O’CONOR (TRANSABDOMINAL) REPAIR: IS IT ALWAYS NECESSARY TO INTERPOSE A FLAP IN SIMPLE VESICO-VAGINAL FISTULA? A COMPARATIVE STUDY

Objective: To assess morbidity and success of transabdominal (O’Conor) repair of vesicovaginal fistula with orwithout interposition of flap between vagina and urinary bladder. Study Design: Prospective comparative study. Place and Duration of Study: Armed Forces Institute of Urology, Rawalpindi, from Mar 2016 to Jan 2019. Methodology: Fifty five patients were randomized into group A & B by lottery method. An inclusion criterionwas single fistulous opening of ≤3cm. Complex and recurrent fistulae were excluded. Patients in group A underwent O’Conor repair without interpositional flap while in group B vesicovaginal fistulae were repaired with flap interposition. Results: Twenty two patients were randomized in group A while 27 in group B. Mean age of patients was 41.65± 11.93 years. Gynecological and obstetrical surgery was the main cause of fistula. Mean duration of surgerywas 162.7 ± 18.49 minutes. Per-operative ureteric catheterization was done in 9 (16.8%) patients. Seventeen(30.6%) patients had paralytic ileus. There was transient fever in 4 (7.6%) of cases and wound infection was seenin 3 (5.8%) of patients. Mean hospital stay was 3.4 ± 2.3 days. Cystogram was done in 35 (64.5%) of patients before the removal of per-urethral catheter. The overall success rate was 92.9%. Ten (18.2%) of patients developed denovo urgency which was managed conservatively. There was no statistical difference in both groups in terms of morbidity and success. Conclusion: In simple Vesico-vaginal fistulae repair, interposition of flap can be omitted and it does not affect the outcomes in terms of success and morbidity.

Congenital Bronchobiliary Fistula in Association with Multiple Other Congenital Anomalies: Case Report

Congenital bronchobiliary fistula (CBBF) is a rare anomaly in which a fistulous opening exists between the biliary tract and the tracheobronchial tree. CBBF may be accompanied by many congenital anomalies, with biliary system anomalies being the most common. CBBF was also reported to be associated with esophageal atresia in one case and right diaphragmatic hernia in another case. However, as far as we have known, CBBF case accompanied by multiple congenital anomalies has not been reported previously. In this article, we firstly present a case of a neonatal CBBF, incidentally diagnosed intraoperatively, accompanied by multiple congenital anomalies, including congenital diaphragmatic hernia. Secondly, we present our conclusions and updates about CBBF based on what we have learned from both our case and the literature.

Repair of vesicouterine fistula by not using traditional o connor method

A 25-year-old female patient visited our clinic with complaint of cyclic haematuria. She had previous two Caesarean Sections at a secondary care hospital. Her complete urinalysis showed abundant red blood cells. Through computed tomography a fistula tract between the posterior wall of the bladder and the anterior wall of the lower uterine segment was diagnosed. The Cystoscopy revealed a fistulous opening with a diameter of nearly 1.5 cm localized between the bladder and uterine cavity. Fistulae was repaired by abdominal approach without transection of bladder. Surgery was performed by mobilization of bladder and wide anterior uterine dissection. A 2cm defect in the lower uterine segment was identified and was closed with 0 polyglycolic acid suture. Bladder defect was repaired in two layers. Then omental tissue flap was placed between the two surfaces. At 6 months follow the up patient was asymptomatic. Keywords: cyclic menouria; vesicouterine fistulas; Youssef’s syndrome. Continuous..

Choledochogastric Fistula after Recurrent Acute Cholangitis Post-Cholecystectomy

This is a case of a 46 years old male presented with acute cholangitis 2 years after laparoscopic cholecystectomy for cholecystolithiasis. He underwent biliary drainage and common bile duct (CBD) exploration for multiple stones at 2017. A year later, he presented with a recurrent acute cholangitis associated with choledocholithiasis and dilatation of left hepatic bile duct. Cholangiogram revealed that there is contract flowing to the stomach from the CBD, showing a choledochogastric fistula. Exploratory laparotomy was performed with CBD exploration with extraction of multiple stones, choledochoscopy and hepatojejunostomy. Insertion of PTC drain over a guidewire passed through a fistulous opening into the stomach. We decided on conservative management for fistula tract to heal.

FILAC TECHNOLOGY FOR EXTRASPHINCTERIC FISTULAS

AIM: to assess efficacy of FiLaC technology for extrasphincteric fistulas.PATIENTS AND METHODS: the retrospective cohort study included 56 patients with extrasphincteric fistulas of Grade III and IV. All patients underwent a modified FiLaC procedure, which consisted of excision of the fistula tract, preservation of the fistula tract inside anal canal with its laser exposure by water-absorbing Biolitec laser power of 13W and energy density of 100 J/cm. Internal fistula opening was closed with a Z-shaped absorbable suture.RESULTS: after fistula tract excision up to the anal canal we failed to insert laser probe to the internal fistulous opening in 6 (10.7%) patients due to scars. Thirty-nine (78.0%) 50 patients, who underwent FiLaC procedure were under observation with median follow-up of 27 months. Twenty (51.3%) patients had fistulas of Grade III with the recurrence occurred in 7 (35.0%) patients. Among 19 (48.7%) patients with fistulas Grade IV the recurrence was detected in all cases.CONCLUSION: FiLaC procedure is effective only for extrasphincteric fistulas Grade III.

A Man with Diarrhea

ABSTRACT Diarrhea, a common presenting complaint which we come across in our day‑to‑day practice, is often self‑limited but can be challenging at times. Here, we report one such patient. A 54‑year‑old male presented with diarrhea, abdominal pain, anorexia, and weight loss. Routine blood and stool examination was not helpful. A colonoscopy done elsewhere showed a fistulous opening in the anal canal for which he underwent a fistulectomy. Esophagogastroduodenoscopy revealed severe esophagitis, multiple duodenal ulcers, and a fundic gland polyp from which biopsies were taken. The fundic gland polyp showed oxyntic gland hyperplasia. Basal acid output and serum fasting gastrin subsequently measured were also high. A diagnosis of Zollinger–Ellison syndrome was made, and the patient was started on high‑dose proton‑pump inhibitors, to which he had excellent response. Repeat endoscopy showed resolutions of all lesions. Endoscopic ultrasound (EUS) and DOTA (Gallium (68Ga) DOTA-TATE) scan revealed a tumor in the duodenum and pylorus, respectively. On surgical exploration, the tumor was identified in the second part of the duodenum and was removed. The patient has remained asymptomatic since then.

A case of post-caesarean vesico-uterine fistula: A rare entity becoming common?

Vesicouterine fistula (VUF) is rare, with an incidence estimated at 1-4% of all genitourinary fistulas. We report a case of VUF which was referred to our institute on the 6th postoperative day following an emergency repeat lower section caesarean section (LSCS) at 39 weeks, with complaints of hematuria and watery discharge per vaginum for further management. Patient had stable vitals with slight abdominal distension and tenderness and watery discharge per vaginum having an ammoniacal odour. USG examination showed Foley’s bulb inside uterine cavity. CT abdomen confirmed the findings and showed presence of contrast inside uterine cavity. Patient was re-operated on 9th postoperative day in concurrence with urologists. Cystoscopy showed a 2 cm size fistulous opening. Intra-operative findings revealed a fistulous track between posterior wall of bladder and uterine incision. Appropriate reparative surgery was done. Obstetricians need to be aware of this condition particularly while operating on previous caesarean sections.

Spontaneous Cholecystocutaneous Fistula

ABSTRACT Spontaneous biliary fistulae are encountered, not very rarely, in one's surgical practice. These fistulae are of three types: Internal, external, and combined. Internal spontaneous biliary fistulae are the commonest. External fistulae could be spontaneous or because of therapeutic, iatrogenic, or traumatic reasons are extremely rare. Spontaneous cholecystocutaneous fistula (SCCF), secondary to calculous cholecystitis, is an extremely rare presentation in the present-day scenario. It used to be quite common before the year 1900, but is very rare now because of better management of cholecystitis and cholelithiasis. Usually, SCCF is a complication of neglected chronic cholelithiasis. This is seldom seen today because of the early diagnosis and better management made feasible by ultrasound as first-line investigation, broad spectrum antibiotics, and effective surgical management of biliary tract diseases. It is a very rare case of 35-year-old female patient presenting in the outpatient department, with the multiple stones carefully preserved, which she had been extruding through the fistulous opening in the umbilicus, for the last 1 year. She was investigated and was operated for the same condition. Though the entity is very rare, clinicians should keep this condition in mind while examining any case of chronic discharging sinus or fistula on the abdominal wall, particularly the wound extruding stones in which case the diagnosis is selfrevealing. In the absence of positive history of expelling stones, the diagnosis can be confirmed by computerized tomogram fistulography. Though the early diagnosis and improvement in the management of gallbladder disease has improved tremendously, the possibility of this condition arising mostly from the neglected gallbladder disease should always be kept in mind as such cases are again being reported from all over the world. How to cite this article Abbey R. Spontaneous Cholecystocutaneous Fistula. Int J Adv Integ Med Sci 2016; 1(4):196-198.

Cardiac Tamponade following Mitral Valve Replacement for Active Infective Endocarditis with Ring Abscess

Periannular extension and abscess formation are rare but deadly complications of infective endocarditis (IE) with high mortality. Multimodality cardiac imaging, invasive and noninvasive, is needed to accurately define the extent of the disease. Debridement, reconstruction, and valve replacement, often performed in an emergent setting, remain the treatment of choice. Here we present a case of severe IE in a 29-year-old intravenous drug user who after undergoing debridement of the abscess, annular reconstruction, and mitral valve replacement (MVR) presented with recurrence of shortness of breath and pedal edema. Transthoracic echocardiogram (TTE) showed a6.2×5.5 cm cavity, posterior to and communicating with the left ventricle through a 3 cm wide fistulous opening, in proximity of the reconstructed mitral annulus. The patient underwent a redo MVR with patch closure of the fistulous opening, with good clinical outcome. This case highlights the classic TTE findings and the necessity for close follow-up in the perioperative period in patients undergoing surgery for periannular extension of infection. A cardiac magnetic resonance imaging can be considered, preoperatively, in such cases to identify the extent of myocardial involvement and surgical planning.