[Pelvic ostheomyelitis: diagnostics and treatment]

Results of treatment of 223 patients with ostheomyelitis of various etiology and localization were analyzed. Such aspects as diagnostic difficulties, polifocal type of the disease, sepsis development on the background of pelvic ostheomyelitis were discussed. Ostheoscintygraphy, magnetic resonance imaging and computed tomography proved to be of highest diagnostic value by pelvic ostheomyelitis. The original method of surgical treatment of purulent sacroileitis with the use of combined (pelvic and extrapelvic) access was represented.

Pacifying the open abdomen with concomitant intestinal fistula: a novel approach

The management of the open abdomen, particularly when complicated by the presence of intestinal fistula, remains a significant challenge of modern trauma care. Although several approaches have been proposed, these varied and complex cases defy the application of a universal approach to local therapy. Ultimately, abdominal closure is desired but is not always possible. Accordingly, surgeons must be well versed in the application of a number of useful approaches that may serve to facilitate control of fistula drainage while permitting management of the surrounding open wound. We contribute a management approach that is simplistic in design, provides for effective fistula control, and permits the subsequent unhindered granulation of the surrounding wound in abdomens not amenable to delayed closure techniques.

Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt

An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion.

Endometriotic uterocutaneous fistula after cesarean section. A case report

Endometriosis outside the pelvis is rare and most cases occur in surgical scars after operations involving the female genital tract. Fistulae involving the uterus are also very rare, usually being the result of postpartum and postoperative complications. In the present report, a case of a 44-year-old patient with an endometriotic uterocutaneous fistula is described. The patient presented 6 years after her fourth cesarean section with a painful nodule on the cesarean scar, which was bleeding during menstruation. The lesion extended to the uterine fundus, connecting the endometrial cavity with the skin. This is merely the second case of a uterocutaneous fistula to be reported in the literature and the first case developed on grounds of endometriosis.

Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula

BACKGROUND/PURPOSE

Few reports have documented the rate of persistence of a gastrocutaneous fistula (GCF) after gastrostomy removal or the reason for the persistence of a GCF. The purpose of this report was to analyze a large group of pediatric patients with a persistent GCF to determine the rate of persistence and any factors that correlate with the persistence of a GCF.

METHODS

This was a retrospective review of 1,042 children from The Children's Hospital, Denver, Colorado who had a gastrostomy constructed between 1992 and 2002. The charts of all children with a persistent GCF after gastrostomy catheter removal were analyzed for correlation between 13 clinical parameters and the persistence of a GCF.

RESULTS

There were 150 children with a persistent GCF for an incidence of 34%. Time elapsed between the creation of the GCF and removal of the gastrostomy appliance (< or =8 months versus >8 months) was the only parameter that showed any correlation with persistence of a GCF (P <.05). None of the other parameters studied showed any conclusive correlation with persistence of a GCF.

CONCLUSIONS

Time was the only factor that determined whether a surgically created GCF would persist after removal of a gastrostomy appliance.

Spontaneous cholecystocutaneous fistula

Spontaneous cholecystocutaneous fistula is rarely observed today because of the early diagnosis and management made possible by ultrasonography, broad-spectrum antibiotics, and effective surgical management of biliary tract disease. We present a case of spontaneous cholecystocutaneous fistula due to cholecystitis.

Pharyngocutaneous fistula

The occurrence of pharyngocutaneous fistula after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. The cause and management guidelines are still controversial. Contributing risk factors of impaired wound healing should be recognized in preoperative planning. Perioperative technical issues and preventive postoperative care play a major role in the prevention of fistulae, limiting the severity of the fistula and minimizing secondary complications. Surgical salvage of cancers treated with organ preservation approaches is associated with higher rates of postoperative complications, particularly in cases in which mucosal membranes are transgressed and surgically closed. Patients who require surgical repair are best treated by the use of regional myocutaneous flaps or free tissue transfers. This subset of patients is likely best treated in regional centers of excellence with well developed multidisciplinary programs for ablative and reconstructive head and neck surgery.

Management of wound sinuses

An update on the development, assessment and management of wound sinuses.

Artificial nutritional support in patients with gastrointestinal fistulas

Gastrointestinal (GI) fistulas allow abnormal diversions of GI contents, digestive juices, water, electrolytes, and nutrients from one hollow viscus to another or to the skin, potentially precipitating a wide variety of pathophysiologic effects. Mortality rates have decreased significantly during the past few decades from as high as 40% to 65% to 5.3% to 21.3% largely as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques. The primary causes of death secondary to enterocutaneous fistulas have been, and continue to be, malnutrition, electrolyte imbalances, and sepsis, especially in high-output fistulas, which continue to have a mortality rate of about 35%. Priorities in the management of GI fistulas include restoration of blood volume and correction of fluid, electrolyte, and acid-base imbalances; control of infection and sepsis with appropriate antibiotics and drainage of abscesses; initiation of GI tract rest including secretory inhibition and nasogastric suction; control and collection of fistula drainage with protection of the surrounding skin; and provision of optimal nutrition by total parenteral nutrition (TPN) or enteral nutrition (EN) (or both). The role of nutrition support in the management of enterocutaneous fistulas as either TPN or EN is primarily one of supportive care to prevent malnutrition, thereby obviating further deterioration of an already debilitated patient. It has been shown in several studies that TPN has substantially improved the prognosis of GI fistula patients by increasing the rate of spontaneous closure and improving the nutritional status of patients requiring repeat operations. Moreover, other studies have shown that nutritional support decreases or modifies the composition of the GI tract secretions and is thus considered to have a primary therapeutic role in the management of fistula patients. Finally, if a fistula has not closed within 30 to 40 days, or if it is unlikely to close because of a variety of collateral or compounding pathophysiologic conditions, consideration must be given to operative resection of the fistula while continuing to maintain the previous nutritional and metabolic support. The morbidity and mortality rates in such unfortunate patients remain high despite the many recent advances in surgical and metabolic technology.

Magnetic resonance imaging of nonhealing pressure ulcers and myocutaneous flaps

OBJECTIVE

To evaluate the use of magnetic resonance imaging (MRI) in making clinical decisions when assessing nonhealing pressure ulcers and nonhealing myocutaneous flaps for the presence of an abscess, osteomyelitis, sinus tracts, and fluid collections.

DESIGN

Retrospective review of patient charts and radiographic studies.

SETTING

Regional spinal cord injury center.

SUBJECTS

Twelve patients who had MRI as part of their evaluation for a nonhealing pressure ulcer or myocutaneous flap.

RESULTS

Seven patients had MRI for preoperative evaluation, four with a previous flap that had recurrent breakdown and three with a new grade III or IV ulcer. Five patients had MRI for postoperative evaluation of myocutaneous flaps with delayed healing. MRI was useful in identifying osteomyelitis in three patients and sinus tracts that required surgical revision in six patients. MRI was also used in two patients to assess the size of fluid collections postoperatively in determining whether the patients should be mobilized after surgery. These chronic nonhealing wounds resulted in multiple admissions and lengthy hospital stays and required multiple surgical revisions. Patients who did poorly with healing or had repeated breakdown tended to have concurrent issues such as poor self care, increased age, increased time of spinal cord injury, poor nutrition, or other medical problems.

CONCLUSION

Chronic nonhealing pressure ulcers and myocutaneous flaps can be difficult to treat and evaluate with conventional methods. There are multiple reasons for failure to heal. MRI can be a useful tool for identifying some of these factors including osteomyelitis, fluid collections, abcesses, and sinus tracts in the perioperative period. Identifying the appropriate patient populations and clinical indications for the optimal use of MRI should be subject of further study.

Classification and pathophysiology of enterocutaneous fistulas

Enterocutaneous and aortoenteric fistulas arise from a diverse array of pathophysiologic states. Classification by anatomic, physiologic, and etiologic systems is critical to both nonoperative and operative treatment planning.

Effect of blood transfusion on tumor recurrence and postoperative pharyngocutaneous fistula formation in patients subjected to total laryngectomy

Some surgical oncologists and otolaryngologists have reported that transfusion-induced immunosuppression may increase the incidence of recurrence and infectious complications in patients subjected to head and neck surgery for carcinoma. The relationship between intra-operative blood transfusion and postoperative pharyngocutaneous fistula formation and/or tumor recurrence is controversial. In a retrospective study of 110 total laryngectomized patients, we found no statistically significant differences between the transfused and nontransfused groups in terms of tumor recurrence and fistula formation.

Pancreatic secretion in man: effect of fasting, drugs, pancreatic enzymes, and somatostatin

The inhibitory effect of different drugs on pancreatic secretions was assessed in a patient with a posttraumatic pancreatic-cutaneous fistula. The various drugs examined were: pancreatic enzymes, cimetidine, verapamil, propantheline, acetazolamide, and somatostatin analog octreotide. Only fasting and octreotide reduced pancreatic secretion. The optimum dose of octreotide was 50 micrograms bid given subcutaneously; increasing the dose up to 100 micrograms tid had no additional benefit. A stable pancreatic-cutaneous fistula is an excellent model to assess the effect of different therapeutic measures on pancreatic secretion.