Canalith repositioning procedure for relief of post-stapedectomy benign paroxysmal positional vertigo

A 41-year-old woman underwent a successful stapedectomy for relief of conductive hearing loss due to otosclerosis. Post-operatively, she developed persistent symptoms of benign paroxysmal positional vertigo (BPPV). Eight weeks later, a canalith repositioning procedure was performed in the office, with immediate complete resolution of her vertigo. Anatomic and pathophysiologic implications of these observations will be discussed.     

Urinary fistula after transplantation: eleven cases

OBJECTIVES: To specify the anatomical features of urinary fistulas and to evaluate the results of percutaneous and surgical treatment of post-transplantation urinary fistulas. PATIENTS AND METHODS: 11 urinary fistulas were observed after 160 renal transplantations, corresponding to an incidence of this complication of 6.8%. Urinary fistulas were treated percutaneously in three cases and surgically in eight cases. THE FOLLOWING COMPLICATIONS WERE OBSERVED DURING SURGICAL TREATMENT: extensive necrosis of the urethra in four cases, rupture of the sutures in two cases, a punctate pelvic fistula in one case. RESULTS: The incidence of fistula was 5.8% for Leadbetter reimplantation and 8.1% for Lich-Gregoir extravesical reimplantation. We obtained one success in three patients treated percutaneously and one death and seven successes out of eight patients treated surgically. We performed ureteropelvic anastomosis with the native ureter in the case of extensive necrosis of the ureter (4 cases), a new reimplantation in three cases and suture of the pelvic fistula in one case. CONCLUSION: More than one half of post-transplantation urinary fistulas observed in our department are secondary to ischaemic necrosis of the ureter. We emphasize the value of preservation of the ureteric blood supply during organ harvesting. Post-transplantation urinary fistulas must be treated surgically, as soon as possible, to avoid infectious complications.     

Bronchopleural fistula: a review of 86 cases

A review of all the bronchopleural fistulas which developed following pulmonary resection in the Department of Cardio-Vascular and Thoracic Surgery of The London Hospital between 1953 and 1973 is presented. During this period 3150 pulmonary resections were performed for various conditions and 86 fistulas occurred, an incidence of 2-7 per cent. The aetiology, diagnosis and treatment of these fistulas are discussed.     

The primary aortoenteric fistula in The Netherlands--the unpublished cases

OBJECTIVE: Primary aortoenteric fistula is a rare disorder of which only four patients have been reported in the Dutch literature so far. The objective of our study was to obtain more realistic figures on the incidence of this condition, with data on the clinical presentation, diagnostic procedures, treatment and results in a group of patients not previously reported as "case histories". METHODS: A questionnaire was sent to all surgical clinics in The Netherlands. Out of 180 questionnaires, 102 have been returned reporting 27 patients to which data of eight others treated in our own institution were added. RESULTS: In all but one of these 29 patients the fistula was caused by an atherosclerotic aneurysm, the one exception being caused by an ingested cocktail pin. Gastrointestinal haemorrhage was the predominant symptom, being present in 28 of the patients, while the complete triad of haemorrhage, pain and a pulsating mass was found in only eight patients. Twenty-seven patients were treated with an in situ graft of which 14 are doing well at long term follow-up. CONCLUSIONS: Primary aortoenteric fistula is far more common than one would expect from the number of patients reported in literature. A high index of suspicion based on a complete physical examination remains the key to a correct diagnosis. Direct closure of the intestine and in situ grafting of the aorta is the treatment of first choice.     

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

Transforming growth factor-beta (TGF-beta) is synthesised as an inactive precursor protein; this is cleaved to produce the mature peptide and a latency associated protein (LAP), which remains associated with the mature peptide until activation by LAP degradation. Isoform specific antibodies raised against the LAPs for TGF-beta 2 and -beta 3 were used to determine the myocardial levels of LAP (activatable TGF-beta) and full length precursor (inactive TGF-beta) forms during post-natal development in the rat. TGF-beta 2 was present predominantly as the precursor in 2 day old myocardium. There was an age-dependent shift from precursor protein to LAP between 2 and 28 days. A corresponding increase in the level of mature (activatable) TGF-beta 2 was found. TGF-beta 3 was detected in significant quantities only as LAP. However, a four-fold increase in the expression of TGF-beta 3 LAP was observed between 2 and 28 days. The substantial increases in activatable forms of TGF-beta 2 and -beta 3 that occur in myocardium during the first 28 days of life in the rat support a role for these proteins in post-natal cardiac development.     

2 cases of solitary pulmonary arteriovenous fistula presenting in the neonatal period

Two case reports of pulmonary arterio-venous fistulae presenting in the neonatal period are described. One child had severe respiratory distress with cardiac failure and the other presented with cyanosis and a continuous murmur. In both, chest X-ray demonstrated a localised lesion and the presence of an arteriovenous fistula was confirmed by pulmonary angiography. Lobectomy cured both children.     

Gastric bypass for malignant esophagotracheal fistula: a series of 21 cases

OBJECTIVE: Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. METHODS: Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2). RESULTS: Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. CONCLUSION: The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.     

Ureterovaginal fistula: a report of 12 cases and review of the literature

Ureterovaginal fistula is an uncommon complication of pelvic operations, seen most often after Wertheim's hysterectomy. We report 12 cases of ureterovaginal fistulas seen during a 20-year period, all of which followed operations for benign gynecologic conditions. Most patients had no urinary symptoms until the sudden onset of incontinence 1 to 4 weeks postoperatively. Diagnosis was established readily by a combination of excretory urography, cystography, cystoscopy, retrograde pyeloureterography and dye studies. In our series only 1 patient was treated by primary nephrectomy, while 11 underwent ureteroneocystostomy: 2 with a Boari flap and 9 by a direct method. Reconstruction failed in 2 patients, 1 of whom required a secondary nephrectomy.     

Fistula-in-Ano: perineal fistula of intra-abdominal or intrapelvic origin simulating fistula-in-ano--report of seven cases

In 219 normal pregnancies between 28 and 42 weeks the relationships of different ultrasound measurements of the fetal head and the fetal body to the gestational age were determined in order to improve the accurate diagnosis of fetal maturity during the last trimester of pregnancy. With the A and B ultrasound apparatus of Kretz, the biparietal diameter was determined by the A mode, the fronto occipital plane and the largest abdominal diamter were determined by the B scan. The following ultrasound measurements were taken: the two horizontal and transverse diameters, the circumferences and the planes. The abdominal measurements showed a higher rate of growth, compared to the cranial measurements a lesser rate of growth retardation and a higher variation of the normals. The correlation of the abdominal measurements with the gestational age was worse than that of the cranial measurements. Wth the exception of the biparietal diameter in the A mode, the mean diameters of the cranial and abdominal measurements gave better results than the single diameters. Circumference and surface measurements showed no advantages. The best results were obtained by combined fetal head and body measurements using the summation of the biparietal diameter in the A mode and the mean abdominal diameter in the B scan.     

Appendico-ileo-vesical fistula

Appendico-vesical fistula is a rare condition. In total, 109 cases, most secondary to appendicitis, have been reported in the English-language literature. We report the first case, to our knowledge, of appendico-ileo-vesical fistula secondary to appendiceal diverticulitis. An enterovesical fistula was diagnosed by urine culture, cystoscopy, and computed tomography. The locations of enteric opening sites were demonstrated by barium enema and colonoscopy. Ileocecal resection and fistulectomy with primary reconstruction were performed. We believe that accurate pre- and intra-operative diagnosis is essential for cure. This case demonstrates the importance of barium enema and colonoscopic examinations in the diagnosis and treatment of complicated enterovesical fistula.     

Uretero-iliac fistula

OBJECTIVE: To describe a case of uretero-iliac fistula, an extremely rare condition that is not easily diagnosed. METHODS/RESULTS: Herein we describe a 76-year-old female who had undergone repeated pelvic surgery for adenocarcinoma of the sigmoid. She had a right ureteral fistula that had been managed conservatively by insertion of a ureteral catheter. Diagnosis was made by selective arteriography of the iliac arteries. The patient was submitted to surgery; primary closure of the arterial fistula and nephroureterectomy were performed. CONCLUSIONS: Uretero-iliac fistula should be suspected in patients with a history of repeated pelvic surgery and ureteral catheter placement that present with massive hematuria.