Secondary aorto-enteric fistulae: towards a more conservative approach

Eight cases of secondary aorto-enteric fistulae are presented occurring 9 months to 10 years after aortic Dacron grafting. In four patients there was a simple fistula between the anastomosis and the adherent duodenum, three patients had clinically infected grafts and one had a false aneurysm that had ruptured into the bowel. The four patients with a simple fistula had direct suture repair of the defect. One developed a recurrent fistula at 2 months and was successfully repaired again by direct suture. All four patients remain well at a follow-up of 1-5 years. The other four patients had the grafts excised, with local regrafting in two cases, both patients remaining well at follow-up. One patient had an axillo-bifemoral graft, but died at 30 days of overwhelming sepsis. The final patient, a girl with diffuse aneurysmal disease, had the aortic stump oversewn but no reconstruction. She died at 9 months of aortic stump disruption. These results suggest that a more conservative approach to the operative correction of secondary fistulae should be used wherever possible.     

Caroli's: a surgical challenge.

A patient operated upon for acalculous cholecystitis was later found to have Caroli's disease, congenital ectasis of intrahepatic bile ducts. Cholangitis, calculi and abscesses occurred in both lobes of the liver. Sepsis was not controlled despite open drainage, hepatic segmentectomy and ductal lavage with antibiotics and saline. At autopsy the liver contained a dozen unsuspected cavities filled with calculi, bile and pus. Diagnosis of Caroli's disease is best made by operative cholangiography in patients with atypical biliary disease. Management with antibiotics alone is seldom successful. Hepatic resection is better than drainage procedures for unilateral lesions. In patients with bilateral abscesses and no extrahepatic ductal obstruction or dilation, surgical treatment is often ineffective.     

Esophagectomy after pneumonectomy: a surgical challenge

Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.     

Urethrovaginal fistulae associated with tension-free vaginal tape procedures: a clinical challenge

Seven women with urethrovaginal fistulae and penetration of tension-free vaginal tape into the urethra were treated at our department between July 2007 and March 2013. Fistulae were diagnosed 1 month to 10 years after midurethral sling placement. All were managed surgically. Five patients developed recurrent postoperative stress urinary incontinence, which was treated conservatively in all cases. In three cases, additional surgical treatment using a midurethral sling was performed.     

Ulno-basilic arteriovenous fistulae: indications and surgical technique

Ulnar-basilic fistula is a vascular access option for hemodialysis first reported in 1967. There is no inherent reason why the ulnar artery cannot be used to create a fistula at the wrist; however, a few reports dealing with its complications and survival rates have been published in the literature. In the present work the results of 9 ulnar-basilic fistulae done in 9 adults patients on chronic hemodialysis, are reported. Two fistulae were created as primary access and the remaining 7 fistulae as secondary access after thrombosis of an ipsilateral and controlateral radiocephalic fistula in 6 cases and in a case of high-flux brachiocephalic fistula. No episodes of surgical complications were observed. This fistula is an additional option to create a distal vascular access for hemodialysis before constructing a proximal access.     

Gestational macromastia: a medical and surgical challenge

Gestational macromastia is a rare and complex disorder. Establishing an optimal medical and surgical management regimen has been challenging. Medical regimens have included tamoxifen, progesterone, bromocriptine, and testosterone. Surgical therapies have included reduction mammaplasty and mastectomy. This report will highlight the successful medical and surgical management in a woman with severe gestational macromastia.     

Life-threatening giant mediastinal goiter: a surgical challenge

Mediastinal goiter is a well known benign disease, usually resectable through a cervical approach with minimal morbidity and mortality. Only occasionally a median sternotomy or a lateral thoracotomy may be required. The present case is worthy of presentation because of the exceptional dimension of the disease and the surgical challenge that it presented. In a 72-year-old woman a large intrathoracic goiter of the right thorax caused a severe dyspnoea due to an important contralateral mediastinal shift with compression of the lung, superior vena cava system and trachea. At surgical exploration, through a cervico-sternotomic approach, the mediastinal structures dislocation and the strong adherences between the anomalous neovascularized capsula of the mass and the surrounding structures, complicated the surgical dissection. An accidental lesion of the innominate artery required its reimplantation on the ascending aorta. An immense mass, was finally removed and pathological examination revealed a rare case of neovascularized, pseudosarcomatoid capsula among a benign hyperplastic proliferation. In spite of its benign nature, a giant goiter caused a life-threatening compression of the respiratory tract and lung parenchyma in this patient. The dimension of the lesions, the mediastinal anatomy alterations and the severe intraoperative haemorrhage represented major technical difficulties during surgical resection.     

Cystinuria: A surgical challenge

A case is reported in which cystinuria was unresponsive to medical treatment. Replacement of both ureters with small intestine gave a satisfactory result.     

Large fungating thyroid cancers: a unique surgical challenge

Large goitres are common in the developing world, particularly in Asia and Africa. Nonetheless, large fungating goitres are extremely rare and represent a unique challenge to surgeons. Surgery should always be considered, when the general condition of the patient permits, to provide a better quality of life as it offers the only hope of long-term survival. The potential gain with surgery is that it allows maximum benefit for more effective radioactive iodine ablation and radiotherapy treatment. We report two cases of large fungating thyroid cancers complicated by anaemia and foul-smelling discharge.     

硬脊膜动静脉瘘伴髓周动静脉瘘的影像学特征及手术治疗

目的 增强临床医师对伴有髓周动静脉瘘的不典型硬脊膜动静脉瘘的认识。方法 回顾分析3例硬脊膜动静脉瘘伴髓周动静脉瘘患者的临床与影像学特征及手术治疗情况。结果3例患者的临床表现与典型的硬脊膜动静脉瘘差异不大,通过反复脊髓血管造影证实其伴有脊髓前动脉供血的硬脊膜动静脉瘘。3例患者均行手术治疗,术后症状全部改善。结论 全面的脊髓血管造影对硬脊膜动静脉瘘的诊断是必要的,有助于发现另外的瘘;伴髓周动静脉瘘的硬脊膜动静脉瘘的治疗关键在于成功地阻断硬脊膜支和脊髓动脉向瘘口的供血。