The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.     

Expenditure and loss of income incurred by tuberculosis patients before reaching effective treatment in Bangladesh

Fistulae arising from the intestinal tract are associated with significant morbidity and mortality rates. Most contemporary studies of fistulae report mortality rates between 6 and 20 per cent. The major causes of death in these patients are sepsis, electrolyte imbalance, and malnutrition. A total of 48 patients with either external or internal intestinal fistulae were reviewed in this study over a 5-year period at the Louisiana State University Medical Center at Shreveport. Intestinal fistulae were classified into three types, anatomic site, physiologic type, and etiology, to evaluate morbidity and mortality rates. We also attempted to evaluate the role of parenteral nutrition in this patient population, but our data were inconclusive because of the limited number of patients. There was no difference in mortality rates associated with anatomical sites. High-output fistulae were associated with a higher mortality rate compared to low-output fistulae. Fifty-six per cent of the patients achieved closure. The overall mortality rate was 21 per cent. Spontaneous closure rates were lower when compared to those in other studies. This was attributed to sepsis, malignancy, and history of previous radiation therapy. Management of intestinal fistulae includes control of sepsis, correction of electrolyte disturbances, nutritional support, and operative intervention if necessary.     

Treatment of scalp arteriovenous malformation

We report seven patients with scalp arteriovenous malformations, including two patients with lesions > 10 cm in diameter, who were successfully treated. The principal complaint of each patient was a deforming mass. Each of four patients had a history of blunt traumatic injury. The lesions, each consisting of the nidus, feeders, and draining veins, evolved in all patients. The nidus consisted of fistulae, which exhibited various angioarchitectures as revealed by angiography. A hemangiomatous component was histologically recognized in one patient. In five patients, in whom the lesions were relatively small and whose nidi included only large fistulae, the malformations were remedied by surgical intervention alone or were cured with embolization alone using liquid adhesives. In the two patients with lesions > 10 cm, the nidi consisted of numerous large fistulae and plexiform fistulae in one patient and plexiform fistulae and a hemangiomatous component in the other patient. These patients were treated with a combination of transarterial embolization and surgical intervention. Preoperative embolization greatly reduced blood loss during resection. Total excision and scalp reconstruction using a soft tissue expander were performed in both patients. The cosmetic results were excellent in all of the patients, and no recurrence has been recognized during the follow-up period, which ranges from 31 to 99 months. The treatment of scalp arteriovenous malformations should strive to improve deforming features and to attain a permanent cure. Because each nidus includes a variety of anomalous angioarchitectural features, there should be different means and a combination of treatments for each patient. Embolization alone could be adequate treatment in relatively small lesions, the nidi of which consist only of several large fistulae. For malformations with more extensive, large fistulae or with anomalous components other than large fistulae, a combined endovascular and surgical approach and scalp reconstruction seems to be the best treatment.     

Fever after extracorporeal shock wave lithotripsy for patients with upper urinary tract calculi associated with bacteriuria before treatment

Twenty five patients with vesicovaginal fistulae were managed at St. Gaspar Hospital, Itigi, Tanzania between February 1993 and March 1994. Most of them, 92% were repaired vaginally routinely using the Martius labial flap and 8% were repaired transabdominally because the fistulae were inaccessible vaginally as they were vesicouterine or vesicocervical fistulae. The success rate was 96% after the first operative attempt.     

Recording of unexpectedly high frequency vibrations of blood vessel walls in experimental arteriovenous fistulae of rabbits using a laser vibrometer

Because arteriovenous fistulae are associated with a palpable thrill and an audible murmur, the vibrational activity of the blood vessel walls about experimental arteriovenous fistulae in rabbits was investigated using, for the first time, a high-resolution laser vibrometer. Frequencies of mural vibrations up to 2200 Hz were recorded at different sites about the fistulae. The relationship of this vibratory activity of blood vessel walls to physiological and pathological conditions warrants further investigation.     

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.     

Aspartate and alanine aminotransferase activity in the adrenal cortex of human embryos and fetuses

In most cases of congenital lacrimal fistulae occuring in the ophthalmic literature the condition is diagnosed only during later life. Then, however, the congenital nature is doubtful. This paper describes a new-born with bilateral congenital lacrimal fistulae. Furthermore, the underfed patient has heart and genital malformations. The indication for surgical management of congenital lacrimal fistulae is discussed.     

Guillain-Barre syndrome and pregnancy

OBJECTIVE: To study the feasibility of tympanic neurectomy in the treatment of parotid fistulae. DESIGN: Five patients with parotid fistulae were treated by tympanic neurectomy at the ENT Department, General Hospital, Kandy. RESULTS: Four were completely and one was partially cured.     

Coronary artery fistula after cardiac transplantation

A cardiac transplant recipient with multiple coronary artery fistulae draining into the right ventricle is described. These fistulae presumably resulted from repeated endomyocardial biopsies. The diagnosis of coronary artery fistulae was made at the annual coronary arteriography. The magnitude of the shunt remained small over eight years of follow-up.     

Arteriovenous fistula. Cutaneous manifestations

The association between congenital large-vessel arteriovenous (AV) fistulae of the extremities with Kaposiform acroangiomatosis is well established. Based on pathogenetic considerations, it is likely that many benign, cutaneous angiomatoses represent minute or microscopic AV fistulae. Combined large vessel and small vessel congenital AV fistulae of the extremity would result in the previously mentioned syndrome.     

L-DOPA effects on sexual behaviour: an experimental study

Five patients underwent operative repair of an aneurysm of the sinus of Valsalva. Four of the aneurysms were considered as congenital and one as mycotic. There were four males and one female. One patient with VSD and characteristics of Marfan's syndrome die on the first postoperative day of a recurrence of fistulae. The follow-up time is over one year for all but one of the surviving patients. There are no late deaths, and all patients are doing well. Aneurysms and fistulae of the sinus of Valsalva, which are perhaps not as rare as was previously thought, present a challenging surgical problem. Ruptured aneurysms and fistulae, even if asymptomatic, should be treated operatively, preferably by a transaortic approach.     

Characterizing flow distributions in AV fistulae for haemodialysis access

BACKGROUND: The arteriovenous fistula is the most widely used means of enabling vascular access for chronic haemodialysis. When interest in vascular access was at its height, in the 1970s, a substantial amount of work was carried out on the physiology of arteriovenous fistulae and on the relationship between fistula flow and patency. One omission in the catalogue of studies was research into the distribution of flow in the fistula and the effects on surgical outcome. METHOD: To address this issue, 30 patients with end-to-side radiocephalic fistulae were studied. Flow measurements were made intraoperatively, and at various intervals postoperatively using colour-flow ultrasonography. RESULTS: In 22 cases, the development of the fistula was monitored at regular intervals for periods of up to 27 months. In seven of the 30 fistulae, flow in the distal artery was antegrade, while in the remaining 23, distal artery flow was retrograde. The proportion of fistula flow supplied by the proximal and distal arteries varied considerably. CONCLUSION: Despite the wide range of flow distributions in the fistulae studied, flow distribution did not appear to affect fistula maturation or long-term function.     

Forearm free skin flap transplantation: a report of 56 cases. 1981

Primary arteriovenous fistulae remain the gold standard for hemodialysis access. The radiocephalic or Brescia-Cimino fistula is the autologous fistula of choice, with a primary success rate of nearly 93% and a 1-year patency rate of up to 82%. Alternative arteriovenous fistulae include the snuff box fistula and a brachiobasilic fistula with a 1-year patency rate of up to 90%. Complications include thrombosis, infection, arterial steal syndrome, venous hypertension, aneurysms, and congestive heart failure. Despite these complications, arteriovenous fistulae provide good long-term hemodialysis access.     

Hydrocephalus: possible role of an internal cerebrospinal fluid fistula in therapy

Transfer of cerebrospinal fluid from the lateral ventricle transcerebrally to the distal subarachnoid space was performed in the hydrocephalic dog. These fistulae were formed with the aid of a small suction tip and the operating microscope. Clinical evaluation of the dogs was made daily until sacrifice at four to six weeks. Documentation of the clinical course and ventricular size of the shunted and control animals was made. The studies indicate that the microsurgically produced fistulae may be an effective form of treatment in the hydrocephalic animal.     

Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae

PURPOSE: We report our approach to the management of postcatheterization femoral artery pseudoaneurysms and arteriovenous fistulae in an attempt to determine the frequency of spontaneous resolution of selected lesions. METHODS: We studied 196 pseudoaneurysms, 81 arteriovenous fistulae, and 9 combined lesions that were identified by duplex scan. Indications for immediate surgical repair included pseudoaneurysm greater than 3 cm, enlarging hematoma, pain, groin infection, nerve compression, limb ischemia, concomitant surgical procedure, and patient refusal or inability to comply with follow-up. All other lesions were observed. RESULTS: One hundred thirty-nine patients underwent prompt surgical repair, and 147 patients were initially managed without operation. There were no limb-threatening complications associated with nonoperative management in this subset of patients. Eighty-six percent of the lesions being observed resolved spontaneously within a mean of 23 days, whereas 14% required surgical closure for a variety of reasons (at a mean of 111 days after the initial diagnosis). There was no statistically significant difference in the rate of spontaneous pseudoaneurysm closure (89%) as opposed to fistulae (81%) (p < 0.17). By life-table analysis, 90% of selected pseudoaneurysms had resolved by 2 months. Patients selected for observation underwent an average of 2.6 duplex scans per patient versus 1.4 scans per patient for those treated with immediate surgery (p < 0.01). CONCLUSION: The natural history of stable pseudoaneurysms and arteriovenous fistulae is benign and frequently results in spontaneous resolution, which allows properly selected patients to be managed without operation.     

Increase in myocardial digoxin content associated with circulatory volume overload in the dog

1. Tritiated (12alpha-3H) digoxin (0-05 mg/kg body weight) was administered intravenously to conscious dogs with circulatory volume overload induced by previous creation of aorto-caval fistulae. Dogs were killed after 5 min, 1, or 4 h, and the myocardium sampled. Digoxin was extracted and counted and results compared to those in normal dogs. 2. At each time, myocardial digoxin concentration of all cardiac chambers in test dogs was greater than normal. Plasma digoxin concentration measured 5 min after administration was greater in dogs with fistulae but the subsequent levels were not different. 3. Anaesthetized and open-chest dogs with fistulae studied 5 min after digoxin administration had greater myocardial concentrations than similarly studied normal dogs. Although myocardial concentrations of digoxin were higher in anaesthetized than in conscious dogs the group with fistulae had higher values than did the normal group, as was the case for unanaesthetized dogs. 4. The basis for the effect of fistula is probably multifactorial. Diminised peripheral blood flow and peripheral digoxin delivery and uptake, resulting initially in higher digoxin levels in plasma perfusing the myocardium, may play a role. Increased myocardial mechanical and metabolic activity almost certainly are important. Cardiac hypertrophy, cardiac failure per se and plasma electrolyte changes are probably not. 5. The results are consistent with previously demonstrated reduced digitalis tolerance in the dog with circulatory volume overload.     

Autosomal recessive omodysplasia: report of three additional cases

AIM: To determine the results of transluminal angioplasty in patients with Brescia-Cimino arteriovenous fistulae. PATIENTS AND METHODS: Thirty-one patients underwent transluminal angioplasty of 36 stenotic lesions related to Brescia-Cimino arteriovenous fistulae over a 5-year period. The lesions treated were characterized by review of pre-angioplasty fistulograms. Medical and radiological records were reviewed to assess medium-term patency of each patient's fistula. RESULTS: Angioplasty was performed successfully in 28 out of 31 patients initially (90% technical success rate). Duration of follow-up for the 31 patients ranged from 4 to 65 months (median = 34 months). At 6 months, seven patients required further surgical or endovascular intervention (18 patients remained event-free) and at 1 year, 10 patients required further endovascular or surgical intervention (14 patients remained event-free). Life-table analysis revealed primary patency rates of 77%, 64% and 39% at 6 months, 1 year and 2 years, respectively. At 6 months and 1 year, four and five patients, respectively, required surgical revision or closure of fistula. Secondary patency rates were 85%, 81% and 65% at 6 months, 1 year and 2 years, respectively. All patients with a primary patency at 2 years remained event-free during the follow-up period. CONCLUSIONS: Transluminal angioplasty is an effective treatment for stenoses developed in relation to Brescia-Cimino haemodialysis fistulae. Further endovascular procedures may be required, especially in the first 24 months, to preserve patency. These techniques extend the lifetime of fistulae, thereby preserving proximal venous access sites for future use. Our result is in broad agreement with results from other series.     

Home care. Doing right for the wrong reason

Abomasal fistulae resulting from right paramedian abomasopexy in eight adult dairy cattle were treated by primary closure of the abdominal wall after surgical resection of the fistulae. The median elapsed time from the abomasopexy to recognition of fistula formation was 16 days (range, 10 to 90 days). All cows had normal electrolyte values, and five cows had mildly increased base excess values (range = 4.0 to 7.8 mEq/L). Surgery was performed with the cows in dorsal recumbency using general anesthesia. The fistulated tissue was resected and the abomasum and body wall were closed primarily. One or two layers of appositional sutures using #2 or #3 polyglactin 910 were used to close the body wall. Mean surgical time was 2.2 hours (range, 1.8 to 2.9 hours). Two cows were lost to follow-up. Five of the remaining six cows returned to production (range, 5 to 30 months). Primary closure of the abdominal wall should be considered in the surgical repair of abomasal fistulae in cows that do not have diffuse peritonitis.     

Secondary tracheoesophageal puncture: factors predictive of voice quality and prosthesis use

OBJECTIVE: To evaluate retrospectively our surgical experience, techniques and long-term results in 11 patients with coronary artery fistulae associated with other cardiovascular anomalies. METHODS: From January 1980 to April 1995, 11 patients with coronary artery fistulae associated with other cardiovascular anomalies were found among 20,000 open-heart procedures and treated surgically. Besides closure of the fistulae, coronary artery bypass grafting was performed in 5 patients with atherosclerotic coronary artery disease, and aneurysm angioplasty was done in 4 patients with coronary artery aneurysm. Ventricular septal defect and patent ductus arteriosus were closed in one patient and mitral valve replacement was performed in another patient. RESULTS: There were no surgical deaths, but one late death due to acute myocardial infarction occurred 6 months after surgery. The mean follow-up time was 75.7 months and all patients' functional status improved by an average 1.4 judged by the New York Heart Association functional classification. CONCLUSIONS: Coronary artery fistula associated with other cardiovascular anomalies will aggravate symptoms and cause deterioration of heart function. Therefore, evaluation and surgical intervention should be done as soon as possible to restore coronary blood flow and correct concomitant cardiovascular anomalies. The surgical results are excellent with a low operative risk and good long-term results.     

Influence of SDZ-PSC833 on daunorubicin intracellular accumulation in bone marrow specimens from patients with acute myeloid leukaemia

From August 1987 through February 1995 we performed 42 surgical procedures in 29 patients with occluded or stenotic radiocephalic arteriovenous fistulae. Operations were designed to preserve native veins for cannulation (Group I) or to preserve access in the same forearm, bypassing the failed fistula (Group II). For 27 procedures in 22 Group I patients, cumulative primary patency was 70%, 57%, and 47% at 6, 12, and 18 months, respectively. A subgroup of patients was identified, however, in whom excellent results could be reliably predicted. Among 19 hemodynamically stable patients with mature fistulae amendable to more proximal arteriovenous anastomoses, cumulative primary patency was 100%, 81%, and 67% at 6, 12, and 18 months, respectively. Secondary patency for 17 such patients was 100%, 89% and 89% for these same intervals. In Group II only two of ten patients required use of other access sites (9 1/2, 18 1/2 months). We believe that all occluded or stenotic radiocephalic arteriovenous fistulae should be considered for surgical salvage. Excellent results can be predicted for (1) hemodynamically stable patients with (2) mature fistulae that (3) fail near the arterial anastomosis and are (4) amendable to new more proximal arteriovenous anastomoses.