Cutaneous fistula formation after thyroid nodule rupture: A rare complication after radiofrequency ablation

BACKGROUND

With innovative treatment options such as radiofrequency ablation (RFA) for thyroid nodules, new complications are being identified. It is important to define and delineate complications in order to counsel patients appropriately about treatment options and their associated risks and benefits.

METHODS

A 46-year-old male presented with a left thyroid nodule (6.5 cm). Fine needle aspiration results were benign. He started to develop intermittent dyspnea and underwent one RFA procedure. Approximately 6 days post-RFA, the neck area was raised and red with blister. The skin overlying the blister underwent eventual dehiscence with fluid spillage. Several months later, MRI imaging showed substernal extension with tracheal deviation.

RESULTS

A left thyroid lobectomy was performed with cutaneous excision and successful closure of a fistula.

CONCLUSIONS

This is the first reported case of a thyroid nodule rupture following RFA which manifested into a thyro-cutaneous fistula and required surgical intervention.

Novel application of Roux-en-Y for diversion of a cutaneous fistula from an irresectable mesenteric root mature teratoma: a case report

Reconfiguration of the alimentary tract with the Roux-en-Y has been utilized in a wide variety of contexts since its first description by Swiss physician César Roux. We present a novel and unique application of the Roux-en-Y whereby a chronically discharging cutaneous fistula originating at a retroperitoneal mature teratoma within the root of the mesentery was diverted enterically via a cystojejunostomy and the fistula tract excised, providing a resolution of symptoms. The location of the tumour in the root of the mesentery and the involvement of major mesenteric vessels made a radical resection of the tumour technically impossible but due to the distressing symptoms caused by the fistula made diversion of the fistula an excellent treatment option.

Adipose tissue-derived stem cells as a therapeutic strategy for enterocutaneous fistula: an experimental model study

PURPOSE

Enterocutaneous fistula (ECF) is a condition in which there is an abnormal connection between the intestinal tract and the skin. It can lead to high morbidity and mortality rates despite the availability of therapeutic options. Stem cells have emerged as a potential strategy to treat ECF. This study aimed to evaluate the effect of adipose tissue-derived stem cells (ASC) on ECF in an experimental model.

METHODS

ECF was induced in 21 Wistar rats, and after one month, they were divided into three groups: control group (C), culture medium without ASC group (CM), and allogeneic ASC group (ASC). After 30 days, the animals underwent macroscopic analysis of ECF diameter and histopathological analysis of inflammatory cells, tissue fibrosis, and vascular density.

RESULTS

The study found a 55% decrease in the ECF diameter in the ASC group (4.5 ± 1.4 mm) compared to the control group (10.0 ± 2.1 mm, p = 0.001) and a 59.1% decrease in the CM group (11.0 ± 4.3 mm, p = 0.003). The fibrosis score in the ASC group was 20.9% lower than the control group (p = 0.03). There were no significant differences in inflammation scores among the three groups.

CONCLUSIONS

This study suggests that ASC treatment can reduce ECF diameter, and reduction in tissue fibrosis may be a related mechanism. Further studies are needed to understand the underlying mechanisms fully.

Cutaneous fistula after open repair of a popliteal artery aneurysm: case report and review of the literature

BACKGROUND

For many years, the reference treatment for popliteal artery aneurysms (PA) consists of surgical exclusion by proximal and distal ligation, combined with popliteopopliteal, femoropopliteal or femorotibial bypass. These aneurysms excluded, but left in situ, generally decrease in size by thrombosis. However, this is not always the case. We report on a patient with bilateral PAs. The right aneurysm was completely resected, with a normal follow-up. The left one was excluded by ligation and bypass, without resection, but continued to be perfused, and fistulised to the skin. The aneurysm continued to grow due to retrograde collateral circulation through the knee's articular arteries, corresponding to a "type 2 endoleak." We therefore performed resection of the aneurysm and its fistulous path. The evolution was favourable and the patient has a satisfactory arterial condition since then. This extremely rare case prompted us to review PAs' treatment options and explore the arterial aneurysms' fistulising potential.

METHODS

A review of the literature was performed on the aneurysmal fistulas' clinical manifestation, their pathophysiology, and the PAs' surgical and endovascular treatment.

RESULTS

Various studies demonstrated a superiority of resection treatments, with better results and fewer reinterventions than exclusion treatments alone.

CONCLUSIONS

In view of this case, and as demonstrated by a literature search, we consider the surgical resection of PAs to be the optimal method for their management, rather than the surgical or endovascular exclusion treatment alone.

[Spontaneous cholecysto-cutaneous fistula: about two cases]

Cholecysto-cutaneous fistula (CCF) is a rare complication of untreated biliary pathology, with fewer than 100 cases documented in the literature. Most are secondary to bacterial infection, although it has also been described in gallbladder adenocarcinoma and post trauma. Its clinical presentation is variable, being able to present systemic affection, and its most frequent external drainage site is in the right hypochondrium. Due to the low incidence of this pathology, and the variety of forms of presentation, its management does not have, to date, standardized bases. We present two cases of patients who consulted in the emergency room at the Hospital Nacional de Clínicas for presenting cholecysto-cutaneous fistula. The treatment of both was surgical.

Corpus spongiosum flap: a unique technique in the management of urosymphyseal fistula

Urosymphseal fistulas are a debilitating but treatable consequence of the combination of radiotherapy and endoscopic interventions in prostate cancer patients. Treatment includes fistula excision with a tissue flap to prevent communication of involved structures and provide structural and vascular support. We introduce a unique surgical approach of mobilizing and utilizing a corpus spongiosum flap in urosymphyseal fistula repair. A retrospective study identified two patients who underwent repair with a pedicled corpus spongiosum flap at our institution. The corpus spongiosum had adequate length and vascularization and limited the need for extra-pelvic muscle flaps, thus maintaining muscle integrity in the abdomen and thighs. Following extirpative surgery, both patients had durable fistula closure, decreased pelvic pain, and resolution of lower urinary tract symptoms and osteomyelitis. These cases highlight the potential of the corpus spongiosum to be a reasonable alternative interpositional flap in genitourinary reconstruction.

Laparoscopic management of Crohn's disease-related complex enterovesical, enterocutaneous and enteroenteric fistula: A case report

The management of Crohn's disease is medical, with surgery reserved for emergencies and complications. Fistulizing Crohn's disease can present with either an internal or external fistula. Internal fistulae are common in patients with ileocolonic disease. Enterovesical fistulae form a very small part of these internal fistulae. An ileovesical fistula with other concomitant internal or external fistulae is a complex fistula. A patient with an ileovesical fistula further compounded by an enteroenteric fistula and an enterocutaneous fistula is a difficult surgical patient to manage because of the resultant dense inflammation. Here we report a case of complex ileovesical fistula (concomitant enterocutaneous fistula and enteroenteric fistula) managed by a laparoscopic approach.

Multiple cutaneous fistula after titanium dental implant: A case report

BACKGROUND

Dental implants allow functional and aesthetic reestablishment. Titanium (Ti) implants emerge as the preferred choice because Ti is considered an inert material, highly resistant to corrosion. However, virtually no material can be considered universally biocompatible and this includes titanium.

PURPOSE

To report an unusual presentation of inflammatory reaction after a Ti dental implant.

MATERIALS AND METHODS

The patient presented to a dermatology clinic to evaluate lesions on her face. She reported the placement of dental implants 2 years earlier, one of which evolved with inflammatory signs and instability a few days after the procedure. As anti-inflammatory and antibiotic therapy were fruitless, after 3 months the implant was removed, but the inflammation persisted. On physical examination, painful erythematous-papule-nodular lesions were found on the left mandibular and submandibular region.

RESULTS

Culture tests for microorganisms were negative and histopathological examination revealed a chronic fistula with a foreign body reaction. Using X-ray fluorescence, Ti particles were found along the fistula wall.

CONCLUSIONS

Professionals should be aware of complications arising from dental implants, including Ti implants. Detailed anamnesis and laboratory investigation can assure diagnosis for specific therapeutic approaches.

Hepatic hydatid cyst presenting as a cutaneous fistula

Hepatic hydatid cysts are usually asymptomatic. Nevertheless, they may rupture, causing anaphylactic shock or fistulation. Cutaneous fistulae caused by ruptured hepatic hydatid cysts are extremely rare. Herein, we report a case of infected cutaneous fistula caused by a ruptured hepatic hydatid cyst. A 57-year-old man presented to Al-Ain Hospital complaining of swelling in his right upper quadrant (RUQ) of 5 months' duration. The abdomen was soft, having a fluctuant tender swelling of 12 cm × 15 cm in the RUQ associated with a pus discharging fistula. The patient was admitted with a provisional diagnosis of abdominal wall abscess with pending sepsis. Surgical incision and drainage were performed under general anesthesia. Initially, around 15 ml of pus was drained, followed by the removal of multiple sized transparent cysts typical of hydatid disease. Postoperative abdominal computed tomography (CT) scan showed multiloculated hepatic cysts in the sixth, seventh, and left lobes with the involvement of the abdominal wall. The patient was treated with oral albendazole 400 mg twice daily for 30 days. Repeated CT scan at 4-month follow-up showed a significant reduction of size of the cysts, indicating proper response to treatment. A cutaneous fistula as a complication of a ruptured hepatic hydatid cyst is extremely rare. Awareness of this complication, especially in endemic areas, and using proper imaging and serological tests are vital for reaching a proper diagnosis.

Surgical Management of Deep Brain Stimulator Infection without Electrode Removal: Report of Two Cases

Objective  Stimulation of the subthalamic nucleus by implanted electrodes (deep brain stimulation [DBS]) is performed to suppress symptoms of Parkinson's disease. However, postoperative wound dehiscence and infection can require removal of the implanted electrode leads. This report describes treatment of intractable unilateral wound infection in two patients without removing the DBS device. Methods  First, components of the DBS system were removed except for the electrode lead and thorough debridement of the infected wound was conducted. Second, the edges of the bone defect left by removal of DBS components were smoothed to eliminate dead space. Subsequently, the electrode lead was covered by using a pericranial-frontalis-muscle flap or a bi-pedicled-scalp flap with good blood supply. Closed intrawound continuous negative pressure and irrigation treatment was conducted for 1 week after the surgery, and then the drain was removed. Results  We treated two patients with wound infection after implantation of DBS electrodes. Case 1 developed a cutaneous fistula and Case 2 had wound dehiscence. After treatment by the method described above, complete wound healing was achieved in both patients. Conclusion  DBS is always associated with a risk of infection or exposure of components and treatment can be very difficult. We successfully managed intractable wound infection while leaving the electrode lead in situ, so that it was subsequently possible to continue DBS for Parkinson's disease.

Case for diagnosis. Suppurative nodule or something deeper?

The authors report the case of a 62-year-old man with a history of total left hip arthroplasty nine years previously presenting with a large infiltrated plaque on the posterior area of the left thigh with three months of evolution without systemic symptoms or elevated inflammatory markers. Computed tomography of the left lower limb revealed a 12-centimeter linear extension of the lesion to the posterior part of the left proximal femur. Prosthesis joint infection, although rare, is a surgical complication to be taken into account, even if the surgery was performed many years before.

Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases

BACKGROUND

A tracheocutaneous fistula is a known complication following tracheostomy decannulation. Although surgical techniques for its repair are well described, there is no consensus about perioperative management and this procedure may generate significant airway and respiratory complications intraoperatively, and in the early postoperative period. We aimed to describe variations in perioperative management in tracheocutaneous fistula closure, estimate the incidence of early airway and respiratory complications, and identify any predisposing factors.

METHODS

The otorhinolaryngology surgical database identified 118 tracheocutaneous fistula closures from August 1994 to September 2015. Ninety-seven case notes were located generating 96 procedures for retrospective review. The data collected included demographics, comorbidities, anesthetic, and surgical technique, and complications up to 24 hours postoperatively.

RESULTS

The median age at surgery was 5 years 10 months (range 1 year 8 months to 19 years 6 months). Preoperatively, 72% of patients had a "mini" sleep study (where the tracheocutaneous fistula is covered and saturations measured overnight). Ninety percent had an inhalational induction and 96% a tracheal intubation. Intraoperatively, laryngospasm occurred in 2% and there was difficulty ventilating in another 2%. A "leak test" to check fistula repair airtightness was recorded in 35%. Postoperatively 24% had one or more episodes of oxygen desaturation. Major complications occurred in five patients (incidence 5%, 95% CI 0.8-9.7); four patients had pneumothoraxes with two needing postoperative mechanical ventilation and one patient developed life-threatening subcutaneous emphysema.

CONCLUSION

Perioperative care for children undergoing tracheocutaneous fistula closure was not standardized. Advocated tests such as preoperative "mini" sleep studies and "leak test" intraoperatively were not consistently performed. Intraoperative anesthetic complications were uncommon; however, major postoperative respiratory complications were 5%.

Treatment of Enterocutaneous Fistulas, Then and Now

BACKGROUND

An enterocutaneous fistula (ECF) is an aberrant connection between the gastrointestinal tract and the skin or atmosphere (enteroatmospheric fistula [EAF]). Multimodal treatment includes surgical procedures, nutrition support, and wound care. We evaluated our practice and compared our outcomes with previous results published from our institution.

MATERIALS AND METHODS

We performed a retrospective analysis of hospitalized ECF/EAF patients admitted between January 2011 and November 2015. Patients with internal fistulas; active inflammatory bowel disease; malignancy; radiation treatment; end-stage renal, hepatic, or cardiac disease; and active alcoholism were excluded. Data collected included demographics, fistula characteristics, nutrition therapy, treatment, operative success, and hospital mortality. Parametric and nonparametric tests for independent and paired groups were performed.

RESULTS

Thirty-one patients were included in the analysis. The median (interquartile range) age was 60 (53-76) years, and 81% were female. Parenteral nutrition was initially prescribed in 80% of patients, but 61% received enteral nutrition (EN) at some point during their hospitalization. Two patients were fed by fistuloclysis. Eighty percent of the patients underwent surgical repair a median of 12 months after diagnosis with 92% operative success. Surgical repair had a modest correlation with home discharge (ρ = 0.517, P = .003). A large proportion of patients (77%) were discharged home. The in-hospital mortality at our institution decreased from 44% in 1960 to 21% in 1970 to 3% in the current study.

CONCLUSIONS

Modern treatment of ECF/EAF, including EN and advanced local wound care, is associated with improvements in clinical outcomes such as hospital mortality.

Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors

BACKGROUND

Pharyngocutaneous fistula (PCF) is the most common surgical complication after total laryngectomy. Controversy still remains regarding the multiple risk factors implicated. The purpose of this study was to evaluate the potential risk factors for PCF.

METHODS

The strategy for our literature survey included research in MEDLINE up to December 2013. The risk factors analyzed were age, sex, smoking habit, alcohol use, comorbidity, preoperative hemoglobin level, blood transfusion, preoperative tracheotomy, previous radiotherapy and chemoradiotherapy, primary tumor site, T classification, cartilage invasion, tumor grade, surgical margins, suture material, second layer of suture, reconstruction, tracheoesophageal prosthesis, and neck dissection.

RESULTS

The electronic search resulted in 311 studies from which 63 met the inclusion criteria.

CONCLUSION

Chronic obstructive pulmonary disease (COPD), previous hemoglobin <12.5g/dL, blood transfusion, previous radiotherapy or chemoradiotherapy, advanced primary tumors, supraglottic subsite, hypopharyngeal tumor site, positive surgical margins, and the performance of neck dissection were risk factors for PCF.

Cutaneous fistula of liver echinococcal cyst previously misdiagnosed as fistulizated rib osteomyelitis

External fistulization or subcutaneous rupture of liver echinococcal cyst (EC) is found occasionally with total of 15 cases reported in the literature. We report a case of 60-year-old female previously misdiagnosed as fistulizated osteomyelitis of the 11^th rib. At computed tomography scan, non-vital EC was noted in the third liver segment. Under suspicion of external fistulization of perforated EC the patient underwent one-stage operation-pericystectomy and complete fistula excision. A retrospective analysis of the reported cases in the literature was performed with special references to classifying this rare entity. The main purpose of this report is to highlight the possibility of such a diagnosis when cutaneous fistula occurs in a same anatomic area with hydatid EC, even that cyst is proven to be calcified. We emphasize the role of a swift and radical surgical procedure including complete fistula excision to prevent secondary dissemination and post-operative complications.

Efficacy of stapler pharyngeal closure after total laryngectomy: A systematic review

BACKGROUND

Some primary studies compare manual and mechanical pharyngeal closures after total laryngectomy. The purpose of this study was to evaluate the advantages of the mechanical suture in pharyngeal closure.

METHODS

The literature survey included research in MEDLINE, EMBASE, and LILACS. The intervention analyzed was stapler-assisted pharyngeal closure, whereas the control group was manual suture pharyngeal closure.

RESULTS

The survey resulted in 319 studies. However, 4 studies were selected (417 patients). In the group of patients in whom the stapler was used, the incidence of pharyngocutaneous fistula was 8.7%, whereas in the other, it was 22.9%, with an absolute risk reduction of 15% (95% confidence interval [CI], 0.02-0.28; p = .02; I(2) = 66%). Regarding the surgical time, the average difference was 80 minutes in favor of the stapler group (95% CI, 23.16-136.58 minutes; p < .006).

CONCLUSION

The difference for starting oral feeding was 8 days in favor of the mechanical suture (95% CI, 4.01-11.73 days; p < .001). Patients who underwent mechanical suture had a shorter hospitalization period.