Coronary artery-descending aorta fistula as an unusual collateral in a patient with postductal coarctation

We report on the case of a 45-year-old man with recurrent syncope and angina with shortness of breath on exertion. Invasive and noninvasive diagnostic methods revealed severely stenosed bicuspid aortic valve, postductal coarctation of the aorta, and a coronary artery-descending aorta fistula. After surgical correction of the coarctation, ligation of the fistula, and aortic valve replacement, the patient's symptoms resolved. Cathet. Cardiovasc. Diagn. 44:431–433, 1998. © 1998 Wiley-Liss, Inc.     

Transcatheter closure of a large coronary arteriovenous fistula using the new Amplatzer™ duct occluder

A 9-year-old patient with a large coronary arteriovenous fistula (circumflex-right atrium) underwent successful complete percutaneous closure, using the new Amplatzer™ Duct Occluder (ADO) inserted via a 6 Fr sheath. Cathet. Cardiovasc. Diagn. 45:155–157, 1998. © 1998 Wiley-Liss, Inc.     

Congenital arteriovenous fistula of internal thoracic artery: Successfully managed by transcatheter embolization

An asymptomatic young woman was found to have a continuous machinery murmur over the second right interspace near the sternum. Investigations showed an arteriovenous fistula involving the right internal thoracic artery and accompanying vein. Selective transcatheter embolization was successfully performed. Cathet. Cardiovasc. Diagn. 43: 198–200, 1998. © 1998 Wiley-Liss, Inc.     

Higher anti-TNF serum levels are associated with perianal fistula closure in Crohn’s disease patients

Objectives: Anti-TNF agents are effective to treat perianal Crohn’s disease (CD). Evidence suggests that Crohn’s disease patients with perianal fistulas need higher infliximab (IFX) serum concentrations compared to patients without perianal CD to achieve complete disease control. Our aim was to compare anti-TNF serum concentrations between patients with actively draining and closed perianal fistulas.

Methods: A retrospective survey was performed in CD patients with perianal disease treated with IFX or adalimumab (ADL). Fistula closure was defined as absence of active drainage at gentle finger compression and/or fistula healing on magnetic resonance imaging.

Results: We identified 66?CD patients with a history of perianal fistulas treated with IFX (n?=?47) and ADL (n?=?19). Median IFX serum trough concentrations ([interquartile range]) were higher in patients with closed fistulas (n?=?32) compared to patients with actively draining fistulas (n?=?15): 6.0?µg/ml [5.4–6.9] versus 2.3?µg/ml [1.1–4.0], respectively (p?<?.001)). A similar difference was seen in patients treated with ADL: median serum concentrations were 7.4?µg/ml [6.5–10.8] in 13 patients with closed fistulas versus 4.8?µg/ml [1.7–6.2] in 6 patients with producing fistulas (p?=?.003). Serum concentrations of ≥5.0?µg/ml for IFX (area under the curve of 0.92; 95% CI: 0.82–1.00)) and 5.9?µg/ml for ADL (area under the curve of 0.89; 95% CI 0.71–1.00) were associated with fistula closure.

Conclusion: Cut-off serum concentrations ≥5.0?µg/ml for IFX and ≥5.9?µg/ml for ADL were associated with perianal fistula closure. Hence, patients with producing perianal fistulas may benefit from anti-TNF dose intensification to achieve fistula closure.     

Simultaneous anus and bowel operation is preferable for anal fistula in Crohn's disease

Background: Background: Anal fistula in Crohn's disease is reportedly intractable, and little is known about factors influencing the outcome of surgery. The purpose of this study was to clarify the current status of surgery for anal fistula in Crohn's disease, and possible factors influencing surgical outcome were investigated. Methods: From August 1993 to September 1998, 39 of 239 Crohn's disease patients underwent long-term seton drainage. The patients were divided into two groups: patients who received simultaneous bowel and anus operation (simultaneous group; n= 11) and a control group (n= 28). Results: Twenty-nine of the 39 (74%) patients received two seton drains or more, with a mean of 2.7. Twenty-one (54%) patients received two or more operations. The rate of seton drain removal was 52% at 12 months after operation and 86% at 24 months. The cumulative rate of seton drains remaining at 12 months after the first operation was 10% in the simultaneous group and 37.7% in the control group, with a significant difference (P= 0.038). Multivariate analysis revealed that simultaneous operation was the only significant factor that influenced the surgical results (P= 0.0489). Seven of the 21 (33%) patients recurred after total removal of seton drain(s). All the patients who had recurrence belonged to the control group. Continence did not deteriorate after seton drainage. Ten patients (26%) required enterostomy and no patient received proctectomy. Conclusions: Healing of Crohn's anal fistula was significantly better in the simultaneous group than in the control group, and the recurrence rate was lower in the simultaneous group. Seton drainage for anal fistula in Crohn's disease was effective and preserved sphincter function. Received: April 4, 2001 / Accepted: January 15, 2002     

Efficacy of Anal Fistula Plug vs. Fibrin Glue in Closure of Anorectal Fistulas

Purpose Long-term closure rates of anorectal fistulas using fibrin glue have been disappointing, possibly because of the liquid consistency of the glue. A suturable bioprosthetic plug (Surgisis?, Cook Surgical, Inc.) was fashioned to close the primary opening of fistula tracts. A prospective cohort study was performed to compare fibrin glue vs. the anal fistula plug. Methods Patients with high transsphincteric fistulas, or deeper, were prospectively enrolled. Patients with Crohn's disease or superficial fistulas were excluded. Age, gender, number and type of fistula tracts, and previous fistula surgeries were compared between groups. Under general anesthesia and in prone jackknife position, the tract was irrigated with hydrogen peroxide. Fistula tracts were occluded by fibrin glue vs. closure of the primary opening using a Surgisis^? anal fistula plug. Results Twenty-five patients were prospectively enrolled. Ten patients underwent fibrin glue closure, and 15 used a fistula plug. Patient's age, gender, fistula tract characteristics, and number of previous closure attempts was similar in both groups. In the fibrin glue group, six patients (60 percent) had persistence of one or more fistulas at three months, compared with two patients (13 percent) in the plug group (P < 0.05, Fisher exact test). Conclusions Closure of the primary opening of a fistula tract using a suturable biologic anal fistula plug is an effective method of treating anorectal fistulas. The method seems to be more reliable than fibrin glue closure. The greater efficacy of the fistula plug may be the result of the ability to suture the plug in the primary opening, therefore, closing the primary opening more effectively. Further prospective, long-term studies are warranted. Dr. David Armstrong has a patent-licensing agreement with the manufacturers of Surgisis? (Cook Surgical, Bloomington, IN). Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Influence of cholangitis after preoperative endoscopic biliary drainage on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures

Background and Aim

Preoperative cholangitis after preoperative drainage has been reported to increase postoperative complications, particularly pancreatic fistula. We therefore examined the effects of cholangitis after preoperative endoscopic biliary drainage (EBD) on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures.

Methods

The study group comprised 102 patients who underwent EBD among patients who underwent surgery.

Results

Of the 102 patients, 33 (32%) had postoperative pancreatic fistulas, and 56 (55%) had preoperative cholangitis after preoperative drainage. Analysis of risk factors for preoperative cholangitis showed that a total bilirubin level of 2.9 mg/dL or higher (hazard ratio [HR], 2.95; 95% confidence interval [CI], 1.223–7.130; P = 0.016) and a surgical waiting time of 29 days or longer (HR, 4.23; 95% CI, 1.681–10.637; P = 0.02) were independent risk factors for cholangitis. Patients with preoperative cholangitis had a significantly higher incidence of pancreatic fistula than did patients without preoperative cholangitis (78.8 vs 21.2%; P = 0.001). Patients with biliary cancer had a significantly higher incidence of pancreatic fistula than did those with pancreatic cancer (72.7 vs 27.2%; P = 0.005). Multivariate analysis showed that preoperative cholangitis (HR, 4.8; 95% CI, 1.785–12.992; P = 0.001) and biliary cancer (HR, 3.5; 95% CI, 1.335–8.942; P = 0.006) were significant independent risk factors for postoperative pancreatic fistula.

Conclusion

Prevention of preoperative cholangitis, a risk factor for postoperative pancreatic fistula, is likely to decrease the incidence of postoperative pancreatic fistula.     

Conventional cutting vs. internal anal sphincter-preserving seton for high trans-sphincteric fistula: a prospective randomized manometric and clinical trial

Abstract. Background: Cutting setons have been used in complicated perirectal sepsis with good effect, although there is a moderately high incidence of fecal leakage after their use. The aim of this study was to compare a modified cutting seton, which repaired the internal anal sphincter muscle and re-routed the seton through the intersphincteric space, with a conventional cutting seton. Methods: A total of 34 patients were randomized between 1998 and 2002. They were prospectively assessed by continence score and anorectal manometry, and for anal function, clinical sepsis and fistula recurrence. Results: There was no difference in postoperative continence score, incidence of recurrent fistula or healing time between groups after a mean follow-up of 12 months. Resting anal manometric pressures and vector volumes were consistently higher with the modified seton (although not statistically significant), as was the area under the inhibitory curve during elicitation of the rectoanal inhibitory reflex across the full sphincter length. (p<0.05). Conclusion: A larger prospective study of internal anal sphincter-preserving seton use in cryptogenic high transshincteric fistula-in-ano appears justified.     

Success of Episioproctotomy for Cloaca and Rectovaginal Fistula

Purpose Surgical repair of rectovaginal fistula with an advancement flap has had suboptimal results. The existing literature documenting episioproctotomy as a surgical option in females with rectovaginal fistula or cloaca is limited. This study was designed to examine our experience with episioproctotomy in this group. Additionally we were interested in risk factors, which might predict failure. Methods All females who had repair of a rectovaginal fistula or cloaca with episioproctotomy from 1998 to 2004 were studied. Data were collected from chart review and telephone contact. This included demographics, body mass index, tobacco use, Crohn’s disease, previous surgery, and diverting stoma. Results Data were obtained from 42 females (mean age, 39.2 (range, 25–70) years). The mean follow-up was 37 (range, 2–84) months. Nine females had a cloaca and the rest had a rectovaginal fistula with an anterior sphincter defect. Eleven (all with anterior tissue) had recurrence of fistula. None with cloaca had recurrence. Eight of 11 recurrences occurred in females who had failed at least one previous repair. No variables that were studied significantly affected recurrence. Median (25th, 75th percentiles) postoperative Wexner incontinence scores for those with and without recurrence were 8 (7, 12) and 5 (2, 6) respectively. Conclusions Episioproctotomy is a successful technique for repair of rectovaginal fistula and cloaca. Incontinence score postoperatively were acceptable. It should be considered a first line of surgical treatment in those with a fistula that includes compromise of the anterior sphincter complex. This multimedia article (video) has been published online and is available for viewing at . As a subscriber to Diseases of the Colon & Rectum, you have access to our SpringerLink electronic service, including Online First. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Coronary artery perforation repair using microcoil embolization

An 82-year-old woman undergoing percutaneous transluminal coronary angioplasty experienced perforation of the terminal portion of the left anterior descending coronary artery caused by guidewire trauma. The coronary artery perforation was successfully closed using a vascular occlusion system consisting of individual thrombogenic coils delivered to the site. Coronary artery perforation (CAP) during percutaneous transluminal coronary angioplasty (PTCA) has been reported to occur in less than 1% of cases. The incidence seems to be higher with the new interventional devices, e.g., DCA, TEC, and laser CAP may result in pericardial hemorrhage and cardiac tamponade or a coronary artery fistula to either the left or right ventricle. The management of CAP may include prolonged balloon inflations, reversal of anticoagulation, pericardiocentesis, and emergency surgery. Proximal perforations sometimes can be managed with vein covered stents. We describe another option in the treatment of distal CAP using a vascular occlusion system. Cathet. Cardiovasc. Diagn. 43:474–476, 1998. © 1998 Wiley-Liss, Inc.     

Does technique of anastomosis play any role in developing late perianal abscess or fistula?

PURPOSE: This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. METHODS: A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. RESULTS: A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P>0.05), nor did the risk of fistula formation differ significantly between the patients with handsewnvs. stapled anastomoses (P>0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P=0.012). CONCLUSION: The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique.Poster presentation at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Colovesical Fistula: Not a Contraindication to Elective Laparoscopic Colectomy

PURPOSE Traditionally, diverticular fistula was thought to be a contraindication for laparoscopic colectomy. The advent of hand-assisted laparoscopy has allowed repair of a diverticular fistula to be technically feasible laparoscopically. We present our experience with laparoscopic colectomy in patients with diverticular fistulas.METHODS Patients with colovesical or colovaginal fistulas secondary to diverticular disease were consecutively entered into a database over a five-year period. All operations were electively performed by a single group of colorectal surgeons. Patient demographics, American Society of Anesthesiologists classification, type of surgery, operating time, hospital length of stay, and early and late complications were recovered by chart review. These results were then compared to results from a group of patients who had undergone elective laparoscopic colectomy for recurrent diverticulitis during the same period by the same group of surgeons.RESULTS Altogether, 40 consecutive operations for diverticular fistulas were performed, 36 of which were started laparoscopically (90 percent). The average patient age was 65 years and the average American Society of Anesthesiologists class was 2. Patient demographics were similar among the group with recurrent diverticulitis (n = 149). The average hospital stay was 6.2 days for the fistula group and 4.4 days in the recurrent diverticulitis group. The average operating time was 220 minutes for the fistula group vs. 176 minutes for the uncomplicated group (P < 0.002). The conversion rate was significantly higher in the fistula group (25 percent vs. 5 percent, P < 0.001). There were no postoperative anastomotic leaks or bleeding episodes requiring reoperation in the fistula group.CONCLUSIONS Diverticular fistula should no longer be considered a contraindication for laparoscopic colectomy. These cases are more complex, as evidenced by the longer operating times and higher conversion rates when compared with resections for uncomplicated recurrent diverticulitis. Although the length of hospital stay was longer for patients who underwent laparoscopic colectomy for diverticular fistula, those whose operations were completed laparoscopically had the same outcome as patients with uncomplicated disease. We anticipate that minimally invasive surgery will become the standard of care for colovesical fistula, as it now is for uncomplicated diverticular disease.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

An Audit of Gastroduodenal Crohn Disease: Clinicopathologic Features and Management

Background: This study was undertaken to assess the clinicopathologic features and management of gastroduodenal Crohn disease. Methods: The medical records of 54 patients with gastroduodenal Crohn disease treated between 1958 and 1997 were reviewed. Results: Gastroduodenal Crohn disease occurred in association with disease elsewhere in 52 patients (96%). The commonest pathology was stricture (n = 41), followed by ulceration (n = 4) and duodenocutaneous fistula (n = 2). Medical treatment was initially attempted in 31 patients, of whom 12 required no surgical treatment for gastroduodenal disease. Nineteen patients required surgery for gastroduodenal obstruction or fistula despite medical treatment. Overall, 33 patients (61%) required surgery; the indication was obstruction in 30, duodenocutaneous fistula in 2, and bleeding in 1. There was one postoperative death because of persistent bleeding and intra-abdominal sepsis after oversewing of a bleeding ulcer. In obstructive disease 16 patients were treated by bypass surgery, 10 by strictureplasty, and 4 by gastrectomy. After surgery for obstructive disease anastomotic leak developed in three patients, and persistent gastric outlet obstruction was seen in six patients. In the long term 11 patients required reoperation for anastomotic obstruction (n = 9) or stomal ulceration (n = 2). For duodenocutaneous fistula one patient underwent simple closure of fistula, and the other patient duodenojejunostomy. Both of these patients developed an intra-abdominal abscess without evidence of leak. There has been no fistula recurrence. Conclusions: Gastroduodenal Crohn disease is a complex and difficult problem that is associated with serious complications and need for reoperation.     

Pilot Study: Fibrin Sealant in Anal Fistula Model

PURPOSE The aim of this study was to investigate the failure of fibrin sealant treatment for fistula-in-ano in an experimental porcine model and to determine histologic changes associated with the sealant and setons.METHODS Three surgically created fistulas were treated by seton drainage in each of eight male pigs. After 26 days, magnetic resonance imaging was performed and setons were removed. Two pigs were killed as controls for stereologic histologic fistula track assessment. In six, fistulas were curetted, and in four the fistulas were treated with fibrin sealant. In these four sealant and two seton pigs, magnetic resonance imaging was repeated a median of 47.5 days after fistula formation. The pigs were killed and stereologic histologic fistula track examination was performed to determine granulation tissue and fistula lumen volumes. These values were compared among control, seton, and sealant groups over time, and related to fistula volumes derived from magnetic resonance imaging.RESULTS Sealant was not visible microscopically within tracks, although some sections revealed a foreign body–type reaction. On stereologic assessment, granulation tissue volumes were smaller in sealant and seton groups than in controls (median, 88 vs. 187 vs. 453 mm³, respectively; P = 0.002) and decreased over time (median, 408 and 152 mm³ (Day 42) vs. 88 and 75 (Day 53), respectively; P = 0.002). Fistula lumen (P < 0.001), and granulation tissue combined with fistula lumen volumes (P = 0.002) were similarly smaller. Magnetic resonance imaging of fistula intensity was less in the sealant group than in the seton group and controls (mean, 777 vs. 978 vs. 1214 units/mm², P = 0.003). Magnetic resonance imaging fistula volumes were least in sealant and seton groups vs. controls (P = 0.024), decreasing significantly in the sealant group over time (P = 0.018). No direct relationship was found between imaging and histologic volumes.CONCLUSIONS In an experimental porcine model of anal fistula, granulation tissue was still present, albeit diminished, following track curettage combined with seton or sealant therapy, and was minimal in the sealant group, confirming some benefit from this procedure. Eradication of all longstanding granulation tissue may ensure complete success of fibrin sealant therapy.G.N.B. was supported by The St. Marks Hospital Foundation. Baxter Healthcare provided fibrin sealant in this study.Published online: 31 January 2005     

Somatostatin analog treatment of pancreatic fistulas

Summary In order to hasten healing of pancreatic fistulas, we have treated 11 men and one woman with octreotide, a long-lasting somatostatin analog. This agent was administered subcutaneously in doses of 0.05–0.20 mg, two to three times per day. Fistulas were secondary to pancreatic biopsy (1), pancreatic abscess drainage (2), operative injury (3), and blunt abdominal trauma (4). The two patients with fistulas secondary to pancreatic biopsy had outputs of 1000 mL/d. The patient with blunt trauma had pancreatic ascites, with outputs of 750 mL/d. The remainder had outputs of 100–250 mL/d for periods ranging from 1 wk to 11 mo. After octreotide administration, fistula output decreased from 360±347 mL/d to 110±131 mL/d on the first day of therapy (p<0.05) and to 44±72 mL/d on the seventh day (p<0.05). Seven patients eventually closed their fistulas. Failure to achieve fistula closure with octreotide was secondary to pancreatic duct stenosis (4); pseudocyst (1) or recurrent sepsis (4); and patient noncompliance (4). Somatostatin analogs are useful in the management of pancreatic fistulas. They significantly decrease (p<0.05) the volume of fistula output, and they seem to aid fistula healing. Somatostatin analogs are safe even for outpatient management of pancreatic fistulas.     

Factors That Predict Conversion in 69 Consecutive Patients Undergoing Laparoscopic Ileocecal Resection for Crohn’s Disease: A Prospective Study

PURPOSE This prospective study was designed to identify factors that could predict conversion in patients undergoing first laparoscopic ileocecal resection for Crohn’s disease. METHODS Between 1998 and 2004, 69 consecutive patients (32 males; mean age, 32 ± 9 years) who had undergone a first laparoscopic ileocecal resection for Crohn’s disease were included in a prospective study. Twenty-one patients (30 percent) were converted into laparotomy. Possible factors for conversion were analyzed by both univariate and multivariate analyses. RESULTS No patient died. Four patients (9 percent; 2 in each group) required five reoperations because of intraperitoneal hemorrhage (n = 1), anastomotic fistula (n = 3), and small-bowel obstruction (n = 1). Mean hospital stay was significantly increased in converted compared with laparoscopic patients (9 ± 4 vs. 7 ± 3 days; P < 0.05). On univariate analysis, more than three episodes of acute flare of Crohn’s disease (P = 0.02), male gender (P = 0.03), preoperative immunosuppressive drugs (P = 0.04), intra-abdominal abscess or fistula at the time of laparoscopy (P = 0.02), and resection of other intestinal segment (P = 0.02) were factors that predicted conversion. On multivariate analysis, recurrent medical episodes of Crohn’s disease (odds ratio, 2; 95 percent confidence interval, 1–4), and intra-abdominal abscess or fistula at the time of laparoscopy (odds ratio, 15; 95 percent confidence interval, 4–78) were the two independent risk factors for conversion. CONCLUSIONS This prospective study demonstrated that the severity of the disease increased significantly the conversion rate of the first laparoscopic ileocecal resection. Knowledge of these risk factors for conversion could be helpful in preoperative preparation and counseling of patients. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available.     

Over‐the‐scope clip system: A review of 1517 cases over 9 years

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over‐the‐scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC‐associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.     

Characterization of intra-arterial flow velocity within left coronary to pulmonary artery fistula

The physiology of a coronary to pulmonary artery fistula has not been well characterized. This case report demonstrates the flow velocity pattern of a coronary fistula to the pulmonary artery, which supports the hypothesized physiology that flow is predominantly continuous without a phasic pattern. The flow velocity within a coronary fistula has not been previously demonstrated. Cathet. Cardiovasc. Diagn. 41:208–212, 1997. © 1997 Wiley-Liss, Inc.     

Transcatheter closure of a huge pulmonary arteriovenous fistula with embolization coils

A 46-year-old female with bilateral pulmonary arteriovenous fistulas was treated with Gianturco coil occlusion. The small right lung fistula was closed with a 6 mm coil, whereas the huge left lung fistula was occluded with three coils (one 10-mm and two 8-mm). Angiography 3 d later demonstrated recanalization of the left fistula. Two 8 mm coils were inserted to achieve complete obstruction again. She developed pulmonary infarction in the left lung 2 d later, which recovered without sequelae. We conclude that coil embolization for huge pulmonary arteriovenous fistula is feasible but may result in pulmonary infarction. Cathet. Cardiovasc. Diagn. 42:286–289, 1997.© 1997 Wiley-Liss, Inc.     

Incidence of fistulas after drainage of acute anorectal abscesses

PURPOSE: The aim of this study was to assess the incidence of anal fistulas and factors related to this incidence after incision and drainage of acute cryptoglandular anorectal abscesses. METHODS: Of 170 patients without previous anal fistulas, 146 were followed up for an average of 99 (range, 22–187) months after abscess drainage or until a fistula appeared. RESULTS: Fifty-four (37 percent) patients developed a fistula, and 15 (10 percent) patients developed a recurrent abscess. The incidence of fistulas was higher in females than in males (50vs. 31 percent;P=0.0403), especially regarding anterior abscesses (88vs. 33 percent). Abscesses growingEscherichia coli were more prone to fistula formation than those growing other bacteria (46vs. 27 percent;P=0.0368). CONCLUSION: Incision and drainage alone of acute anorectal abscesses is recommended, because an unnecessary primary fistulotomy can be avoided in more than half of the patients by this approach. For superficial anterior abscesses in females, however, primary fistulotomy may be considered.