fue hacia la mejoría sin más recurrencias. Conclusión. El presente caso muestra que el tratamiento exitoso incluye reconocimiento temprano, reanimación, tratamiento de la sepsis, estudio y localización de la fistula, cuidados de la piel, soporte nutricional, manejo en equipo y estimar el tiempo de operación apropiado...

Enterocutaneous Fistula: a Tanzanian Experience in a Tertiary Care Hospital

Background: Enterocutaneous fistulae pose a therapeutic challenge to general surgeons all over the world and contribute significantly to high morbidity and mortality. The aim of this study was to describe our experience in the management of enterocutaneous fistulas; outlining the causes; fistula characteristics; treatment outcome and prognostic factors for fistula closure and mortality in our local setting. Methods: A prospective study of patients with enterocutaneous fistulae was conducted at Bugando Medical Centre between December 2007 and November 2009. After informed written consent for the study and HIV testing; all patients who met the inclusion criteria were consecutively enrolled into the study. Data were collected using a pre-tested; coded questionnaire and analyzed using SPSS software version 11.5. Results: Ninety two patients were seen during the study. There were 54 males (58.7) and 38 (41.3) females (M: F ratio = 1.4:1). Post-operative complication was the commonest cause of enterocutaneous fistulae in 91.3of cases. The majority of patients (63.0) had high output fistulae and the jejuno-ileum was commonly affected (60.9). The complication rate was 34.8and sepsis was the most common complication. Sixteen patients (17.4) had HIV infection. Fistula closure was successfully achieved in 64 patients (69.6). Of these; 42 patients (65.6) had spontaneous closure and 22 patients (34.4) underwent surgical closure. Mortality rate was 30.4. Using multivariate logistic regression; the cause of fistula; fistula output; presence of complications and institutional origin of the patient were found to be significant predictors of spontaneous closure (p-value 0.001); where as surgical closure was significantly associated with presence of complications and pre-morbid illness (p-value 0.001). Fistula output; institutional origin of the patient; presence of complications and premorbid illness; HIV positivity and CD4 count were significant predictors of mortality. Conclusion: Enterocutaneous fistulae pose a therapeutic challenge at BMC and contribute significantly to high morbidity and mortality. A multidisciplinary approach focusing on fluid resuscitation; nutritional supplementation; electrolyte replenishment; control of sepsis; containment of effluent; skin integrity and surgery at appropriate time is necessary to lessen morbidity and mortality with a higher fistula closure rate. The high rate of postoperative enterocutaneous fistulae resulting from anastomotic breakdown in patients referred from peripheral hospitals calls for urgent surgical skill training course in this region. The high rate of HIV infection in these patients needs further studies

Vesicocutaneous Fistula Presenting Groin Abscess and Chronic Osteomyelitis in Pubic Bone

The authors report a case of bladder fistula associated with a medial thigh cutaneous fistula and chronic osteomyelitis of the pubic bone 11 years after surgery for a pelvic bone fracture and bladder rupture. In the presenting case, despite the clinical suspicion, none of the diagnostic tools demonstrated the bladder fistula preoperatively. This case suggests that bladder repair should be prepared, even if the bladder fistula cannot be confirmed by imaging studies because the amount of urine leakage can be minimal or the fistula can close spontaneously.

Fístula colecistocutânea espontânea:uma rara complicação da doença calculosa da vesícula biliar / Spontaneous cholecystocutaneous fistula: a rare complication of gallbladder disease

Introdução: As fístulas colecistocutâneas são complicações infrequentes decorrentes de processos inflamatórios ou infecciosos que ocorrem envolvendo a vesícula biliar ou vias biliares incluindo colédoco e ducto cístico. O primeiro relato data de 1640 por Thilesus, e sua incidência vem diminuindo provavelmente devido à melhora dos métodos diagnósticos de imagem e tratamentos medicamentosos. Relato de caso: Relatamos aqui um caso de um paciente do sexo masculino, de 63 anos de idade, que apresentou como queixa inicial uma dor em hipocôndrio direito do tipo cólica, há cerca de quatro meses, que evoluiu com abscesso local, drenado em outro serviço. Seguiu-se à drenagem débito bilioso persistente. O paciente foi submetido à colangiopancreatografia retrógrada endoscópica com retirada de múltiplos cálculos do colédoco. Após 30 dias o paciente foi operado, sendo realizada colecistectomia com exploração radiológica das vias biliares que evidenciou normalidade das vias biliares intra e extra-hepáticas, obstrução do ducto cístico, estenose de colédoco proximal de cerca de dois centímetros e ausência de cálculos biliares. Realizou-se ainda a ressecção da porção estenosada do colédoco com anastomose primária término-terminal e drenagem a Kher. O paciente evoluiu com fístula biliar pós-operatória orientada por dreno cavitário, evoluindo com baixo débito de cerca de 150 mililitros até o 15º pós-operatório. Discussão: As fístulas colecistocutâneas são uma complicação cada vez mais rara de processos inflamatórios ou infecciosos do trato colecistobiliar, os quais exigem tratamento cirúrgico efetivo envolvendo a colecistectomia com reestabelecimento do trajeto fisiológico de drenagem biliar.

Introduction: The cholecystocutaneous fistulae are unusual complications resulting from infectious or inflammatory processes that occur involving the gallbladder or biliary tract, including choledochal and cystic duct. The first report dates from 1640 by Thilesus, and its incidence has decreased due to improved diagnostic methods for image and drug treatments. Case report: We report a case of a 63 years old male patient who presented an initial complaint of pain in the right hypochondrium, type colic, for about four months, who developed local abscess, drained in another service. Following, there was persistent bilious drainage flow. The patient underwent endoscopic retrograde cholangiopancreatography with the withdrawal of multiple choledochal gallbladder. After 30 days the patient was operated with cholecystectomy performed, with the usage of radiological exploration of the biliary tract, which showed normal intra and extra-hepatic bile ducts, obstruction of the cystic duct, stenosis of proximal choledochal of about two centimeters and absence of gallstones. There was also the resection of the portion of choledochal stenosis with primary end-to-end anastomosis and drainage to Khera. The patient evolved with postoperative biliary fistula guided by drain cavity, evolving with low debt of about 150 milliliters to 15 postoperatively. Discussion: The cholecystocutaneous fistula is an increasingly rare complication of infectious or inflammatory processes of biliary tract, which require surgical treatment with cholecystectomy involving the effective re-establishment of the physiological pathway of bile drainage.

Loss of permanent mandibular lateral incisor and canine tooth buds through extraoral sinus: report of a case.

Extraoral sinus tract may occur as a result of an inflammatory process associated with the necrotic pulp. Several non odontogenic disorders may also produce an extraoral sinus tract, the differential diagnosis of these clinical findings is of prime importance in providing appropriate clinical care. Presented here is a case report of 4 year old female child with extraoral sinus tract through which the tooth buds of mandibular permanent left lateral incisor and mandibular permanent left canine were lost. The extraoral sinus was due to mandibular left primary canine with class IX fracture (Ellis and Davey's classification).

Fístula cutánea de líquido cefalorraquídeo / Cerebrospinal fluid cutaneous fistula

Se presenta un caso de paciente embarazada de 33 semanas más 6 días por fecha de última regla, atendida en la emergencia obstétrica del Hospital Universitario de Caracas por cuadro clínico de pielonefritis y oligoamnios severo, quien posterior a mejorar sus condiciones clínicas es sometida a cesárea segmentaria con técnica epidural sin complicaciones, presentando seis horas más tarde salida de líquido cefalorraquídeo a través de las zona de punción de forma persistente constatado al realizársele prueba de glucosa al mismo que reportó 95 mg/dL; consistente con líquido cefalorraquídeo. Proceso que ameritó parche hemático a las 72 horas evolucionando satisfactoriamente