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The commonest non-neoplastic conditions in the anal canal include haemorrhoids, fissures, fibroepithelial polyps and associated abscesses, manifestations of Crohn’s disease, Human Papilloma Virus infection, and other sexually transmitted infections (some of which are secondary to HIV). Several dermatoses that are not site-specific may also involve the anal canal and perianal areas. These include eczema, psoriasis, lichen planus, lichen sclerosus, acanthosis nigricans, and hidradenitis suppurativa. Non-neoplastic polypoid lesions may occur, and these include condylomata acuminata and inflammatory cloacogenic polyps. Congenital abnormalities include imperforate anus and anal duplication. The former rarely, if ever, comes to attention of the histopathologist whereas the latter is occasionally encountered.
Pharyngocutaneous fistula is a troublesome complication. Recently, synthetic materials such as fibrin sealant have been used as a secondary measure to treat fistula. This work assessed whether the primary use of fibrin sealant can reduce the rate of fistula.
A retrospective review of 50 cases from 2 centres was completed. Tisseel was an adjunct to primary closure in all cases.
In the first centre, 3 out of 34 cases developed pharyngocutaneous fistula (fistula rate of 9 per cent). All three were salvage cases. In the second centre, 0 out of 16 cases developed a fistula.
The incidence of pharyngocutaneous fistula post-radiation and post-chemoradiotherapy in laryngectomy cases has been quoted as 23 per cent and 34 per cent respectively. This study represents the first patient series on the use of fibrin sealant as an adjunct in primary closure following laryngectomy. The results are promising, encouraging the use of Tisseel as an adjunct to meticulous closure.
The diagnostic value of exploratory tympanotomy in sudden sensorineural hearing loss remains controversial. This study and review were performed to identify the incidence of perilymphatic fistula in patients with sudden sensorineural hearing loss. The effectiveness of tympanotomy for sealing of the cochlear windows in cases with perilymphatic fistula was evaluated.
A search in common databases was performed. Overall, 5034 studies were retrieved. Further, a retrospective analysis on 90 patients was performed.
Eight publications dealing with tympanotomy in patients with sudden sensorineural hearing loss were identified. In 90 patients diagnosed with sudden sensorineural hearing loss and undergoing exploratory tympanotomy, 10 patients (11 per cent) were identified with a perilymphatic fistula, and this corresponds to the results obtained from our review (13.6 per cent).
There was no significant improvement after exploratory tympanotomy and sealing of the membranes for patients with a definite perilymphatic fistula.
Vessel occlusion is a frequently used procedure to close congenital or acquired collaterals or communications. We report two cases of successful vessel closure, in small infants with CHD, using the Azur CX Peripheral Coil System. The low profile of the device, the controlled delivery of the coils, and the delivery through a microcatheter make it particularly interesting for the occlusion of highly tortuous vessels in children.
Pharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3–5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae.
A retrospective case–control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3–5 ml) post-operative gastrografin videofluoroscopy.
In the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively.
Small-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae.
A brief reprise of normal coronary artery structure is followed by a discussion of normal anatomical variants of the coronary arteries. The commoner abnormal variants, including origin of the left coronary artery from the pulmonary artery and intramural course of a coronary artery, are described and illustrated, followed by a discussion of coronary fistula and atresia. A section is devoted to the variations in coronary anatomy associated with the commoner forms of congenital heart disease. Coronary arteritis is discussed, chiefly in the context of Kawasaki disease, but polyarteritis and eosinophilic arteritis are also described. Fibromuscular dysplasia is treated in some detail and idiopathic arterial calcification rounds off the chapter.
Tracheocutaneous fistula represents one of the most troublesome complications of prolonged tracheostomy. Simple closure of a fistula can be ineffective, particularly in the context of prior surgery and adjuvant radiation. As such, modes of repair have expanded to include locoregional flaps and even free tissue transfers.
This paper describes a case of persistent tracheocutaneous fistula in an irradiated patient who had undergone previous unsuccessful attempts at repair.
Method and results
The use of regional fasciocutaneous supraclavicular flap with prefabricated conchal bowl cartilage resulted in successful closure of the tracheocutaneous fistula.
This represents a novel technique for closure of such fistulas in patients for whom previous attempts have failed. This mode of repair should be added to the surgeon's repertoire of reparative techniques.
This study aimed to evaluate the impact of an onlay pectoralis major flap in reducing the incidence of pharyngocutaneous fistula after salvage total laryngectomy and determine the complications of pectoralis major flap reconstruction.
A retrospective study was conducted of consecutive patients who underwent salvage total laryngectomy between 1995 and 2016. The pharyngeal defects were primarily closed with or without the pectoralis major flap.
Of 64 patients, 34 had primary pharyngeal closure alone (control group) and 30 received an onlay pectoralis major flap (pectoralis major flap group). The overall fistula rate was 15.6 per cent, with 17.6 per cent occurring in the control group and 13.3 per cent in the pectoralis major flap group (p = 0.74). The incidence rates of voice failure (p = 0.02) and shoulder disability (p < 0.001) were significantly higher in the pectoralis major flap group.
The pectoralis major flap in salvage total laryngectomy did not decrease the pharyngocutaneous fistula rate, and the incidence of flap-related complications was high. Appropriate surgical technique and post-operative care may reduce the incidence of pharyngocutaneous fistula.
The formation of a fistula between the right pulmonary artery and the left atrium via a sac is a very rare cyanotic congenital cardiopulmonary defect. A fistula between the pulmonary artery and left atrium may cause cardiac failure in utero. It can safely be treated surgically and in selected cases closure can be performed with transcatheter insertion of a device. In this article, we present a case with a fistula between the right pulmonary artery and the left atrium that was considered unsuitable for transcatheter closure and was safely treated surgically.
We describe a rare case of aneurysmal right coronary artery drainage into left ventricle in a 38-year old male with entailed coronary CT images. After median sternotomy surgery, the patient recovered well.
To assess an alternative to bed rest and surgery for suspected perilymphatic fistulas using intratympanic blood injections.
A review was conducted of patients’ history, physical and audiometric data, before and after treatment by intratympanic blood injections performed from 2009 to 2015.
Twelve ears were identified, with trauma associated with air travel, water sports or nose blowing. Ten of these cases had hearing loss, six had vestibular symptoms. Four cases had audiological and vestibular symptoms, two had vestibular symptoms only, and six had audiological symptoms only. Time-to-treat varied from 1 day to 30 days. Magnetic resonance imaging scans were obtained for five cases. Ten cases received steroids. Six out of seven cases showed improvement of hearing loss. Five cases showed positive fistula test results, four with documented resolution. Seven cases had full resolution of all symptoms, four had near-full resolution and one had no improvement.
Intratympanic blood injections offer an effective alternative to conservative or surgical therapy. Advantages include sooner time-to-treat, lower financial costs and decreased psychosocial burdens. It allows a more flexible and liberal use of a potential definite treatment for perilymphatic fistula.
This study aimed to assess the utility of onlay pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage total laryngectomy.
A retrospective analysis was performed of 172 patients who underwent salvage laryngectomy for recurrent carcinoma of the larynx or hypopharynx between 1999 and 2014. One hundred and ten patients underwent primary closure and 62 patients had pectoralis major myofascial flap onlay.
The overall pharyngocutaneous fistula rate was 43 per cent, and was similar in both groups (primary closure group, 43.6 per cent; onlay flap group, 41.9 per cent; p = 0.8). Fistulae in the onlay flap group healed faster: the median and mean fistula duration were 37 and 55 days, respectively, in the primary closure group and 20 and 25 days, respectively, in the onlay flap group (p = 0.008).
Use of an onlay pectoralis major myofascial flap did not decrease the pharyngocutaneous fistula rate, although fistula duration was shortened. A well-designed randomised-controlled trial is needed to establish parameters for its routine use in clinical practice.
Coronary fistula is defined as an anomalous connection between a coronary artery and any of the four chambers of the heart or any of its great vessels. A coronary fistula connecting the left main coronary artery to the right atrium is the most uncommon. In the present study, we report the surgical management of a very uncommon case of an aneurysm-like fistula connecting the left main coronary artery to the right atrium in a 2-year-old boy.
This study aimed to assess the experiences and outcomes of patients who underwent surgical repair of a perilymph fistula in Norfolk, UK.
The study involved a retrospective questionnaire-based patient survey and case note review of patients who had undergone tympanotomy and perilymph fistula repair between 1998 and 2012 in two district general hospitals.
Fourteen patients underwent 20 procedures, of whom 7 completed the pre- and post-operative Vertigo Symptom Scale. In five patients, there was no obvious precipitating cause. Perilymph fistula was precipitated by noise in one patient, by a pressure-increasing event in six patients and by trauma in two patients. The Vertigo Symptom Scale scores showed a statistically significant improvement following surgical repair, from a median of 67 (out of 175) pre-operatively to 19 post-operatively.
In selected patients with vertigo, perilymph fistula should be considered; surgical repair can significantly improve symptoms.
The purpose of the present study was to examine the clinical outcomes of using tracheoesophageal diversion for preventing intractable aspiration.
We retrospectively reviewed 25 patients who underwent tracheoesophageal diversion from 2003 to 2009 at our hospital (median age, 25 years; range, 0–78 years). End-to-side anastomosis was used in 16 cases and side-to-side anastomosis was used in 9.
The average operative time was 141 minutes for end-to-side anastomosis and 191 minutes for side-to-side anastomosis. Peri-operative complications were observed in only two (8 per cent) cases: one with infection and one with haematoma. No fistulas were observed. Aspiration was prevented in all cases, but the nutritional route depended on the swallowing function of the patient. Oral feeding was the main nutritional route after surgery in only four patients (16 per cent).
This procedure is well suited to patients who lack speech communication and are at high risk of aspiration.
With the increasing use of chemoradiotherapy protocols, total laryngectomy carries increasing risks such as pharyngocutaneous fistula. There is little reference to the use of antibiotic prophylaxis in salvage surgery. This study aimed to determine the current practice in antibiotic prophylaxis for total laryngectomy in the UK.
A questionnaire was designed using SurveyMonkey software, and distributed to all ENT-UK registered head and neck surgeons.
The survey revealed that 19 surgeons (51 per cent) follow a protocol for antibiotic prophylaxis in primary total laryngectomy and 17 (46 per cent) follow a protocol in salvage total laryngectomy. Only 11 (30 per cent) use anti-methicillin-resistant Staphylococcus aureus agents in their antibiotic prophylaxis. The duration of prophylaxis varies considerably. Nineteen surgeons (51 per cent) revealed that their choice of antibiotic prophylaxis reflected non-evidence-based practices.
There appears to be little evidence-based guidance on antibiotic prophylaxis in primary and salvage total laryngectomy. The survey highlights the need for more research in order to inform national guidance on antibiotic prophylaxis in primary and salvage total laryngectomy.
Coronary arteriovenous fistula is an uncommon clinical entity. The right coronary artery is the most common site of origin, and the fistula commonly drains into the right-sided cardiac chambers. Very rarely it can arise from the left main coronary artery, and fistulas draining into the superior vena cavity are extremely rare. We report a 12-year-old asymptomatic boy with a large coronary arteriovenous fistula between the left main coronary artery and superior vena cava, with aneurysmal dilatation of the left main coronary artery. As the fistula was very large and to prevent its complications, it was planned to close the fistula percutaneously.
The main purpose of this study was to evaluate the effect of the pectoralis major myofascial flap on pharyngocutaneous fistula formation and time to oral feeding.
This retrospective study reviewed 155 total laryngectomies. Patients were divided into two main groups. Group 1 included 110 patients who were treated primarily by total laryngectomy and group 2 comprised 45 patients who were treated by salvage laryngectomy with or without a pectoralis major myofascial flap.
The use of a pectoralis major myofascial flap did not have a significant effect on pharyngocutaneous fistula formation in the salvage group (p = 0.376). When comparing the oral feeding day of patients with pharyngocutaneous fistula, a significant difference was observed between the salvage group with pectoralis major myofascial flap reinforcement and the salvage group without pectoralis major myofascial flap reinforcement (p = 0.004).
Our study demonstrated that pectoralis major myofascial flap reinforcement did not decrease the rate of pharyngocutaneous fistula formation. Instead, it prevented the formation of large fistulas that would require surgical management, and showed a similar time to oral feeding and length of hospital stay to primary laryngectomy.
In recent practice, we have used tissue transfer (pedicled or free flap) to augment the pharyngeal circumference of the neopharynx following salvage total laryngectomy, even in patients who have sufficient pharyngeal mucosa for primary closure. In this study, the rates of pharyngocutaneous fistula were compared in soft tissue flap reconstructed patients versus patients who underwent primary closure.
A retrospective assessment was carried out of all patients who had undergone a salvage total laryngectomy between 2000 and 2010. The presence or absence of a pharyngocutaneous fistula was compared in those who received reconstruction closure versus those who received primary closure.
The reconstruction closure group (n = 7) had no incidence of pharyngocutaneous fistula, whereas the primary closure group (n = 38) had 10 fistulas, giving pharyngocutaneous fistula rates of 0 per cent versus 26 per cent, respectively.
The findings revealed a lower rate of pharyngocutaneous fistula with tissue transfer compared with primary closure of the neopharynx.