Partial colpocleisis for vesicovaginal fistulas

Four patients with a vesicovaginal fistula were operated upon transvaginally using the Latzko technique of partial colpocleisis. In 3 of the 4 patients, the fistulas had been formed after total hysterectomy for myoma uteri or endometriosis. The periods from fistulization-to-surgery intervals in these 3 patients were 4 months, 12 months, and 4 years and 4 months, respectively. The fistulas in the remaining one patient had been formed after forceps delivery. The patient underwent surgery 8 days after delivery. An indwelling catheter was retained for 3 to 14 days after surgery. The 4 patients were all cured of vesicovaginal fistulas after a single operation. This paper describes our partial colpocleisis technique and discusses its clinical utility. The partial colpocleisis has the advantages of dispensing with such procedures as fistula excision, fistula opening suture, and suturation of the bladder musculature, and of closing the fistulas using a demucosated vaginal wall. Having minimal surgical invasiveness and being easy to perform and reliable, the technique appears to be excellent for coping with vesicovaginal fistulas.     

Synchronous combined transvaginal-transvesical repair of vesicovaginal fistulas

Nine cases of vesicovaginal fistula which followed hysterectomy, with or without radiotherapy, are presented. The repair by the above-mentioned technique eventually led to successful closure in all cases. A strong argument can now be advanced that this is the technique of choice in the large, high postoperative type of vesicovaginal fistula which is now the common type of fistula seen in affluent countries.     

Trans-symphyseal approach in the treatment of cervico-urethro-vaginal fistulas. Apropos of 2 cases

We opted for a symphysiotomy approach in the management of cervico-urethro-vaginal fistulae in two patients. This approach offers an excellent exposure of the region of the bladder neck. After section of the symphysis pubis with a Gigli's wire saw, the anterior wall of the bladder was taken down to the fistulae and we excised the fistulous tract. Longitudinal closure of the fistulae and the bladder followed. Results were satisfactory and there were no urinary incontinence.     

Laparoscopic approach in the surgical treatment of non-advanced achalasia]

A 23-year-old woman presented with a 10 year history of excessive sweating (hyperhidrosis), mostly in the axillae, and to a lesser extent the groin and hands. Initial treatment with a sedative antihistamine and topical Driclor (aluminium chloride hexahydrate in 2% alcohol) for 14 weeks resulted in no improvement. Axillary liposuction, a short and simple procedure, then produced a very satisfactory result.     

Outcome and prognostic factors in the surgical treatment of spinal dural arteriovenous fistulas. A long-term study

The small leucine-rich bone proteoglycans, biglycan and decorin, can be purified by chromatography on hydroxyapatite columns, demonstrating their potential affinities for bone apatite. To determine their effects on in vitro apatite formation and growth, a mixture of the chondroitin-sulfate (CS) bone proteoglycans, or purified fractions of the dermatan sulfate (DS) containing proteoglycans, DS-decorin and DS-biglycan obtained from skin and articular cartilage, respectively, were analyzed in a gelatin gel diffusion system in which apatite formation occurs in the absence of proteins in a 3.5 day period. Low concentrations of the bone CS-proteoglycan mixture and low DS-biglycan concentrations (5-25 microg/ml) increased apatite formation relative to proteoglycan-free controls at 3.5 days. The CS-proteoglycan mixture was less effective at 50 microg/ml than at 10 microg/ml. DS-biglycan was similarly most effective at 5-25 microg/ml. At 5 days, when apatite growth and proliferation were assessed, 10 and 50 microg/ml of both CS-bone proteoglycan and DS-biglycan increased mineral yields. DS-decorin, in contrast, had no significant effect on mineral accumulation at any of these concentrations. In seeded growth experiments, 1 and 10 microg/ml CS-proteoglycan and 10 and 50 microg/ml DS-biglycan were significant effective inhibitors of mineral accretion, whereas DS-decorin showed no tendency to inhibit seeded growth. Using molar extinction coefficients to determine concentrations, the binding of DS-biglycan and DS-decorin to apatite (specific surface 54 m2/g) was determined using a Langmuir adsorption isotherm model. DS-biglycan had a greater affinity for apatite than DS-decorin (0.285 ml/micromol versus 0.0098 ml/micromol). DS-biglycan binding was more specific with fewer binding sites (3.5 micromol/m2 compared with 18. 2 micromol/m2 for DS-decorin). Data suggest that of the small proteoglycans, biglycan may play a more significant role than decorin in the regulation of mineralization.     

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.     

Endoscopic transvesico-transurethral approach for repair of vesicovaginal fistula: initial case report

New synthesized polymerized complexes of 3-amino-1,2,4-triazole with transition metals such as Cu+2, Ni+2, Co+2 and Zn+2 were investigated for fungicidal activity. Most of the tested complexes showed fungicidal activity which is not connected with activity of copper fungicides.     

New approach to the surgical treatment of severe exophthalmos in Graves disease

In the last few years, various surgical techniques to correct orbital decompression in patients with Graves ophthalmopathy have been proposed. In those patients in whom a high degree of exophthalmos is mainly the result of the hypertrophied endorbital muscles with respect to endorbital fat hypertrophy, lipectomy is insufficient to obtain an acceptable increase of endorbital volume. The authors propose a method that provides for the monobloc bilateral quadrantotomy by extracranial access. Despite traditional methods of decompression, the advantage of this technique is better advancement of the orbital margins. The bicoronal and endoral incisions guarantee no facial scars. Compared with the craniotomy, the extracranial access is also less stressful for the patient.     

A physiological approach to surgical treatment of progressive early idiopathic scoliosis

The Christ-Siemens-Touraine syndrome (CST syndrome) is the rare an- or hypohidrotic form of the ectodermal dysplasia. During embryonic development, the formation and maturation of the central nervous system and the epithelia of the sense organs, skin, teeth, hair (and less frequently the nails) are disturbed. In addition to the cosmetic impairment, insufficient or absent secretion of sweat and sebum is particularly discomforting as it leads to extreme heat intolerance. The decreased number of apocrine sweat glands and mucous glands in the upper nasopharynx results in diminished resistance to respiratory infections. We describe typical features of the disease in a 60 year old female patient, distinguishing this disease from other forms of ectodermal dysplasia. Diagnostic criteria as well as therapeutic options are discussed.     

Repair of complex ureterovaginal and vesicovaginal fistulas with ileal cystoplasty and ureteric reimplantation into an antireflux ileal nipple valve--a case report

We report a case of a 59-year-old woman with bilateral ureterovaginal and vesicovaginal fistulas after radical total hysterectomy and bilateral salphingo-oophorectomy who failed transvesical repair of the vesicovaginal fistula. The bladder was extensively scarred, half of which had to be excised. This was replaced with an ileal cystoplasty with an antireflux ileal nipple valve into which the ureters were reimplanted. Continuity of the urinary tract was re-established without a urinary diversion or stoma.     

Contemporary treatment strategies for external pancreatic fistulas

BACKGROUND: Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions. METHODS: Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract. RESULTS: Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups. CONCLUSIONS: Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.     

Stepwise concept for treatment of complex anal fistulas

Most anal fistulas can be easily dealt with by simple fistulotomy. So called complex fistulas-in-ano need a differentiated, individually tailored surgical approach in order to avoid recurrence and sphincter incompetence. Complex fistulas comprise either tracks with high trans-, supra-, or extrasphincteric extension or fistulas that are complicated by multiple side branches, chronic inflammatory disease, previous operations etc. Prior to treatment a thorough preoperative diagnostic work-up is warranted. A precise intraoperative evaluation is paramount to allow radical excision of all inflamed tissue, often necessitating anal sphincter division with subsequent reconstruction. The treatment plan involves staged operations over a period of many months, usually with the (laparoscopic) fashioning of a protective stoma at the primary operation. Analysing our patients in the study period from 1/95 to 12/96 our different surgical approaches and their results are presented and discussed. During this period 96 patients with a fistula-in-ano were operated upon in the Department of Surgery at Würzburg University Hospital, of which 11 (11.5%) had complex disease. We encountered one early and one late recurrence as well as a parastomal hernia and a stoma prolapse. Anal continence was re-assessed three months following reversal of colostomy. All patients (n = 7) who had perfect continence preoperatively remained unchanged. Preoperatively, four patients were incontinent for gas and liquid stool. Two of these were fully continent, one remained unchanged at re-assessment. The fourth patient did not undergo stoma reversal as yet, because all examinations revealed an incompetent sphincter. This patient is therefore fully incontinent. Successful treatment of complex anal fistulas needs an individual approach and planning over a lengthy period of time, requiring a high level of motivation on the part of both patient and surgeon.     

Octreotide for treatment of postoperative alimentary tract fistulas

Eighteen patients with postoperative fistulas of the gastrointestinal tract were treated with the somatostatin analog octreotide between November 1989 and November 1992. Fourteen patients had enterocutaneous fistulas: seven from the duodenum and seven from the ileum. Another three patients had pancreatic fistulas, and one patient had a biliary fistula. Within 24 hours of octreotide treatment, a mean reduction of 52% in the intestinal fistulas' output, 40% in the pancreatic fistulas, and 30% in the biliary fistula was noted. In the intestinal fistulas group the closure rate was 72% after a mean of 11 days. Early closure (mean 6 days) was achieved in all three pancreatic fistulas. In the patient with the biliary fistula a 30% reduction was observed twice following the administration of octreotide, and an increase occurred when it was withheld. The reduction rate of the secretions in high-output intestinal fistulas (> 500 ml/day) was higher than in the low-output fistulas (63 +/- 8% versus 39 +/- 4%, p < 0.05). Fistula output and the initial response to octreotide treatment had no value in predicting spontaneous healing. In conclusion, octreotide is a valuable tool for the conservative treatment of fistulas of the digestive tract. It is especially valuable for management of high-output enteric fistulas and pancreatic fistulas.     

Use of fibrin glue in vesico-vaginal fistulas after gynecologic treatment

Vesicovaginal fistulas develop as an early complication following gynaecological operations or as a late complication following irradiation. The waiting period for the surgical closure of the fistula implies social and psychic problems for patients and attending physicians. Three cases report on the exclusive fibrin sealing for closing vesicovaginal fistulas after which continence was re-established.     

The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children

BACKGROUND: The surgical approach to children with complex cardiovascular and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting. OBJECTIVE: The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requiring surgical repair were reviewed retrospectively. METHODS: Between January 1993 and June 1995, 33 patients, aged between 2 months and 17 years (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascular or pulmonary disease using a clamshell approach. Twenty-one patients (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient). The technique involved supine position placement, submammary incision, access to the pleural space bilaterally through the fourth intercostal space and transverse division of the sternal body. RESULTS: Four groups of patients were operated on via this approach: (1) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atresia (36%); (3) patients with previously corrected miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchial stenosis and atrial septal defect, one-stage repair of partial anomalous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days) deaths, giving a perioperative mortality of 6% for the entire series. Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). There were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experienced complications). Except for 2 infants undergoing complete unifocalization and presently awaiting completion of repair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%) a definitive surgical treatment could be performed in one-stage. CONCLUSIONS: The bilateral thoracosternotomy allows optimal exposure of all intrathoracic anatomic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with the conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex intrathoracic pathology in infants and children is advocated.