Diagnosis and management of traumatic aorto-right ventricular fistulas

BACKGROUND: Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation. METHODS: All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention. RESULTS: Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory. CONCLUSIONS: The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.     

Diagnostic and surgical management of spinal dural arteriovenous fistulas

OBJECTIVE: A retrospective review was conducted to compare magnetic resonance (MR) and conventional spinal angiographic images and to investigate the outcome of our treatment protocol for patients with spinal dural arteriovenous fistulas (DAVFs). MATERIALS AND METHODS: Nine patients with a diagnosis of DAVF based on clinical myelopathy and preoperative MR imaging (MRI) and MR angiography (MRA) findings were treated at our institution by the senior author (BAG). All nine patients initially presented with progressive myelopathy. Preoperative MRI revealed T2-weighted signal abnormalities in all patients, and MRA was diagnostic in all patients. Each patient underwent a laminectomy and ligation of the arterialized draining vein. Selective spinal angiograms were used to confirm the level of fistula immediately before the surgical procedure was performed and to document complete obliteration after clip ligation of the medullary draining vein. Follow-up MRI and MRA were performed approximately 2 months postoperatively. RESULTS: MRI T2-weighted signal hyperintensity improved after surgery in all nine patients. Postoperatively, progression of motor weakness and gait difficulty was halted and some improvement was observed in all patients. No patient was neurologically normal, however. To date, there has been no clinical or MRA evidence of recurrence in any patient. CONCLUSION: Preoperative MRA and intraoperative spinal x-ray angiography present as an effective combination for diagnosing and intraoperatively confirming DAVF. Both T1-weighted enhancement and T2-weighted signal hyperintensity on MR images improved after the obliteration of the DAVFs and correlated with clinical improvement in all nine patients. MRA provides adequate visualization and localization of spinal DAVFs and may serve as a useful noninvasive tool for diagnosing and following patients with spinal DAVFs in the future.     

Clinical evaluation and surgical management of congenital preauricular fistulas

PURPOSE: The retrospective investigation evaluated the clinical data on patients with a preauricular fistula with respect to demographic factors, symptoms, preoperative diagnosis, and surgical therapy. Follow-up studies served to critically assess the outcome of the operations. PATIENTS AND METHODS: The records of 62 patients were studied. Patients were divided into two groups: those operated on for the first time for a preauricular fistula and those operated on for a recurrence. Controlled follow-up was performed by means of a standardized questionnaire filled out by both the patients' physicians and the patients themselves. RESULTS: The mean age of patients operated on for the first time was 16 years, and that of patients operated on for a recurrence was 22 years. Although the overall rate of recurrence was 21%, it differed widely between groups (14% in first operations and 42% in patients operated on for the first time for a recurrence). These figures are within the lower range of the recurrence rates previously reported. Serious side effects, such as persistent damage to the facial nerve, were not observed. CONCLUSIONS: Operative management of a preauricular fistula is a treatment with few side effects that should be offered to each patient with such a malformation. Because the first operation is decisive for the further course of the condition, surgery should be performed under optimum conditions to avoid recurrence.     

Lateral cysts and fistulas of the neck. Diagnosis and treatment

Lateral neck cysts and fistulae are considered to be a well-defined clinical entity which needs a precise knowledge of the development of the branchial system to have an appropriate and subsequent successful treatment. According to the recent classification cysts of I and II type and fistulae of I, II and III type can be recognized. In the former ultrasonography and Computerized Tomography represent the most appropriate diagnostic tools, while in the latter fistulography is preferred. An elective surgical excision seem to be resolutive in the majority of cases: on the contrary emergency surgery is related to a certain relapse of this pathology. 45 cases of branchial pathology are reported; diagnostic and therapeutic choices are then discussed.     

Direct arteriovenous fistulas (carotid-cavernous and vertebral-venous). Diagnosis and intervention

Carotid-cavernous and vertebral-venous fistulas are direct arteriovenous fistulas. Their symptoms range from benign to extremely severe ophthalmologic or neurologic complications. Mechanism of symptoms is mostly related to venous drainage. Therapy is widely indicated, as today's endovascular techniques--using mostly detachable balloons and coils--have a high success rate and very few complications.     

Diagnosis and management of tuberculosis

PURPOSE: To establish a new method for dental imaging using magnetic resonance tomography named Dental-MRT and to demonstrate its usefulness in diagnosing dentogen pathologies of the mandible and maxilla. METHODS: Seven healthy volunteers, three patients with pulpitis, two patients with dentigerous cysts, two patients after tooth transplantation, and three patients with atrophic mandibles have been evaluated. Optimized axial T1- and T2-weighted gradient echo and spin echo sequences in 2D and 3D technique have been established to perform studies of the jaws. The acquired images were reconstructed with a standard dental software package on a work-station as panorama and cross-sectional views of the mandible or maxilla. RESULTS: The entire maxillo-mandibular bone, teeth, dental pulp, and the content of the mandibular canal were well depicted. Patients with pulpitis demonstrate bone marrow edema in the periapical region. Dentigerous cysts and their relation to the surrounding structures are clearly shown. After contrast media administration marked enhancement of the dental pulp can be demonstrated. CONCLUSION: Dental-MRT promises to provide a new tool for visualization and detection of dental diseases.     

Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience

A retrospective study was carried out of patients from a single institution over a 30-year period. Thirty-one patients presented with 33 fistulas, four non-enteric and 27 enteric. In 25 of 27 patients with a prosthesis-related enteric fistula gastrointestinal bleeding was present. Angiography revealed the fistula in five patients endoscopy in three, and barium studies, echography and computed tomography each revealed one fistula. Six patients died before and five died during operation. In 20 patients various techniques were used for treatment. In-hospital mortality decreased from six of eight patients before 1970, to seven of ten between 1971 and 1980, and to four of 13 after 1981. In the long term, patients treated with an extra-anatomic reconstruction had a poorer prognosis than those treated by in situ reconstruction. This experience shows that diagnostic tests often fail to reveal a prosthesis-related fistula and that mortality can be substantially reduced by early exploration in patients with negative diagnostic studies.     

The imaging diagnosis of colovesical fistulae secondary to diverticulitis

BACKGROUND: The diagnostic procedures proposed in the evaluation of sigmoidovesical fistulas complicating diverticulitis are various and their effectiveness is still not well established. METHODS: Personal experience is based on 14 cases of colovesical fistulas secondary to sigmoid diverticulitis. Several diagnostic tools were employed: plain abdominal film (10 cases), large bowel enema (12), urography (3), cystography (2), sonography (4), and CT (5). The semeiotics of these fistulas were distinguished in direct, indirect, secondary, and related to the underlying disease. RESULTS: The fistulous tract itself was recognized in 100% of the cases with sonography, in 75% with enema, in 60% with CT, in 33% with urography, and in none with cystography. Vesical gas was visible in 100% of the cases with sonography and CT, and in 40% with plain radiographs. Diffusion of contrast medium was present in 91% of the cases with enema, in 60% with CT, and in 33% with urography. Focal thickening and/or irregularity of the bladder wall was evident with cystography and urography in 67% of the cases, with CT in 60%, with sonography in 50%, with enema in 8%. Diverticulosis/diverticulitis was recognizable in 100% of the cases with CT, in 91% with enema, in 25% with sonography. A paravesical abscess was recognizable in 40% of the cases with CT, in 25% with sonography, in 8% with enema. CONCLUSIONS: The radiourological procedures, though of limited use in our series, have a poor effectiveness. Large bowel enema and, specially, CT confirm as the method with greatest accuracy in the evaluation of these fistulas. The sonographic examination, according to personal preliminary experiences, is a valuable diagnostic alternative. Sonography and CT allow analysis of the perivisceral structures and, if compared with barium enema, provide a larger number of information on diverticulitis, which is essentially an extraluminal disease, and its complications.     

Diagnosis and management of steroid-resistant asthma

The term "steroid-resistant (SR) asthma" has been used to describe a group of asthmatics who demonstrate persistent airway obstruction and inflammation despite treatment with high doses of systemic glucocorticoids. There are at least two forms of SR asthma, that is, primary and acquired types. Type I SR asthma is acquired and is associated with abnormally reduced glucocorticoid receptor (GR) ligand and DNA binding affinity. Type II SR asthma is due to a primary GR binding abnormality. An important distinction between these two types of SR asthma is that the GR defect in Type I, but not Type II, SR asthma is reversible in culture and is sustained by incubation with combination IL-2 and IL-4. The treatment of these patients requires a systematic approach to rule out confounding factors, including triggers of immune activation, optimizing steroid therapy, and use of alternative strategies to inhibit airway inflammation.     

Diagnosis and management of the adnexal mass

Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy.     

Diagnosis and management of female urinary incontinence

Urinary incontinence affects an estimated 13 million Americans of which 85% are women. It is an embarrassing and lifestyle limiting condition for which effective treatment is available. Health care providers should be alert to the signs and symptoms of UI and pursue its etiology. Those patients who fail medical therapy, in whom the etiology for the incontinence is unclear, or those patients with concomitant cystocele, enterocele, or rectocele, should be referred to an incontinence specialist.     

Diagnosis and surgical management of pancreatic pseudocysts

Fifty-two patients with pancreatic pseudocysts were treated surgically between 1968 and 1994. Clinical symptoms were non-specific. Ten patients with acute pancreatitis were managed conservatively and resolution occurred in 3 patients. 42 patients underwent operation. Internal drainage was performed in 28 patients, external drainage in 8, others in 6. Pancreatic fistulas occurred in the external drainage group, 2 patients died and 1 patient had the of recurred pseudocyst. There were no complications in the internal drainage group. It was quite different in the external drainage group. The management should differ in that acute and chronic pancreatic pseudocysts. Patients with pseudocysts of chronic pancreatitis could undergo emergent surgery of internal drainage because waiting 6 weeks for maturation of the pseudocysts after diagnosis was unnecessary and even hazardous. However, if pseudocyst developed after acute pancreatitis, it should be watched for up to 6-8 weeks. During this period the pseudocyst perhap disappeared spontanously or matured for surgery.     

Diagnosis and patient management of oral cancer

With an average age of 60 at diagnosis, oral cancer is largely a disease of older adults. This article reviews the incidence, risk factors, early detection and diagnosis of oral cancer, as well as the principles of multidisciplinary management. Considerations for dental treatment planning prior to radiation therapy and surgery for oral cancer are included.