Home About us Contact
|
Home About us Contact | ||
|
|
||
Fistulae
Kinds of Fistulae Selected AbstractsCR12 ENTEROCUTANEOUS FISTULAE , ARE WE GETTING IT RIGHT?ANZ JOURNAL OF SURGERY, Issue 2007D. E. Gyorki Purpose Enterocutaneous fistulae (ECF) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients. Methodology A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006. Demographic, management and outcome data was recorded. Factors influencing ECF closure and outcome were assessed with Cox regression analysis. Results Thirty-three patients (17 male) were identified with ECF (median age 63, range 27,84). The primary aetiology was Crohn's (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4,72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 hours (SD = 1.8). The median hospital stay for the operative group was 19 days (7,85). Four patients required post-operative TPN. Fistula closure rate was 97% (operative group 21/21, non-operative group 11/12). Mean follow up was 37.3 months (0.5,217). Six operative patients (19%) developed fistula recurrence. There were 2 deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis respectively). No factor was predictive of fistula recurrence. Conclusion Patients with enterocutaneous fistula can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. Patients with ECF should be referred to specialist units for management. [source] POST CAESAREAN VESICOUTERINE FISTULAE , YOUSSEF SYNDROME: OUR EXPERIENCE AND REVIEW OF PUBLISHED WORKANZ JOURNAL OF SURGERY, Issue 4 2006M. Prasad Rao Objective: To analyse the incidence, symptomatology, diagnosis and therapeutic aspects of Youssef syndrome (post caesarean vesicouterine fistula), and to review relevant published work. Methods: A retrospective study from the urosurgical unit of a tertiary care referral hospital was carried out. In a retrospective analysis of urogenital fistulae over 10 years, we identified 14 patients with uterovesical fistulae, resulting from caesarean section. All the patients were evaluated by history, physical examination, radiological tests and cystoscopy. All patients underwent transperitoneal repair of these fistulae with omental interposition. Results of surgery were evaluated by absence of cyclic haematuria, stoppage of urinary incontinence, and achievement of fertility. Results: A total of 12 patients who had minimum follow up was included in the present study. The results showed that 50% of the fistulae resulted from emergency caesarean operation with 58% of patients presenting after their second caesarean section. The mean age of the patients was 19 years (range 15,29) and mean duration of symptoms was 7 months (range 3,16). Menouria and amenorrhoea were predominant presenting symptoms. The results of surgical treatment were excellent with good continence and resolution of the cyclic haematuria. Three pregnancies (37.5%) which resulted in elective caesarean section were recorded. Conclusion: Vesicouterine fistulae, despite being infrequent, are no longer a rare diagnosis and are most commonly secondary to lower segment caesarean section. With patient history and selected investigations diagnosis is relatively easy. The surgical repair of these fistulae is standard treatment, especially with delayed fistulae with achievement of total continence, and complete resolution of cyclic haematuria. Meticulous practice of obstetric and surgical principles during caesarean section can prevent the formation of these fistulae. [source] A Comparison of CV-Catheters (CV) Grafts (GR) and Fistulae (FI) in Quotidian HemodialysisHEMODIALYSIS INTERNATIONAL, Issue 1 2003C Kjellstrand We studied longevity and complications from CV, GR, and FI in 23 patients on quotidian hemodialysis. There were a total of 409 patient months, mean 18,10 months observation and a total of 9209 dialyses. There were 14 FI, 5 GR and 4 CV. 1, 1 and 2 replacements were necessary during a total observation time of 254, 105 and 50 patient months, respectively. For fistulae there were 0.02 replacements/year vs. 0.30 for GR and 0.41 for CV. P = 0.042 FI vs. other. The cumulative survival at 15 months was 100% for FI, 80% for GR and 20% for CV. P = 0.041. The cumulative survival at 3 years were 80% for fistulae and grafts, no CV lasted beyond 15 months. P = 0.013. There were 27 events requiring hospitalization or outpatient intervention. FI: 0.42/patient year, GR 1.22/patient year and CV 1.36/patient year. P = 0.080, FI vs. Other. Patients reported more problems between dialysis for FI, 3.2% of the days and least on GR (0.2%), CV (0.4%). P < 0.0001. Of the problems 85% were pain and redness. To the contrary there were more problems during dialysis with CV, 9.1% vs. FI 2.7%, and GR 0.9%. P < 0.0001. The complications and survival data are similar to those reported by others for quotidian hemodialysis and no different from reports on conventional 3 times per week dialyses. Conclusion: Daily hemodialysis does not adversely affect the different types of blood access. The survival and intervention need of accesses is best for fistulae, worst for CV, but GR, when functioning, have fewer problems between and during dialyses. [source] Gastrointestinal: Fistulae in Crohn's diseaseJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 3 2006G Savoye [source] Incontinence following sphincter division for treatment of anal fistulaCOLORECTAL DISEASE, Issue 7Online 2010S. Bokhari Abstract Objective, Management of anal fistula poses problems because of competing goals of cure and maintenance of continence. There is increasing recognition of significant rates of incontinence after sphincter-dividing anal surgery. We aimed to determine cure and continence status in a cohort of anal fistula patients managed by both sphincter-dividing and conserving approaches. Method, Data on fistula, healing and continence status were gathered by patient questionnaire (Cleveland Clinic incontinence questionnaire), telephone interview and chart review. Fistulae were defined as simple (low risk of incontinence) or complex (high risk). Surgery was defined as sphincter conservation and sphincter division. Incontinence was graded by traditional severity scale (minor/major). Fistula healing was defined as absence of acute or chronic sepsis symptoms from surgery to date of last follow-up. Results, One hundred and twenty-eight patients were evaluated (out of whom 71% were male subjects, age range 17,82, median age 45 years). Fifty-two percent of the fistulae were complex and 48% were simple, of which 51% and 85% underwent sphincter division respectively. Healing rates were higher for sphincter division than conservation (87%vs 73%, P = 0.06). Complex fistulae undergoing sphincter division led to a higher rate of major incontinence (13%) than sphincter conservation (0%) (P = 0.03). For simple fistulae treated by sphincter division, major (5%) and minor incontinence (11%) was not inconsiderable. Conclusion, Though cure rates are excellent, incontinence rates remain unacceptably high following sphincter division for complex fistulae and are not insignificant even for simple fistulae. More sphincter conservation should be undertaken. [source] Laparoscopic resection of diverticular fistulae: a 10-year experienceCOLORECTAL DISEASE, Issue 7 2007A. H. Engledow Abstract Objective, Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach. Method, Between April 1994 and May 2005, 31 consecutive patients [17 male, median age of 63 years (range 40,85)], underwent attempted laparoscopic resection for diverticular fistulae. Patient data were prospectively recorded. Results, There were 22 colovesical and nine colovaginal fistulae. The median operative time was 150 min (range 60,310) and the median postoperative stay was 7 days (range 3,21). Conversion to an open procedure was required in nine of 31 patients (29%). This rate fell to 10% in cases performed after April 2000. There were two nonsurgically related postoperative deaths. Both occurred in the converted group. At 3 months follow-up, two patients complained of frequency of stools, which settled by 6 months. To date there has been no recurrence of symptomatic diverticulosis or fistulation. Conclusion, Totally laparoscopic resection for diverticular fistulae is safe and feasible. Fistulae should not be considered as a contraindication to laparoscopic resection for an experienced laparoscopic surgeon. [source] Management of diverticular fistulae to the female genital tractCOLORECTAL DISEASE, Issue 5 2007F. Hjern Abstract Objective, Fistulae to the female genital tract are an infrequent but severe complication of diverticular disease. The purpose of this study was to evaluate treatment and outcome in patients with diverticular colo-genital fistulae. Method, Sixty women treated for diverticular fistulae (DF) to the female genital tract during 1992,2004 were identified. Clinic and operative charts were reviewed. Mean age was 70 years and mean follow-up time after surgery was 1 year. Results, Most common presenting symptoms were vaginal discharge of faeces or gas (95% of patients) and abdominal pain (43%). About 75% of patients had undergone a hysterectomy. Forty-six patients underwent at least one radiological contrast study and the fistula was demonstrated in 35 (76%) patients. Fifty-seven patients had surgery, and findings included colo-vaginal fistulae (n = 47), colo-uterine fistulae (n = 2) and multiple fistulae involving vagina and other organs (n = 8). A sigmoid resection and primary anastomosis was performed in 51 and a Hartmann procedure with colostomy in six patients. Sixteen (28%) patients experienced morbidity after surgery, including anastomotic dehiscence (n = 4) and ureteric injury (n = 3). There was no mortality. Conclusion, Diverticular fistulae to the female genital tract usually occur in elderly patients with a prior hysterectomy. Radiological contrast studies demonstrate the fistulous tract in most cases. Sigmoid resection and primary anastomosis results in a satisfactory outcome in the majority of patients. [source] Single Coronary Artery with Right Ventricular Fistula: Case Report and Literature ReviewCONGENITAL HEART DISEASE, Issue 1 2010Yoichiro Ishii MD ABSTRACT We report a rare case of a 6-year-old boy who was diagnosed with coronary artery fistulae communicating with the right ventricle and a left single coronary artery. Preoperative angiography showed a dilated and tortuous single coronary artery draining into the right ventricle. Two coronary artery fistulae draining into the right ventricle were detected at operation and both of these were ligated. Postoperative angiography showed that the single coronary artery diameter was almost normalized, although the vessel was still slightly tortuous. His clinical course was uneventful. In this report, we summarize cases of coronary artery fistula with single coronary artery that have been reported in the literature as well as our case. [source] Transoral laser surgery for supraglottic cancerHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 5 2008Juan P. Rodrigo MD Abstract The goal of treatment for supraglottic cancer is to achieve cure and to preserve laryngeal function. Organ preservation strategies include both endoscopic and open surgical approaches as well as radiation and chemotherapy. The challenge is to select the correct modalities for each patient. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. Most authors advocate bilateral elective neck dissection. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source] Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: A national survey from DAHANCAHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 9 2003Cai Grau MD, DMSc Objective. In 1998, the Danish Society for Head and Neck Oncology decided to conduct a nationwide survey at the five head and neck oncology centers with the aim of evaluating the surgical outcome of salvage laryngectomy after radiotherapy with special emphasis on identifying factors that could contribute to the development of pharyngocutaneous fistulae. Patients. A total of 472 consecutive patients undergoing postirradiation salvage laryngectomy in the period July 1, 1987,June 30, 1997 were recorded at the five head and neck oncology centers in Denmark. Age ranged from 36 to 84 years, median 63 years, 405 men and 67 women. Primary tumor site was glottic larynx (n = 242), supraglottic larynx (n = 149), other larynx (n = 45), pharynx (n = 27), and other (n = 9). All patients had received prior radiotherapy. Results. Median time between radiotherapy and laryngectomy was 10 months (range, 1,348 months). A total of 89 fistulae lasting at least 2 weeks were observed, corresponding to an overall average fistulae risk of 19%. The number of performed laryngectomies per year decreased linearly (from 58 to 37), whereas the annual number of fistulae increased slightly (from 7 to 11), which meant that the corresponding estimated fistulae risk increased significantly from 12% in 1987 to 30% in 1997. Other significant risk factors for fistulae in univariate analysis included younger patient age, primary advanced T and N stage, nonglottic primary site, resection of hyoid bone, high total radiation dose, and large radiation fields. Multiple logistic regression analysis of these parameters suggested that nonglottic tumor site, late laryngectomy period (1987,1992 vs 1993,1997), and advanced initial T stage were independent prognostic factors for fistulae risk. Surgical parameters like resection of thyroid/tongue base/trachea or radiotherapy parameters like overall treatment time or fractions per week did not influence fistulae risk. Conclusions. The risk of fistulae is especially high in patients initially treated with radiotherapy for nonglottic advanced stage tumors. A significant decrease in the number of performed salvage laryngectomies over the 10 years was seen. Over the same time period, the annual number of fistulae remained almost constant. The resulting more than doubling of fistulae rate could thus in part be explained by less surgical routine. © 2003 Wiley Periodicals, Inc. Head Neck 25: 711,716, 2003 [source] Higher arteriovenous fistulae blood flows are associated with a lower level of dialysis-induced cardiac injuryHEMODIALYSIS INTERNATIONAL, Issue 4 2009Shvan KORSHEED Abstract Native arteriovenous fistulae (AVF) remain the vascular access of choice for hemodialysis (HD). Despite being associated with superior long-term outcomes (cf. catheter use), little is known about the systemic hemodynamic consequences of AVFs. Repetitive myocardial injury (myocardial stunning) is an under-recognized common consequence of HD. The aim of this study was to examine the impact of AVF flow (Qa) on dialysis-induced cardiac injury. We studied 50 chronic HD patients. All patients underwent echocardiography (and subsequent quantitative offline analysis) at baseline, during and post dialysis, to assess left ventricular function and the development of regional wall motion abnormalities. Qa was measured using ionic dialysance. Patients were divided into Qa tertiles (<500, mean 291±101 mL/min, 500,1000, mean 739±130 mL/min and >1000, mean 1265±221 mL/min). There were no significant differences between the groups in terms of age, sex, diabetes, or resting ejection fraction. Patients with Qa>1000 mL/min had a lower prevalence of left ventricular hypertrophy (55% vs. 76%, P=0.01). Dialysis-induced myocardial stunning (seen in 65% of the patients studied) was significantly and sequentially reduced in those patients with higher Qas. This was seen in a lower number of segments and ventricular regions developing regional wall motion abnormalities, as well as a significantly reduced mean and cumulative percentage reduction in fractional shortening of those ventricular segments affected (,187±37%, ,161±26%, and ,101±25%, respectively, P=0.04). Relatively higher AVF flows appear to be associated with a lower level of observed HD-induced cardiac injury. [source] Infective endocarditis in a hemodialysis patient: A dreaded complicationHEMODIALYSIS INTERNATIONAL, Issue 4 2007Claudia SCHUBERT Abstract Infection is the most common cause of death in hemodialysis patients, after cardiovascular disease. Dialysis access infections, with secondary septicemia, contribute significantly to patient mortality. The most common source is temporary catheterization. Bacteremia occurs commonly in patients receiving hemodialysis, with infective endocarditis being a relatively uncommon, but potentially lethal complication. Valvular calcification is the most significant risk factor. The diagnosis of infective endocarditis is made clinically and confirmed with the echocardiographic modified Duke's criteria. The most common pathogen is Staphylococcus aureus and the mitral valve is the most common site. Staphylococcus aureus infective endocarditis is commonly associated with embolic phenomenon. A high index of suspicion is critical in the early recognition and management of infective endocarditis. However, prevention of bacteremia is undoubtedly the best strategy with the early placement of arteriovenous fistulae. In the case of temporary catheterization, the use of topical mupirocin or polysporin and gentamicin and/or citrate locking is beneficial. Although catheter salvage has not been studied in randomized trials, catheter removal remains standard therapy during bacteremia. [source] Inadvertent postdialysis anticoagulation due to heparin line locksHEMODIALYSIS INTERNATIONAL, Issue 4 2007Ruth J. PEPPER Abstract Large-bore dual lumen in-dwelling venous catheters are used in hemodialysis. These catheters are usually locked with heparin after the treatment. This study addressed the underappreciated postdialysis coagulopathy that can result. Thirty-six patients were included: 7 dialyzed through arterio-venous fistulae, 29 through in-dwelling venous catheters. The latter group was further subdivided according to whether they received heparin or heparin-free dialysis. To assess the heparin lock, a full-dose heparin lock as well as a much weaker heparin lock and a citrate lock were used. To assess the coagulopathy, blood was taken 1 hr after dialysis. The activated partial thromboplastin time (APTT) and anti-Xa level was measured. Additionally, 6 venous catheters were removed and the amount of fluid expelled upon locking with saline was measured. Clotting from the patient group with arterio-venous fistulae was normal following dialysis. The patients with in-dwelling venous catheters and heparin locks had significantly deranged clotting; 6 out of 10 patients had abnormal APTT results. All patients with catheters, heparin-free dialysis, and heparin locks had deranged clotting (7 out of 7). The rate decreased significantly when heparinized saline was used as a lock. A subset of patients had a citrate lock rather than a heparin lock; the clotting results normalized in all but one patient. An in vitro study demonstrated immediate leakage of fluid from the end of the ports upon locking. Significant postdialysis anticoagulation can occur after dialysis, which can be attributed to the heparin line locks. This risk is considerably reduced when a citrate lock is used instead. [source] The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulatorsHEMODIALYSIS INTERNATIONAL, Issue 2 2006Rosa M. MARTICORENA Abstract We describe the St Michael's Hospital (SMH) modified buttonhole (BH) cannulation technique as a method that offers a solution for fistulae with aneurysmal dilatation due to repetitive cannulation in a restricted area. This is a prospective cohort study of 14 chronic hemodialysis (HD) patients with problematic fistulae (marked aneurysmal formation and thinning of the overlying skin, bleeding during treatment, and prolonged hemostasis post-HD) because of repetitive, localized cannulation. Each patient was followed for 12 months. The protocol was as follows: creation of tunnel tracks by 1 to 3 experienced cannulators per patient, using sharp needles. After the tunnel tracks were established and cannulation was easily achieved with dull needles, additional cannulators were incorporated with the guidance of a mentor. Bleeding from cannulation sites during dialysis ceased within 2 weeks and skin damage resolved within 6 months in all patients. Hemostasis time postdialysis decreased from 24 to 15 min. Cannulation pain scores decreased significantly. Access flows and dynamic venous pressure measurements remained unchanged. No interventions were required to maintain access patency. In 2 cases, the aneurysms became much less evident. Complications included one episode of septic arthritis and one contact dermatitis. A third patient developed acute bacterial endocarditis 9 months following completion of her follow-up. The SMH modified BH cannulation technique can salvage problematic fistulae, prevent further damage, and induce healing of the skin in the areas of repetitive cannulation. This technique can be successfully achieved by multiple cannulators in a busy full-care HD unit. [source] A Comparison of CV-Catheters (CV) Grafts (GR) and Fistulae (FI) in Quotidian HemodialysisHEMODIALYSIS INTERNATIONAL, Issue 1 2003C Kjellstrand We studied longevity and complications from CV, GR, and FI in 23 patients on quotidian hemodialysis. There were a total of 409 patient months, mean 18,10 months observation and a total of 9209 dialyses. There were 14 FI, 5 GR and 4 CV. 1, 1 and 2 replacements were necessary during a total observation time of 254, 105 and 50 patient months, respectively. For fistulae there were 0.02 replacements/year vs. 0.30 for GR and 0.41 for CV. P = 0.042 FI vs. other. The cumulative survival at 15 months was 100% for FI, 80% for GR and 20% for CV. P = 0.041. The cumulative survival at 3 years were 80% for fistulae and grafts, no CV lasted beyond 15 months. P = 0.013. There were 27 events requiring hospitalization or outpatient intervention. FI: 0.42/patient year, GR 1.22/patient year and CV 1.36/patient year. P = 0.080, FI vs. Other. Patients reported more problems between dialysis for FI, 3.2% of the days and least on GR (0.2%), CV (0.4%). P < 0.0001. Of the problems 85% were pain and redness. To the contrary there were more problems during dialysis with CV, 9.1% vs. FI 2.7%, and GR 0.9%. P < 0.0001. The complications and survival data are similar to those reported by others for quotidian hemodialysis and no different from reports on conventional 3 times per week dialyses. Conclusion: Daily hemodialysis does not adversely affect the different types of blood access. The survival and intervention need of accesses is best for fistulae, worst for CV, but GR, when functioning, have fewer problems between and during dialyses. [source] Quantifying anomalous intestinal sterol uptake, lymphatic transport, and biliary secretion in Abcg8,/, mice,,HEPATOLOGY, Issue 4 2007Helen H. Wang Sitosterolemia is caused by mutations in either ABCG5 or ABCG8, but simultaneous mutations of these genes have never been observed. To explore whether ABCG8, the sterol efflux (hemi-)transporter, plays a major role in determining intestinal absorption efficiency and hepatic secretion rates of cholesterol and sitostanol, we performed direct measurements of the absorption and lymphatic transport of these sterols in mice with chronic biliary and lymphatic fistulae, as well as the transport rates of radiolabeled cholesterol and sitostanol from plasma high-density lipoprotein (HDL) into bile in male Abcg8,/, and wild-type mice. We observed that the absorption and lymphatic transport rates of radiolabeled cholesterol and sitostanol were increased by ,40% and ,500%, respectively, in Abcg8,/, mice in the setting of constant intraduodenal infusion of micellar taurocholate and lecithin. Both strains displayed identical intestinal Npc1l1 expression levels and small intestinal transit rates. After 45 minutes of intraduodenal infusion, acute intestinal uptake rates of trace [14C]cholesterol and [3H]sitostanol were essentially similar in both groups of mice with intact biliary secretion. Furthermore, in wild-type mice, mass transport rate of [3H]sitostanol from plasma HDL into bile was significantly faster than that of [14C]cholesterol; however, no [3H]sitostanol and only traces of [14C]cholesterol were detected in bile of Abcg8,/, mice. Conclusion: Deletion of the Abcg8 gene alone significantly increases the mass of intestinal cholesterol and sitostanol absorption and reduces but does not eliminate hepatic secretion of cholesterol. Moreover, the mutation has no influence on acute uptake of cholesterol and sitostanol by the enterocyte nor small intestinal transit time. (HEPATOLOGY 2007;45:998,1006.) [source] Healing of anastomotic enterocutaneous fistulae due to Crohn's disease by anti-tNF-alpha antibodiesINFLAMMATORY BOWEL DISEASES, Issue 10 2010Pierre-Alain Cougard MD No abstract is available for this article. [source] Infliximab treatment for Crohn's disease: One-year experience in a Dutch Academic HospitalINFLAMMATORY BOWEL DISEASES, Issue 2 2002Dr. Daan W. Hommes Abstract The aim of this study was to report the 1-year clinical experience with infliximab treatment for Crohn's disease (CD) in the Netherlands. All 73 CD patients receiving infliximab infusions were prospectively followed during 1 year after the drugs' registration in the Netherlands. Clinical response and adverse events were assessed for both active luminal disease as well as fistulous disease. A total of 212 infusions were administered to 57 patients with active luminal CD and 16 patients with fistulous CD. The mean duration between infusions was 60 days. In 17% of patients, adverse events were recorded, of which one was serious. The response rate was 81% in active luminal CD and 87% in fistulous disease. Response rates were highest in patients receiving concomitant methotrexate as maintenance therapy. Steroids could successfully be tapered off in 73% of responding luminal CD patients and 100% of responding CD patients with fistulae. Eleven patients showed a loss of response to continuous infliximab readministration. Our clinical experience with infliximab for active luminal and fistulous CD showed that the administration is safe, effective, and has high steroid-sparing efficacy. Higher response rates were seen with methotrexate as concomitant medication. [source] A 5-year audit of haemodialysis accessINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 7 2005J. A. Akoh Summary This is a review of our experience with vascular access procedures over a 5-year period at Derriford Hospital, Plymouth, UK. The aims of the study were to examine the outcome of vascular access procedures and factors influencing access survival. Between April 1995 and March 2000, 151 patients who underwent 221 vascular access procedures were studied. Of these, 136 had autogenous arteriovenous fistulae, whereas 85 had prosthetic AV grafts (41% in the thigh). The overall primary failure rate was 21% whereas the 1- and 5-year cumulative access survival rates were 60 and 41%, respectively. Thigh grafts have a mean survival of 36 months compared with 32 months for prosthetic upper limb and 43 months for autogenous fistulae. Age, diabetes and predialysis status did not significantly influence access survival. Thrombosis was responsible for access failure in 62 cases (28%). Avoiding subclavian vein canulation and performing vessel mapping prior to access placement should reduce the risk of access failure due to outflow obstruction. [source] Surgical Treatment of Coronary Artery-Pulmonary Artery Fistula with Coronary Artery DiseaseJOURNAL OF CARDIAC SURGERY, Issue 6 2009Pavle Kova, Ph.D. Usually they are asymptomatic, but sometimes they can mimic other cardiac diseases, most commonly heart failure, myocardial ischemia, and endocarditis. Coronary arteriovenous fistulae have been reported to arise more commonly from the right coronary artery. Most of these fistulae are congenital, and only a small fraction acquired. In this report we present successful surgical treatment of coronary artery to pulmonary artery fistula combined with myocardial revascularization. [source] Closed lesser sac lavage in the management of pancreatic necrosisJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 9 2004JAI DEV WIG Abstract Background and Aim:, Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of morbidity and mortality. We evaluated the efficacy of necrosectomy and closed lesser sac lavage as a method of management of pancreatic necrosis. Methods:, Fifty-eight patients with pancreatic necrosis who underwent pancreatic necrosectomy consecutively in a tertiary care referral center were retrospectively analyzed. The technique of necrosectomy and postoperative lavage is described in detail. Details regarding the patient profile, disease severity, surgical details, postoperative morbidity, repeat interventions and the mortality are presented. Results:, Of the 58 patients, irrigation was able to be started in 48. Lavage was able to be continued until disease resolution or death in all but 10 patients. Post-operative locoregional complications were residual abscesses in 10, bleeding in eight, enteric fistulae in 12 and pancreatic fistulae in nine. Six patients needed postoperative percutaneous procedures, while 16 patients needed repeat surgery. Seventeen patients died (29%), all of whom had multiple organ failure involving more than two organs, while 11 developed sepsis. Conclusion:, Pancreatic necrosectomy and postoperative closed lesser sac lavage is an effective method of managing these patients, with acceptable morbidity, re-operation rates and mortality. [source] An Unusual Case of an Accessory Coronary Artery to Pulmonary Artery Fistula:JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 1 2004Successful Closure with Transcatheter Coil Embolization Coronary artery fistulae (CAF) are rare congenital anomalies. Surgical ligation is the standard treatment for symptomatic CAF, but is associated with higher morbidity. In a select group of patients, transcatheter coil embolization (TCE) is a reasonable alternative to standard surgical treatment. In this article, we present a unique (not previously reported) case of a tortuous accessory anomalous right coronary artery to pulmonary artery fistula with coronary steal phenomenon. TCE of highly tortuous fistulae can be technically difficult and are usually referred for surgery. In this case report we describe how utilization of adult coronary interventional wires and balloon catheters may help overcome some of the technical difficulties encountered with catheter-based closure of CAF. (J Interven Cardiol 2004;17:59,63) [source] Chronic Naltrexone Treatment and Ethanol Responsivity in Outbred RatsALCOHOLISM, Issue 2 2010Katherine G. Hill Background:, Acute naltrexone treatment in rats produces significant alterations in ethanol palatability (increase in the aversiveness of the solution) and ethanol consumption during tests of restricted access (decrease in consumption). The effects of chronic naltrexone exposure, accomplished by implantation of osmotic mini-pumps, were examined in the present study. Methods:, Rats were surgically implanted with intraoral fistulae for taste reactivity testing. The animals were given 2 bottles (distilled water and 10% ethanol, v/v) for 3, 2-week phases: Pre-Drug, Drug, and Post-Drug. After the Pre-Drug phase, rats were assigned to groups (counterbalanced based on ethanol intake) and implanted with a mini-pump containing saline, 7.5 mg/kg/d naltrexone, or 15 mg/kg/d naltrexone. The pumps were removed 2 weeks later. During each 2-week phase, taste reactivity tests with 10% ethanol were conducted at 1, 7, and 14 days (a total of 9 reactivity tests). Results:, The 7.5 mg/kg/d dose produced only minor effects on 10% ethanol reactivity and consumption during the Drug phase. The 15 mg/kg/d naltrexone dose generally shifted taste reactivity responding to 10% ethanol in a negative direction and produced a transient decrease in ethanol consumption. The 15 mg/kg/d group significantly increased ethanol consumption beyond the level of consumption by the Saline group when the pumps were removed, although the increase was delayed 48 hours. By the end of the Post-Drug period, this naltrexone group returned to control levels of ethanol consumption. Conclusions:, Chronic naltrexone treatment at 15 mg/kg/d significantly decreased the palatability of a 10% ethanol solution, an effect seen even after drug withdrawal. Naltrexone had a minor effect on ethanol consumption during treatment but did decrease overall levels of fluid consumption. The significant increase in ethanol consumption postdrug by the high-dose naltrexone group, presumably due to receptor up-regulation during treatment, is important and understanding this effect and developing means of overcoming it within a clinical practice would be useful goals. [source] Angiosarcoma developing in a non-functioning arteriovenous fistula post-renal transplantJOURNAL OF SURGICAL ONCOLOGY, Issue 6 2010Yassar A. Qureshi MBBS Abstract Background Angiosarcomas comprise less than 1% of all sarcomas, arising from endothelial cells of blood or lymph vessels. Chronic immunosuppression increases the risk of many malignancies and an association between the development of angiosarcoma with an immunosuppressed state is established. A few cases have been reported of angiosarcomas arising in the post-renal transplant patient. Specifically, there have been six cases of an angiosarcoma arising in arteriovenous (AV) fistulae in this patient population. We describe a further case and review the relevant literature with specific emphasis on a possible mechanism for the development of angiosarcoma in the post-transplant patient. Case Presentation We report the case of a 48-year-old male who developed an angiosarcoma in a ligated native AV fistula. The lesion arose on the background of immunosuppression following a successful ABO-incompatible renal transplant for chronic renal failure. Conclusion Angiosarcomas are extremely rare tumours but should be considered as a differential diagnosis for an evolving mass near the site of an AV fistula. Diagnosis relies on an index of suspicion and obtaining a definitive histological diagnosis. Both clinicians and patients should be aware that an evolving mass within or around an AV fistula should prompt urgent biopsy. J. Surg. Oncol. 2010; 101:520,523. © 2010 Wiley-Liss, Inc. [source] Appropriateness of therapy for fistulizing Crohn's disease: findings from a national inflammatory bowel disease cohortALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 8 2010V. Pittet Aliment Pharmacol Ther 2010; 32: 1007,1016 Summary Background, About 30,50% of patients with Crohn's disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. Aim, To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn's disease Therapy. Methods, Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. Results, Two hundred and eighty-eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti-tumor necrosis factor , was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). Conclusions, Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three-quarters of the patients with fistulizing CD, therapy was globally appropriate. [source] Health-economic analysis: cost-effectiveness of scheduled maintenance treatment with infliximab for Crohn's disease , modelling outcomes in active luminal and fistulizing disease in adultsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2008J. LINDSAY Summary Background, Infliximab has been shown to be efficacious in moderate-to-severe Crohn's disease (CD). Aim, To evaluate the cost-effectiveness of scheduled maintenance treatment with infliximab in luminal and fistulizing CD patients. Methods, Markov models were constructed to simulate the progression of adult CD patients with and without fistulae during treatment with infliximab (5 mg/kg). Transitions were estimated from published clinical trials of infliximab. Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. An average weight of 60 kg was used to estimate the dose of infliximab. The costs and outcomes were discounted at 3.5% over 5 years. The primary effectiveness measurement was quality-adjusted life years (QALYs) estimated using EQ-5D. One-way and probabilistic sensitivity analyses were performed by varying the infliximab efficacy estimates, costs and utilities. Results, The incremental cost per QALY gained was £26 128 in luminal CD and £29 752 in fistulizing CD at 5 years. Results were robust and remained in the range of £23 752,£38 848 for luminal CD and £27 047,£44 206 for fistulizing CD. Patient body weight was the most important factor affecting cost-effectiveness. Conclusion, Eight-week scheduled maintenance treatment with infliximab is a cost-effective treatment for adult patients suffering from active luminal or fistulizing CD. [source] An open-labelled study of granulocyte colony-stimulating factor in the treatment of active Crohn's diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2005J. R. Korzenik Summary Background :,Immunodeficiency syndromes associated with a Crohn's-like illness suggest innate immune defects may lead to Crohn's disease. Anecdotal cases using haemopoietic colony-stimulating factors report improvement in intestinal disease associated with these syndromes. Aim :,To test the safety and efficacy of recombinant human granulocyte colony-stimulating factor in active Crohn's disease. Methods :,In an open-labelled 12-week trial, patients with a Crohn's Disease Activity Index between 220 and 450 were treated with recombinant human granulocyte colony-stimulating factor (filgrastim, Neupogen). Concomitant immunosuppressants were prohibited except prednisone ,20 mg/day. Patient's received recombinant human granulocyte colony-stimulating factor 300 mcg daily subcutaneously adjusted to achieve an absolute neutrophil count between 25 and 35 × 109/L. Results :,Twenty patients were enrolled with a mean initial Crohn's Disease Activity Index of 307 (range: 234,428). Fifteen patients (75%) completed 8 weeks; 13 patients (65%) completed 12 weeks with the mean Crohn's Disease Activity Index for patients continuing through those times of 196 (range: 36,343) and 162 (range: 20,308), respectively. At week 12, 11 patients (55%) demonstrated a decrease of at least 70 points; five (25%) achieved a sustained remission. The mean decrease was statistically significant at each assessment time-point. Three of four patients with fistulae had a positive response. Adverse effects included bone pain, mostly mild resolving with continued treatment. One patient was hospitalized with a viral-like syndrome but it is uncertain if this was treatment related. Conclusion :,Recombinant human granulocyte colony-stimulating factor is safe and potentially effective therapy for active Crohn's disease. [source] Review article: the clinical role of anti-TNF, antibody treatment in Crohn's diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 5 2000The recent licensing of anti-TNF, antibody treatment offers the potential to radically alter the course of severe Crohn's disease using genetically-engineered drugs directed against a specific inflammatory mediator. Controlled randomized trials have demonstrated clinical benefit associated with tissue healing in patients with active intestinal disease and fistulae, often when conventional therapies were unsuccessful. This therapy is expensive, however, and long-term efficacy and safety data are still awaited. This review considers the nature of this therapy and the current evidence for its clinical benefit and adverse effects. The treatment is also considered in the context of available immunosuppressive agents, with suggestions about its practical application. [source] Venous congestive myelopathy of the cervical spinal cord: An autopsy case showing a rapidly progressive clinical courseNEUROPATHOLOGY, Issue 3 2007Akio Kimura We report a rapidly progressive myelopathy in a 74-year-old Japanese man who was admitted to our hospital with a 4-month history of progressive gait disturbance and died of pneumonia followed by respiratory failure on the 22nd day of admission. During the course of his illness, magnetic resonance imaging (MRI) revealed intramedullary lesions with edematous swelling from the medulla oblongata to the spinal cord at the level of the fourth vertebra. After administration of contrast medium, the ventral portion of the lesion was mildly and irregularly enhanced and a dilated vessel was recognized along the ventral surface of the upper cervical cord. At autopsy, ischemic changes were observed in the upper-to-middle cervical cord segments, with so-called arterialized veins in the subarachnoid space. No neoplastic lesions were found within or outside the brain and spinal cord. These pathological findings were essentially those of venous congestive myelopathy (VCM) associated with dural arteriovenous fistulae (AVF), formerly known as Foix,Alajouanine syndrome. VCM associated with dural AVF, which is now considered to be treatable in the early stages, is rare found in the cervical spinal cord. The present autopsy case, with MRI findings, provides further information that might be useful for recognition and diagnosis. [source] Improvement of migraine symptoms after coil embolotherapy of pulmonary arteriovenous fistulaePEDIATRICS INTERNATIONAL, Issue 3 2010Kentaro Asoh No abstract is available for this article. [source] | ||||||||||||||||||||||||||||||||||