Pancreatico-mediastinal fistula with a mediastinal mass lesion demonstrated by MR imaging

Internal pancreatic fistulas are uncommon but well-recognized complications of inflammatory pancreatic disease. A case of a pancreatico-mediastinal fistula with a mediastinal mass lesion in a patient with a documented history of chronic alcohol consumption and previous episodes of acute pancreatitis is described. Since the clinical symptomatology was dominated by pulmonary complaints, magnetic resonance (MR) imaging using a breathhold coronal T2-weighted sequence with spectral fat saturation was essential in clarifying this difficult and rare pathology. Furthermore, the depiction of a fistulous tract between a mediastinal mass lesion and the retroperitoneum posterior to the pancreas, i.e., a pancreatico-mediastinal fistula by MR imaging has not been previously reported, to the best of our knowledge.     

Multiple Intrapulmonary Arteriovenous Fistulas in Childhood

Pulmonary arteriovenous fistulas (AVFs) are a rare but recognized cause of cyanosis in childhood. Lesions may be acquired as in hepatopulmonary syndrome or they may be congenital, particularly in association with certain multisystem disorders. Large fistulas are more common than multiple small connections. Two cases, both boys, presenting in the first decade of life are described. ``Bubble' echocardiography was the most telling investigation and strongly suggested the presence of AVFs in both cases. Each patient then underwent cardiac catheterization, which demonstrated normal pulmonary artery pressure and diffuse pulmonary telangiectasis. Both patients were treated effectively with nifedipine and continue with this mode of therapy.     

PULMONARY ARTERIOVENOUS FISTULAS IN CHILDREN A Review with Special Reference to the Disperse Telangiectatic Type, Illustrated by Report of a Case

Arteriovenous pulmonary fistulas present in infancy in more than half the number of cases. A distinction is drawn between isolated and multiple fistulas, and as a special category of the latter, the disperse telangiectatic type, is described. A review of the literature reveals 17 cases of this type. The present case extends this series—a girl dying at the age of 6 months, in whom the diagnosis of disperse telangiectatic arteriovenous pulmonary fistulas was regarded as probable on the basis of the investigations made. The diagnosis was confirmed at autopsy, which included bronchovascular injection of contrast during fluoroscopy. The relationship to the dominant hereditary Disease telangiectasia hereditaria (Rendu-Osler disease) is discussed. It is emphasized that this relationship appears particularly clear in the telangiectatic type, a circumstance which is however not confirmed in the present case. The difficulties in diagnosis and the diagnostic procedures are mentioned.     

经血管内栓塞治疗颈外动脉—海绵窦瘘

目的：探讨经血管内栓塞治疗３例颈外动脉海绵窦瘘的临床意义。材料和方法：３例颈外动脉海棉窦瘘均经股动脉入路栓塞，采用微螺旋圈和聚乙烯醇颗粒将瘘口闭塞。结果：术后患者临床症状显著改善。随访１个月至１年病情无复发。结论：颅内无血管杂音是其重要体征。将微导管置入瘘口是栓塞成功的关键     

MRI in Crohn's disease

Technological developments have extended the role of MRI in the evaluation of the gastrointestinal tract. The potential of MRI to evaluate disease activity in Crohn's disease has been investigated extensively, as MRI has intrinsic advantages over other techniques, including noninvasiveness and the absence of ionizing radiation. For perianal fistulizing disease MRI has become a mainstay in evaluation of disease, as localization and extent of disease can be very well appreciated using both T2-weighted and T1-weighted sequences, fat suppression, and intravenous contrast medium. Imaging of the small bowel and colon in Crohn's disease is more complicated due to bowel peristalsis and respiratory movement. However, using fast breathhold sequences and intravenous spasmolytic medication, images of good diagnostic quality can be acquired. To obtain sufficiently distended bowel, which in our estimation is a prerequisite for evaluation of the bowel, MR enteroclysis can be performed. However, applicability of different oral contrast media has been studied, as a noninvasive method for bowel distension would be preferable. Abdominal MRI is a valuable imaging technique for evaluation of luminal, transmural, and extraintestinal manifestations of Crohn's disease as degree of disease activity, presence of luminal pathology (e.g., stenoses), and extraintestinal manifestations of disease (e.g., abscesses, fistulas) can be accurately assessed.     

Surgical interruption of spinal dural arteriovenous fistulas

Spinal dural arteriovenous fistula (SDAVF) is the most common type of spinal vascular malformation. Surgical excision of SDAVF is the most effective treatment and the most often used procedure has been wide laminectomy, which causes instability of the spinal column.     

Endothelial permeability in experimental aneurysms and arteriovenous fistulas in rabbits as demonstrated by the uptake of evans blue

Rabbits with chronic experimental arteriovenous fistulas or different types of aneurysm fashioned by microvascular surgery have been examined for changes in endothelial permeability by means of a protein-bound tracer dye technique. The aneurysms and anastomosed veins of the arteriovenous aneurysms exhibited pronounced dye-uptake in contrast to low uptake at sites of sham operation. The results demonstrate the importance of haemodynamic factors in altered endothelial function, as shown with a tracer dye technique in these experimental vascular models.     

Management of low-output pancreatic fistulas with fibrin glue

BACKGROUND: Despite advances in surgical, endoscopic, and percutaneous therapeutic techniques, pancreatic fistulas remain a source of significant morbidity and long-term patient discomfort. The intraoperative use of fibrin sealant has been used prophylactically to prevent formation of fistula. We recognized the potential use of fibrin glue as a therapeutic modality for successful resolution of low-output pancreatic fistulas. METHODS: Three patients with low (<20 ml per day) output pancreatic fistulas underwent fluoroscopically directed injection of fibrin glue along their fistula tract. RESULTS: All 3 patients underwent successful fibrin glue injection without procedural complication. All fistula output stopped, and the 3 patients remained asymptomatic at 1 year. CONCLUSIONS: Fibrin glue inserted with image-guided catheter delivery systems may be a useful option in selected patients with low-output pancreatic fistulas.     

Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese Society for Esophageal Diseases

PURPOSE: A questionnaire survey was performed to evaluate the complications and prognosis of esophageal cancer treated with esophageal intubation before or during radiotherapy. METHODS AND MATERIALS: Clinical data were accumulated on a total of 47 patients treated at 17 institutions in Japan. Five patients had Stage II, 30 Stage III, and 11 Stage IV, and the stage was unknown in 1 patient. Covered expandable metallic stents were inserted in 30 patients, uncovered expandable metallic stents in 13, plastic or silicon prosthesis in 3, and an unknown type in 1 patient. Esophageal stenting was performed before the start of RT for 23 patients and during the course of RT for 24 patients. The reasons for the stenting were severe stricture in 32 patients (Group 1) and esophageal fistula in 15 patients (Group 2). RESULTS: The most frequent toxicity was formation or worsening of esophageal fistulas in 13 patients (28%), followed by massive hematemesis or GI bleeding in 10 patients (21%). In total, 24 patients (51%), including 10 patients with possible treatment-related deaths (Grade 5), had nonhematologic toxicities of Grade 3-5. The interval from the start of RT to the nonhematologic toxicity ranged from 16 to 312 days (median 78). The incidence of toxicities was higher for Group 1 (59%) than for Group 2 (33%), although the difference was not statistically significant. The median survival time for those with Stage II-III and Stage IV was 5 and 3.5 months, respectively. CONCLUSIONS: Patients with esophageal intubation before or during RT have a high risk of life-threatening complications, especially for those with severe esophageal stricture. Because long survival is expected for a substantial proportion of patients with locally advanced esophageal cancer after chemoradiotherapy, palliative intubation should be delayed until radiotherapy or chemoradiotherapy appears to have failed.     

Laparoscopic surgery for fistulas that complicate diverticular disease

Background Diverticular disease is complicated by colovesical and colovaginal fistulas in 4–20% of patients. Laparoscopic surgery is usually reserved for selected cases of uncomplicated disease. The aim of this study was to assess the efficacy and effectiveness of laparoscopic surgery in the treatment of those patients.Methods Eighteen patients, 15 with colovesical fistulas and three with colovaginal fistulas, were operated on laparoscopically. Prospectively collected data, associated with technical feasibility, short-term outcome and effectiveness, were analysed.Results Twelve sigmoidectomies, four extended left colectomies and two segmentectomies were performed. Fistulas were treated with simple dissection or mechanical division, and the bladder wall was repaired in two patients. Mean operating time was 237 min (range 165–330).There was one conversion (5.5%) and no post-operative death. Morbidity was 27.7% and included one major complication. Return of gastrointestinal function occurred 2.9 days post-operatively, and the mean hospital stay was 10 days after surgery. During the 5.1-year follow-up period there was one fistula recurrence (5.5%) and no recurrent diverticulitis.Conclusions Laparoscopic one-stage surgery was technically feasible and safe, with low morbidity. Effectiveness appears favourable when compared with open surgery, but prospective randomized studies are necessary to support such a conclusion.