AIM:To describe the characteristics of coronary artery fistulas(CAFs) in adults,including donor vessels and whether termination was cameral or vascular. METHODS:A PubMed search was performed for articles between 2000 ...AIM:To describe the characteristics of coronary artery fistulas(CAFs) in adults,including donor vessels and whether termination was cameral or vascular. METHODS:A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults.A group of 304 adults was collected.Clinical data,presentations,diagnostic modalities,angiographic fistula findings and treatment strategies were gathered and analyzed.With regard to CAF origin,the subjects were tabulated into unilateral,bilateral or multilateral fistulas and compared.The group was stratified into two major subsets according to the mode of termination;coronary-cameral fistulas(CCFs) and coronary-vascular fistulas(CVFs) . A comparison was made between the two subsets. Fistula-related major complications[aneurysm formation,infective endocarditis(IE) ,myocardial infarction(MI) ,rupture,pericardial effusion(PE) and tamponade] were described.Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery(PA) . RESULTS:A total of 304 adult subjects(47%male) with congenital CAFs were included.The mean age was51.4 years(range,18-86 years) ,with 20%older than 65 years of age.Dyspnea(31%) ,chest pain(23%) and angina pectoris(21%) were the prevalent clinical presentations.Continuous cardiac murmur was heard in 82%of the subjects.Of the applied diagnostic modalities,chest X-ray showed an abnormal shadow in 4%of the subjects.The cornerstone in establishing the diagnosis was echocardiography(68%) ,and conventional contrast coronary angiography(97%) .However,multislice detector computed tomography was performed in 16%.The unilateral fistula originated from the left in 69%and from the right coronary artery in 31%of the subjects.Most patients(80%) had unilateral fistulas,18%presented with bilateral fistulas and 2%with multilateral fistulas.Termination into the PA was reported in unilateral(44%) ,bilateral(73%) and multilateral展开更多
AIM: To assess whether the use of fibrin sealantshortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with...AIM: To assess whether the use of fibrin sealantshortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support. RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition. CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.展开更多
To describe the etiology, anatomy and pathophysiology of rectovaginal fistulas(RVFs); and to describe a systematic surgical approach to help achieve optimal outcomes. A current review of the literature was performed t...To describe the etiology, anatomy and pathophysiology of rectovaginal fistulas(RVFs); and to describe a systematic surgical approach to help achieve optimal outcomes. A current review of the literature was performed to identify the most up-to-date techniques and outcomes for repair of RVFs. RVFs present a difficult problem that is frustrating for patients and surgeons alike. Multiple trips to the operating room are generally needed to resolve the fistula, and the recurrence rate approaches40% when considering all of the surgical options. At present, surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with colo-anal reconstruction. There are general principles that will allow the best chance for resolution of the fistula with the least morbidity to the patient. These principles include: resolving the sepsis, identifying the anatomy, starting with least invasive surgical options, and interposing healthy tissue for complex or recurrent fistulas.展开更多
Last centuries have witnessed tremendous sophistication and progress in the detection,diagnosis and treatment of coronary artery fistulas(CAFs).In many countries,CAFs were reported to be visualized and treated using s...Last centuries have witnessed tremendous sophistication and progress in the detection,diagnosis and treatment of coronary artery fistulas(CAFs).In many countries,CAFs were reported to be visualized and treated using several imaging techniques and different management strategies.Reports from nearly all continents of the globe have contributed to the description of CAFs,not only in Asia and Europe but also throughout North and Latin America.However,these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias.A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009.A total of 233 subjects were collected,and analysed according to their drainage site and treatment modality.They were divided into two subgroups:percutaneous transluminal embolization group(PTE group,n=122)and surgical ligation group(SL group,n=111).In the SL group,atherosclerotic coronary artery disease(19%)and associated congenital lesions(23%)were more prevalent compared with the PTE group(9%and 8%),respectively.Infective endocarditis was more frequently seen in the SL group besides syncope,congestive heart failure and hemopericardium.In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.展开更多
AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched...AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched for relevant articles(published 2000-November 2016) and congress abstracts(published 2011-November 2016).RESULTS Of 535 records reviewed, 62 relevant sources were identified(mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14%(follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment(failure and relapse rates,respectively: medical, 12%-73% and 0%-41%; surgical:0%-100% and 11%.20%; combined medical/surgical:0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies(1 of infliximab; 3 of surgical interventions)have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD.CONCLUSION Complex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to antitumour necrosis factor-α agents, as evidenced by high failure and relapse rates.展开更多
Aim: This paper aims to report the second case of mucinous carcinoma of the scrotum revealed by scrotal fistulas listed in the literature and highlight the difficulties in the search and difficulties encountered in th...Aim: This paper aims to report the second case of mucinous carcinoma of the scrotum revealed by scrotal fistulas listed in the literature and highlight the difficulties in the search and difficulties encountered in the management of urogenital cancers in developing countries. Case presentation: This was a 62-year-old patient who had consulted for fistulized lesions of the scrotum associated with urinary disorders. Physical examination found budding lesions in the scrotum from which mucus was leaking. The diagnostic assessment carried out consisted of a biopsy sample of the scrotal lesions, a blood analysis and medical imaging, which led to the diagnosis. The mutilating nature of the surgery proposed to the patient after multidisciplinary consultation meeting and the expensive cost of chemotherapy drugs constituted the limits of the patient’s therapeutic management. Conclusion: Mucinous carcinoma of the scrotum is rare and primary lesion should always be sought. The presence of budding lesions of the scrotum with discharge of mucus should suggest the diagnosis.展开更多
Failure of arteriovenous fistulas(AVF) to mature and thrombosis in matured fistulas have been the major causes of morbidity and mortality in hemodialysis patients. Stenosis, which occurs due to adverse remodeling in A...Failure of arteriovenous fistulas(AVF) to mature and thrombosis in matured fistulas have been the major causes of morbidity and mortality in hemodialysis patients. Stenosis, which occurs due to adverse remodeling in AVFs, is one of the major underlying factors under both scenarios. Early diagnosis of a stenosis in an AVF can provide an opportunity to intervene in a timelymanner for either assisting the maturation process or avoiding the thrombosis. The goal of surveillance strategies was to supplement the clinical evaluation(i.e., physical examination) of the AVF for better and earlier diagnosis of a developing stenosis. Surveillance strategies were mainly based on measurement of functional hemodynamic endpoints, including blood flow(Q a) to the vascular access and venous access pressure(VAP). As the changes in arterial pressure(MAP) affects the level of VAP, the ratio of VAP to MAP(VAPR = VAP/MAP) was used for diagnosis. A Q a < 400-500 m L/min or a VAPR > 0.55 is considered sign of significant stenosis, which requires immediate intervention. However, due to the complex nature of AVFs, the surveillance strategies have failed to consistently detect stenosis under different scenarios. VAPR has been primarily developed to detect outflow stenosis in arteriovenous grafts, and it hasn't been successful in accurate diagnosis of outflow lesions in AVFs. Similarly, AVFs can maintain relatively high blood flow despite the presence of a significant outflow stenosis and thus, Q a has been found to be a better predictor of only inflow lesions. Similar shortcomings have been reported in the detection of functional severity of coronary stenosis using diagnostic endpoints that were based on either flow or pressure. This limitation has been associated with the fact that both pressure and flow change in the presence of a stenosis and thus, hemodynamic diagnostic endpoints that employ only one of these parameters are inherently prone to inaccuracies. Recent attempts have resulted in development of new diagnostic endpoints that can展开更多
Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders.Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting,but pati...Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders.Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting,but patients tend not to seek medical attention due to embarrassment or fear of cancer.As a result,patients frequently present with advanced disease after experiencing significant decreases in quality of life.A number of patients with anorectal complaints are referred to gastroenterologists.However,gastroenterologists' knowledge and experience in approaching these conditions may not be sufficient.This article can serve as a guide to gastroenterologists to recognize,evaluate,and manage medically or non-surgically common benign anorectal disorders,and to identify when surgical referrals are most prudent.A review of the current literature is performed to evaluate comprehensive clinical pearls and management guidelines for each topic.Topics reviewed include hemorrhoids,anal fissures,anorectal fistulas and abscesses,and pruritus ani.展开更多
BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,...BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,are rare.The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk.During physical examination,there was right eye exophthalmos and ocular motor palsy.The rest of the neurological examination was clear.Notably,the patient had no history of head injury.The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula.Coils and Onyx were placed through the femoral venous route,followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique.No intraoperative or perioperative complications occurred.Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.展开更多
AIM To assess the functionality of congenital coronary artery fistulas(CAFs) using adenosine stress ^(13)N-ammonia positron emission tomography computed tomography(PET-CT).METHODS Congenital CAFs were incidentally det...AIM To assess the functionality of congenital coronary artery fistulas(CAFs) using adenosine stress ^(13)N-ammonia positron emission tomography computed tomography(PET-CT).METHODS Congenital CAFs were incidentally detected during coronary angiography(CAG) procedures in 11 adult patients(six males and five females) with a mean age of 64.3 years(range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas(origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress ^(13)N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula. RESULTS Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery(n = 8), right coronary artery(n = 2) and circumflex(n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery(n = 11) or coronary sinus(n = 1). The CAG delineated the characteristics of the fistula(origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas(8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components(23/36, 64%). Adenosine pharmacologic stress ^(13)N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.CONCLUSION PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.展开更多
Acquired coronary artery fistulas(CCFs)are infrequently detected during conventional coronary angiography.To delineate the characteristics of congenital(first part)and acquired(second part)CCFs in adults,a PubMed sear...Acquired coronary artery fistulas(CCFs)are infrequently detected during conventional coronary angiography.To delineate the characteristics of congenital(first part)and acquired(second part)CCFs in adults,a PubMed search was conducted for papers dealing with congenital or acquired CCFs.None of the publications describing patients with coronary-vascular fistulas were included.Papers dealing with pediatric subjects were excluded.From the world literature,a total of 243adult patients were selected who had congenital(n=159/243,65%)and acquired(n=84/243,35%)CCFs.Among the acquired types(n=72,85.7%)were traumatic(iatrogenic(n=65/72,90%),accidental(n=7/72,10%)and(n=12,14.3%)spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction.A high incidence of spontaneousresolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported.Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8%of the subjects.Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs.The congenital types are addressed in a previous issue of this journal(first part).In this review(second of two parts,partⅡ),we describe the acquired coronarycameral fistulas.展开更多
Background and Aims:Hepatic arterioportal fistulas(HAPFs)are abnormal shunts or aberrant functional con-nections between the portal venous and the hepatic arte-rial systems.Detection of HAPFs has increased with the ad...Background and Aims:Hepatic arterioportal fistulas(HAPFs)are abnormal shunts or aberrant functional con-nections between the portal venous and the hepatic arte-rial systems.Detection of HAPFs has increased with the ad-vances in diagnostic techniques.Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function.However,the underlying causes of HAPFs and the treatment outcomes are now well character-ized.This study aimed to summarize the clinical character-istics of patients with HAPFs,and to compare the outcomes of different treatment modalities.Methods:Data of 97 pa-tients with HAPFs who were admitted to the Second Xiang-ya Hospital between January 2010 and January 2020 were retrospectively reviewed.Demographic information,clinical manifestations,underlying causes,treatment options,and short-term outcomes were analyzed.Results:The main cause of HAPF in our cohort was hepatocellular carcinoma(78/97,80.41%),followed by cirrhosis(10/97,10.31%).The main clinical manifestations were abdominal distention and abdominal pain.Treatment methods included transcath-eter arterial embolization(n=63,64.9%),surgery(n=13,13.4%),and liver transplantation(n=2,2.1%);nineteen(19.6%)patients received conservative treatment.Among patients who underwent transcatheter arterial embolization,polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy.Conclusions:Hepatocellular carcinoma and cirrhosis are common causes of HAPFs.Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs,and polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy in our cohort.展开更多
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pa...The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.展开更多
AIM To establish and evaluate an experimental porcine model of fistula-in-ano.METHODS Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band l...AIM To establish and evaluate an experimental porcine model of fistula-in-ano.METHODS Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band ligation surgery, and the control group underwent an artificial damage technique. Clinical magnetic resonance imaging(MRI) and histopathological evaluation were performed on the 38 th d and 48 th d after surgery in both groups, respectively. RESULTS There were no significant differences between the experimental group and the control group in general characteristics such as body weight, gender, and the number of fistula(P > 0.05). In the experimental group, 15 fistulas were confirmed clinically, 13 complex fistulas were confirmed by MRI, and 11 complex fistulas were confirmed by histopathology. The success rate in the porcine complex fistula model establishment was 83.33%. Among the 18 fistulas in the control group, 5 fistulas were confirmed clinically, 4 complex fistulas were confirmed by MRI, and 3 fistulas were confirmed by histopathology. The success rate in the porcine fistula model establishment was 27.78%. Thus, the success rate of the rubber band ligation group was significantly higher than the control group(P < 0.05). CONCLUSION Rubber band ligation is a stable and reliable method to establish complex fistula-in-ano models. Large animal models of complex anal fistulas can be used for the diagnosis and treatment of anal fistulas.展开更多
AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aor...AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case- an adult male who presented with ACF between commissures of the right and noncoronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV- is added, the world literature is briefly reviewed.RESULTS A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital(47%) or acquired(53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea(21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23(60%), single method in 14(37%)(echocardiography in 12 and catheterization in 2), and at autopsy in 2(3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12(30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24(63%). CONCLUSION Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.展开更多
BACKGROUND Patients with Crohn’s disease(CD)are at risk of developing complications such as perianal fistulas.Patients with Crohn’s perianal fistulas(CPF)are affected by fecal incontinence(FI),bleeding,pain,swelling...BACKGROUND Patients with Crohn’s disease(CD)are at risk of developing complications such as perianal fistulas.Patients with Crohn’s perianal fistulas(CPF)are affected by fecal incontinence(FI),bleeding,pain,swelling,and purulent perianal discharge,and METHODS This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries(April-August 2021).Patients were recruited into three cohorts:Cohort 1 included patients without perianal fistulas;cohort 2 included patients with perianal fistulas without fistula-related surgery;and cohort 3 included patients with perianal fistulas and fistula-related surgery.Validated patient-reported outcome measures were used to assess quality of life.Drivers of treatment preferences were measured using a discrete choice experiment(DCE).RESULTS In total,929 patients were recruited(cohort 1,n=620;cohort 2,n=174;cohort 3,n=135).Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF(cohorts 2 and 3)than for those with CD without CPF(cohort 1):Mean score 3.8 and 3.7 vs 4.1,respectively,(P<0.001).Similarly,mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF.Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery(cohorts 2 and 3):Mean score 41 and 42,respectively.In the DCE,postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice:Mean relative importance 35.7 and 24.7,respectively.CONCLUSION The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.展开更多
文摘AIM:To describe the characteristics of coronary artery fistulas(CAFs) in adults,including donor vessels and whether termination was cameral or vascular. METHODS:A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults.A group of 304 adults was collected.Clinical data,presentations,diagnostic modalities,angiographic fistula findings and treatment strategies were gathered and analyzed.With regard to CAF origin,the subjects were tabulated into unilateral,bilateral or multilateral fistulas and compared.The group was stratified into two major subsets according to the mode of termination;coronary-cameral fistulas(CCFs) and coronary-vascular fistulas(CVFs) . A comparison was made between the two subsets. Fistula-related major complications[aneurysm formation,infective endocarditis(IE) ,myocardial infarction(MI) ,rupture,pericardial effusion(PE) and tamponade] were described.Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery(PA) . RESULTS:A total of 304 adult subjects(47%male) with congenital CAFs were included.The mean age was51.4 years(range,18-86 years) ,with 20%older than 65 years of age.Dyspnea(31%) ,chest pain(23%) and angina pectoris(21%) were the prevalent clinical presentations.Continuous cardiac murmur was heard in 82%of the subjects.Of the applied diagnostic modalities,chest X-ray showed an abnormal shadow in 4%of the subjects.The cornerstone in establishing the diagnosis was echocardiography(68%) ,and conventional contrast coronary angiography(97%) .However,multislice detector computed tomography was performed in 16%.The unilateral fistula originated from the left in 69%and from the right coronary artery in 31%of the subjects.Most patients(80%) had unilateral fistulas,18%presented with bilateral fistulas and 2%with multilateral fistulas.Termination into the PA was reported in unilateral(44%) ,bilateral(73%) and multilateral
基金Supported by A Grant from the National Council of Scienceand Technology, No. Conacyt-Si Morelos 2000-0302003
文摘AIM: To assess whether the use of fibrin sealantshortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support. RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition. CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.
文摘To describe the etiology, anatomy and pathophysiology of rectovaginal fistulas(RVFs); and to describe a systematic surgical approach to help achieve optimal outcomes. A current review of the literature was performed to identify the most up-to-date techniques and outcomes for repair of RVFs. RVFs present a difficult problem that is frustrating for patients and surgeons alike. Multiple trips to the operating room are generally needed to resolve the fistula, and the recurrence rate approaches40% when considering all of the surgical options. At present, surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with colo-anal reconstruction. There are general principles that will allow the best chance for resolution of the fistula with the least morbidity to the patient. These principles include: resolving the sepsis, identifying the anatomy, starting with least invasive surgical options, and interposing healthy tissue for complex or recurrent fistulas.
文摘Last centuries have witnessed tremendous sophistication and progress in the detection,diagnosis and treatment of coronary artery fistulas(CAFs).In many countries,CAFs were reported to be visualized and treated using several imaging techniques and different management strategies.Reports from nearly all continents of the globe have contributed to the description of CAFs,not only in Asia and Europe but also throughout North and Latin America.However,these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias.A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009.A total of 233 subjects were collected,and analysed according to their drainage site and treatment modality.They were divided into two subgroups:percutaneous transluminal embolization group(PTE group,n=122)and surgical ligation group(SL group,n=111).In the SL group,atherosclerotic coronary artery disease(19%)and associated congenital lesions(23%)were more prevalent compared with the PTE group(9%and 8%),respectively.Infective endocarditis was more frequently seen in the SL group besides syncope,congestive heart failure and hemopericardium.In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.
基金Kate Lothman of RTI Health Solutions provided medical writing services,which were funded by Takeda
文摘AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched for relevant articles(published 2000-November 2016) and congress abstracts(published 2011-November 2016).RESULTS Of 535 records reviewed, 62 relevant sources were identified(mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14%(follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment(failure and relapse rates,respectively: medical, 12%-73% and 0%-41%; surgical:0%-100% and 11%.20%; combined medical/surgical:0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies(1 of infliximab; 3 of surgical interventions)have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD.CONCLUSION Complex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to antitumour necrosis factor-α agents, as evidenced by high failure and relapse rates.
文摘Aim: This paper aims to report the second case of mucinous carcinoma of the scrotum revealed by scrotal fistulas listed in the literature and highlight the difficulties in the search and difficulties encountered in the management of urogenital cancers in developing countries. Case presentation: This was a 62-year-old patient who had consulted for fistulized lesions of the scrotum associated with urinary disorders. Physical examination found budding lesions in the scrotum from which mucus was leaking. The diagnostic assessment carried out consisted of a biopsy sample of the scrotal lesions, a blood analysis and medical imaging, which led to the diagnosis. The mutilating nature of the surgery proposed to the patient after multidisciplinary consultation meeting and the expensive cost of chemotherapy drugs constituted the limits of the patient’s therapeutic management. Conclusion: Mucinous carcinoma of the scrotum is rare and primary lesion should always be sought. The presence of budding lesions of the scrotum with discharge of mucus should suggest the diagnosis.
文摘Failure of arteriovenous fistulas(AVF) to mature and thrombosis in matured fistulas have been the major causes of morbidity and mortality in hemodialysis patients. Stenosis, which occurs due to adverse remodeling in AVFs, is one of the major underlying factors under both scenarios. Early diagnosis of a stenosis in an AVF can provide an opportunity to intervene in a timelymanner for either assisting the maturation process or avoiding the thrombosis. The goal of surveillance strategies was to supplement the clinical evaluation(i.e., physical examination) of the AVF for better and earlier diagnosis of a developing stenosis. Surveillance strategies were mainly based on measurement of functional hemodynamic endpoints, including blood flow(Q a) to the vascular access and venous access pressure(VAP). As the changes in arterial pressure(MAP) affects the level of VAP, the ratio of VAP to MAP(VAPR = VAP/MAP) was used for diagnosis. A Q a < 400-500 m L/min or a VAPR > 0.55 is considered sign of significant stenosis, which requires immediate intervention. However, due to the complex nature of AVFs, the surveillance strategies have failed to consistently detect stenosis under different scenarios. VAPR has been primarily developed to detect outflow stenosis in arteriovenous grafts, and it hasn't been successful in accurate diagnosis of outflow lesions in AVFs. Similarly, AVFs can maintain relatively high blood flow despite the presence of a significant outflow stenosis and thus, Q a has been found to be a better predictor of only inflow lesions. Similar shortcomings have been reported in the detection of functional severity of coronary stenosis using diagnostic endpoints that were based on either flow or pressure. This limitation has been associated with the fact that both pressure and flow change in the presence of a stenosis and thus, hemodynamic diagnostic endpoints that employ only one of these parameters are inherently prone to inaccuracies. Recent attempts have resulted in development of new diagnostic endpoints that can
文摘Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders.Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting,but patients tend not to seek medical attention due to embarrassment or fear of cancer.As a result,patients frequently present with advanced disease after experiencing significant decreases in quality of life.A number of patients with anorectal complaints are referred to gastroenterologists.However,gastroenterologists' knowledge and experience in approaching these conditions may not be sufficient.This article can serve as a guide to gastroenterologists to recognize,evaluate,and manage medically or non-surgically common benign anorectal disorders,and to identify when surgical referrals are most prudent.A review of the current literature is performed to evaluate comprehensive clinical pearls and management guidelines for each topic.Topics reviewed include hemorrhoids,anal fissures,anorectal fistulas and abscesses,and pruritus ani.
文摘BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,are rare.The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk.During physical examination,there was right eye exophthalmos and ocular motor palsy.The rest of the neurological examination was clear.Notably,the patient had no history of head injury.The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula.Coils and Onyx were placed through the femoral venous route,followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique.No intraoperative or perioperative complications occurred.Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.
文摘AIM To assess the functionality of congenital coronary artery fistulas(CAFs) using adenosine stress ^(13)N-ammonia positron emission tomography computed tomography(PET-CT).METHODS Congenital CAFs were incidentally detected during coronary angiography(CAG) procedures in 11 adult patients(six males and five females) with a mean age of 64.3 years(range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas(origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress ^(13)N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula. RESULTS Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery(n = 8), right coronary artery(n = 2) and circumflex(n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery(n = 11) or coronary sinus(n = 1). The CAG delineated the characteristics of the fistula(origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas(8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components(23/36, 64%). Adenosine pharmacologic stress ^(13)N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.CONCLUSION PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.
文摘Acquired coronary artery fistulas(CCFs)are infrequently detected during conventional coronary angiography.To delineate the characteristics of congenital(first part)and acquired(second part)CCFs in adults,a PubMed search was conducted for papers dealing with congenital or acquired CCFs.None of the publications describing patients with coronary-vascular fistulas were included.Papers dealing with pediatric subjects were excluded.From the world literature,a total of 243adult patients were selected who had congenital(n=159/243,65%)and acquired(n=84/243,35%)CCFs.Among the acquired types(n=72,85.7%)were traumatic(iatrogenic(n=65/72,90%),accidental(n=7/72,10%)and(n=12,14.3%)spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction.A high incidence of spontaneousresolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported.Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8%of the subjects.Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs.The congenital types are addressed in a previous issue of this journal(first part).In this review(second of two parts,partⅡ),we describe the acquired coronarycameral fistulas.
文摘Background and Aims:Hepatic arterioportal fistulas(HAPFs)are abnormal shunts or aberrant functional con-nections between the portal venous and the hepatic arte-rial systems.Detection of HAPFs has increased with the ad-vances in diagnostic techniques.Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function.However,the underlying causes of HAPFs and the treatment outcomes are now well character-ized.This study aimed to summarize the clinical character-istics of patients with HAPFs,and to compare the outcomes of different treatment modalities.Methods:Data of 97 pa-tients with HAPFs who were admitted to the Second Xiang-ya Hospital between January 2010 and January 2020 were retrospectively reviewed.Demographic information,clinical manifestations,underlying causes,treatment options,and short-term outcomes were analyzed.Results:The main cause of HAPF in our cohort was hepatocellular carcinoma(78/97,80.41%),followed by cirrhosis(10/97,10.31%).The main clinical manifestations were abdominal distention and abdominal pain.Treatment methods included transcath-eter arterial embolization(n=63,64.9%),surgery(n=13,13.4%),and liver transplantation(n=2,2.1%);nineteen(19.6%)patients received conservative treatment.Among patients who underwent transcatheter arterial embolization,polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy.Conclusions:Hepatocellular carcinoma and cirrhosis are common causes of HAPFs.Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs,and polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy in our cohort.
文摘The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
基金Supported by the National Natural Science Foundation of China,No.81460133Innovation program of regional cooperation of Xinjiang Autonomous Region,China,No.2016E02063
文摘AIM To establish and evaluate an experimental porcine model of fistula-in-ano.METHODS Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band ligation surgery, and the control group underwent an artificial damage technique. Clinical magnetic resonance imaging(MRI) and histopathological evaluation were performed on the 38 th d and 48 th d after surgery in both groups, respectively. RESULTS There were no significant differences between the experimental group and the control group in general characteristics such as body weight, gender, and the number of fistula(P > 0.05). In the experimental group, 15 fistulas were confirmed clinically, 13 complex fistulas were confirmed by MRI, and 11 complex fistulas were confirmed by histopathology. The success rate in the porcine complex fistula model establishment was 83.33%. Among the 18 fistulas in the control group, 5 fistulas were confirmed clinically, 4 complex fistulas were confirmed by MRI, and 3 fistulas were confirmed by histopathology. The success rate in the porcine fistula model establishment was 27.78%. Thus, the success rate of the rubber band ligation group was significantly higher than the control group(P < 0.05). CONCLUSION Rubber band ligation is a stable and reliable method to establish complex fistula-in-ano models. Large animal models of complex anal fistulas can be used for the diagnosis and treatment of anal fistulas.
文摘AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case- an adult male who presented with ACF between commissures of the right and noncoronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV- is added, the world literature is briefly reviewed.RESULTS A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital(47%) or acquired(53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea(21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23(60%), single method in 14(37%)(echocardiography in 12 and catheterization in 2), and at autopsy in 2(3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12(30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24(63%). CONCLUSION Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.
文摘BACKGROUND Patients with Crohn’s disease(CD)are at risk of developing complications such as perianal fistulas.Patients with Crohn’s perianal fistulas(CPF)are affected by fecal incontinence(FI),bleeding,pain,swelling,and purulent perianal discharge,and METHODS This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries(April-August 2021).Patients were recruited into three cohorts:Cohort 1 included patients without perianal fistulas;cohort 2 included patients with perianal fistulas without fistula-related surgery;and cohort 3 included patients with perianal fistulas and fistula-related surgery.Validated patient-reported outcome measures were used to assess quality of life.Drivers of treatment preferences were measured using a discrete choice experiment(DCE).RESULTS In total,929 patients were recruited(cohort 1,n=620;cohort 2,n=174;cohort 3,n=135).Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF(cohorts 2 and 3)than for those with CD without CPF(cohort 1):Mean score 3.8 and 3.7 vs 4.1,respectively,(P<0.001).Similarly,mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF.Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery(cohorts 2 and 3):Mean score 41 and 42,respectively.In the DCE,postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice:Mean relative importance 35.7 and 24.7,respectively.CONCLUSION The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.
