REPAIR OF VESICO-VAGINAL FISTULA

One hundred and thirteen patients with vesico-vaginal fistula were seen at the University of California Hospital from 1932 through 1959. The most common cause of fistula was trauma associated with pelvic operation, and the operation most often involved was total abdominal hysterectomy. Malignant disease of the pelvic organs was the second most common cause, while radiation therapy and obstetrical causes were next in the order of frequency.Three fistulas healed spontaneously. Twelve bladder by-pass operations were done and 54 repairs were carried out in 46 patients. Thirty-eight patients (82.6 per cent) were cured after one or more repair operations. A variety of operative approaches were used, selected in accordance with the needs of the individual case. Bladder distention postoperatively, due to a plugged catheter, was held responsible for failure of the repair in three cases, and this complication was considered preventable.Close attention to surgical technique, the recognition of bladder injury, and proper repair at the time of operation are prime factors in the prevention of vesico-vaginal fistula.     

TRANSECTION OF THE PANCREAS BY BLUNT TRAUMA

If a diagnosis of traumatic pancreatitis is made and the patient does not improve clinically during the first 24 hours, transection of the pancreas should be suspected. If this is found to be the case at operation, the distal pancreas should be resected and the proximal end of the pancreas closed carefully with interrupted mattress suture of non-absorbable suture material. Particularly, the pancreatic duct should be ligated to prevent the formation of an external fistula. Any attempt at reapproximation of the transected pancreas will invariably result in an external pancreatic fistula if the patient survives the immediate postoperative period.     

UNUSUAL CASE OF PULMONARY ARTERIOVENOUS FISTULA CONCEALED BY THE CARDIAC SILHOUETTE ON CHEST ROENTGENOGRAM

A large pulmonary arteriovenous fistula was discovered in a patient with long-standing cyanosis, clubbing and dyspnea, with no other cardiovascular signs or symptoms and a normal chest roentgenogram at the time of cardiac catheterization and pulmonary angiography. The fistula was overshadowed by the cardiac silhouette. Surgical resection was successful. Although rarely undetected on the chest roentgenogram, this potentially lethal malformation should be considered in the differential diagnosis of cyanosis unaccompanied by other cardiovascular signs or symptoms.     

Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study

Ten patients with hard palate fistulas and velopharyngeal incompetence were examined cineradiographically with lateral and frontal projections during connected speech. The purpose was to study velopharyngeal function for open versus covered fistulas. Fistula length, width, and size were measured. With an open fistula, the degree of lateral pharyngeal wall activity was significantly correlated at the 0.05 level to fistula size. There was no statistically significant correlation between fistula size and the degree of velar activity. With the fistula covered, the velopharyngeal movements improved or even normalized in all patients regardless of fistula size. These findings indicate that patients with both velopharyngeal incompetence and an additional fistula will need covering of the fistula. If velopharyngeal incompetence persists after a temporary covering of the fistula, a combination of velopharyngeal flap surgery and fistula covering ought to be performed to normalize the velopharyngeal activity and speech and resonance.     

RELATIONSHIP OF DELIVERY DATE TO PREDICTED DATE

Gastroduodenostomy after gastric resection is a procedure which can be readily performed if the short gastric vessels are first divided. It makes for a more physiological restoration of the gastrointestinal tract than is accomplished with gastrojejunostomy and permits proper admixture of the food with the bile and pancreatic enzymes. It avoids several potential dangers such as leakage from the duodenal stump, the possibility of a gastrocolic fistula, and malfunction of the anastomosis due to distortion of a jejunal loop. Apparently the "dumping syndrome" does not occur after gastroduodenostomy as it sometimes does after gastrojejunostomy.     

苏木科植物上的拟茎点霉新种及中国新纪录种

报道了苏木科植物上的两个拟茎点霉 Phomopsis 新种:羊蹄甲生拟茎点霉 Phomopsis bauhinicola 和决明生拟茎点霉 Phomopsis cassiicola , 和两个中国新记录种:羊蹄甲拟茎点霉 Phomopsis bauhiniae 和决明拟茎点霉 Phomopsis cassiae 。新种附有拉丁文、英文描述和显微结构图。模式标本保存于华南农业大学真菌标本室 (HMA) 。     

医用生物胶黏合封堵乳糜瘘10例的临床效果观察

目的:评价颈淋巴清扫术中应用医用生物胶黏合周围自体肌肉组织封堵胸导管瘘口预防术后乳糜瘘的临床疗效及安全性。方法:选择2005年1月~2012年4月我科收治的10例口腔癌患者,在颈淋巴清扫术中发现并确诊为乳糜瘘后,立即行瘘口缝扎并应用医用生物胶黏合周围自体肌肉组织封堵瘘口,观察其临床效果及不良反应的发生情况。结果:经此方法治疗后,10例患者术中术后均未出现乳糜瘘及其他严重并发症;2例患者经此法治疗无效后,二次手术探查行瘘口缝扎及应用医用生物胶黏合封堵治疗后有效。术后随访10例患者3个月均未发现有乳糜瘘复发,亦未出现局部刺激反应及变态反应。结论:术中医用生物胶黏合封堵胸导管瘘口是预防颈淋巴结清扫术后乳糜瘘理想、安全的治疗方法。     

RELATIONSHIP OF DELIVERY DATE TO PREDICTED DATE

Gastroduodenostomy after gastric resection is a procedure which can be readily performed if the short gastric vessels are first divided. It makes for a more physiological restoration of the gastrointestinal tract than is accomplished with gastrojejunostomy and permits proper admixture of the food with the bile and pancreatic enzymes. It avoids several potential dangers such as leakage from the duodenal stump, the possibility of a gastrocolic fistula, and malfunction of the anastomosis due to distortion of a jejunal loop. Apparently the “dumping syndrome” does not occur after gastroduodenostomy as it sometimes does after gastrojejunostomy.     

Pressure-flow behavior of a bronchopleural fistula during mechanical ventilation with positive pressure

We examined the mechanical behavior of a bronchopleural fistula created by sectioning a small subpleural bronchus in seven anesthetized lambs. The pressure across the fistula was measured as the difference between the pressure recorded by a retrograde bronchial catheter inserted in the vicinity of the fistula and the outflow pressure at the fistula exit. The effective resistance of the fistula (Rf) was computed by dividing this pressure difference by the gas flow through the fistula measured at the outlet of an intrapleural tube adjacent to the fistula. Rf increased by 114 +/- 25% (SE) when we inflated the lungs in a stepwise manner from a tracheal pressure of 2-20 cmH2O. Rf also increased when inflation pressure varied continuously; this increase, however, was less evident when we decreased the inflation time from 1.0 to 0.2 s. The relationship between Rf and lung volume was similar during the stepwise inflations and deflations but showed marked hysteresis during the continuous inflation-deflation maneuvers, when Rf was greater during deflation than inflation. Our results suggest that the fistula behaves as a compliant pathway whose relevant transmural pressure is the transmural pressure at or near the fistula's exit. We attribute the increase in Rf during inflation to decreases in transmural pressure caused by convective and dissipative losses inside the fistula and by the stress applied by the chest wall on the outer surface of the fistula.     

磁共振检查对复杂性肛瘘手术治疗患者的指导价值及术后复发的危险因素分析

目的:探讨磁共振成像技术(MRI)对复杂性肛瘘诊断和术前评估的指导意义及术后复发的危险因素。方法:前瞻性选取2015年6月至2017年12月到我院诊断并接受手术治疗的359例复杂性肛瘘患者,将其随机分为观察组182例和对照组177例。对照组患者术前未行MRI检查,术中行亚甲蓝染色指导手术治疗。观察组术前行MRI检查,术中给予亚甲蓝染色结合术前评估行手术治疗,以术中探查结果为金标准,统计MRI术前检查复杂性肛瘘的准确率,Kappa检验评估MRI检查结果与术中探查结果的一致性,经1-2年的随访统计所有患者复发情况,单因素和多因素Logistic回归分析术后复发的危险因素。结果:观察组术中探查共发现瘘管内口281个,合并肛周脓肿57例,多发瘘管及支管151例,MRI术前检查瘘管内口、合并肛周脓肿、多发瘘管及支管的准确率分别为98.22%(276/281)、85.96%(49/57)、96.03%(145/151),观察组中MRI结果与术中探查结果对患者Parks分型通过一致性检验显示,两结果一致性较好(k=0.890,P=0.001)。单因素分析结果显示,肛瘘位置、内口位置、合并肛周脓肿、既往肛瘘手术史及术前是否行MRI检查均会影响复发率(均P0.05),Logistic回归多因素分析显示,术前未进行MRI检查、高位肛瘘、内口位于后正中线、既往肛瘘手术史是复杂性肛瘘术后复发的危险因素(均P0.05)。结论:MRI检查复杂性肛瘘能够术前明确瘘管及内口数量,可较为精确地识别瘘管Parks分型,有助于提高手术疗效,合并肛周脓肿、术前未进行MRI检查、高位肛瘘、内口位于后位、既往肛瘘手术史是复杂性肛瘘术后复发的危险因素。     

UNILATERAL PARALYSIS OF EYE MUSCLES ASSOCIATED WITH INTRACRANIAL SACCULAR ANEURYSMS

Unexplained unilateral paralysis of eye muscles with or without evidence of altered function of other cranial nerves, or of the presence of intracranial bruit, is strong positive diagnostic evidence of saccular aneurysm of the intracranial internal carotid or of the circle of Willis. If pulsating exophthalmos is present the lesion probably is an arteriovenous fistula.The presence of such clinical signs strongly indicates the desirability of cerebral angiography. Once demonstrated, the lesion can usually be treated successfully by ligation of the contributing vascular connections.     

SURGICAL TREATMENT OF PATENT DUCTUS ARTERIOSUS

Since it would appear that diagnosis of patent ductus arteriosus can be made accurately in a high percentage of cases, and as the surgical treatment of this lesion is highly successful with a low mortality and morbidity rate, operation is advisable for all patients with this lesion except those who are 35 years of age or older and who have no progressive cardiac hypertrophy and no incapacitation due to the fistula. The optimum age for operation is three years. The vast majority of the patients have a ductus that can be divided, and division has advantages over ligation.In cases in which patent ductus arteriosus is complicated by subacute bacterial endocarditis, operation should be done following intensive penicillin therapy.     

Systemic arteriovenous fistula leads to pulmonary artery remodeling and abnormal vasoreactivity in the fetal lamb

Several cases of systemic arteriovenous fistula diagnosed in the human fetus have been associated with the postnatal development of persistent pulmonary hypertension. The aim of this study was to determine the effects of a prenatally created systemic arteriovenous fistula on the structure and reactivity of the pulmonary circulation in the fetal lamb. A fistula between the jugular vein and carotid artery was created in fetal lambs at 119-124 days of gestation. At delivery (134-139 days), left pulmonary artery (LPA) pressure was increased in the fistula group (n = 12) compared with controls (n = 11, P < 0.01). The pulmonary vascular resistance was significantly higher in the fistula group (P < 0.05), whereas mean LPA blood flow was not statistically different between the two groups. Morphometric analysis of the pulmonary vascular bed revealed an increase in the number of peripheral muscular arteries, together with an increase in pulmonary arterial medial thickness in the fistula group. There was no difference in the relative number or size of intraacinar arteries. In vitro organ bath studies on pulmonary arterial rings showed impaired endothelium-dependent relaxation in the fistula group compared with controls. However, endothelial nitric oxide synthase protein expression was similar in both groups, whereas endothelium-independent relaxation to sodium nitroprusside was greater in the fistula group compared with controls. A systemic arteriovenous fistula leads to both structural and functional alteration of the pulmonary vasculature, which might lead to the development of persistent pulmonary hypertension after birth.     

SUCCESSFUL CLOSURE OF POST-TRAUMATIC CAROTID-JUGULAR ARTERIOVENOUS FISTULA COMPLICATED BY CONGESTIVE HEART FAILURE AND CEREBROVASCULAR INSUFFICIENCY

This report describes a patient who received a traumatic injury of the neck 28 years prior to admission to this institution. He had required multiple hospitalizations, along with medications for congestive heart failure. After ligation of a large arteriovenous fistula and replacement of a 3 cm segment of the left common carotid artery with an 8 mm double-velour graft, the patient was greatly improved.     

男性尿道直肠瘘数字化三维重建的初步应用

目的：基于CT扫描图象建立精确的男性尿道直肠瘘数字化模型,探讨其在临床诊断及治疗中的应用。方法：选择1例男性尿道直肠瘘病例,进行尿道CT连续断层扫描,扫描结果导入Mimics软件中进行三维重建,利用三维重建模型指导临床。结果：建立男性尿道直肠瘘及周围结构的三维立体模型,可以方便地从任意角度和方向观察瘘管情况,测量有关的数据;还可以在数字化模型上进行手术设计。结论：男性尿道直肠瘘的数字化三维模型能够更直观、准确地反映病变部位的三维立体结构。对男性尿道直肠瘘的诊断、手术规划等有较大帮助。     

Esophageal Atresia and Tracheo-Esophageal Fistula — 25 Years' Experience and Current Management

A review of the experience with esophageal atresia and tracheoesophageal fistula over a 25-year period appears to lead to the advisability of the following procedures in surgical management:• Emergency gastrostomy under local anesthesia in all patients.• Extrapleural interruption of tracheo-esophageal fistula and end-to-end esophago-esophagostomy in patients who have the common type of upper esophageal atresia with distal tracheo-esophageal fistula.• Upper esophageal stretching and eventual esophago-esophagostomy in patients with proximal and distal esophageal atresia with or without proximal tracheo-esophageal fistula.     

DISCUSSION ON THE TREATMENT OF URETHRAL STRICTURE AND FISTULÆ BY EXCISION

For hard tunnel strictures and in cases of perineal fistula we should be bolder to adopt the principle of excision rather than that of mere external urethrotomy.A preliminary suprapubic cystotomy is advised, and also the avoidance, as far as possible, of the indwelling catheter. All fistul? should be excised completely, not merely opened, scraped and drained.The operator should not be in too great a hurry to pass sounds of too large a calibre after the operation, as in many cases there is little tendency to re-formation of the stricture.     

Autogenous arteriovenous elbow fistula for haemodialysis and upper extremity ischemia

BACKGROUND: The autogenous brachiocephalic or brachiobasilic arteriovenous elbow fistula is not considered to be only the secondary haemodialysis access. In patients with an unsuitable forearm vessel bundle, it is indicated as primary access and it is the method preferred to the fistula creation using a vascular prosthesis. Its rather rare complication is the development of upper extremity ischemia. AIM: To summarise current knowledge of this fistula type and its associated complications METHODS: Review of the literature. RESULTS: The creation and maturation of the fistula and occurrence of the steal syndrome is influenced by a number of factors. The analysis and awareness of such factors will provide for creation of a suitable fistula as well as for timely complication diagnostics and treatment. CONCLUSIONS: The autogenous elbow fistula utilising the brachial artery and the cephalic or basilic vein in the upper extremity represents a high-quality haemodialysis access. Its potential complication is the occurrence of the steal syndrome. Its occurrence and manifestations do not constitute indications for ligation of the access. The gathered information shows that a suitable surgical procedure can help meet the basic rule for haemodialysis access--resolving the ischemia and maintaining the access.     

护理干预在直肠癌前切除术后并发吻合口瘘的应用及效果

目的：探讨护理干预在直肠癌前切除术后并发吻合口瘘的应用及效果。方法：将179例患者分为对照组和观察组,分别给予 常规护理和综合护理,观察护理干预在直肠癌前切除术后并发吻合口瘘的应用效果。结果：对照组术后3 d内5例患者发生吻合 口瘘,3例患者术后4-7 d发生吻合口瘘;观察组术后3 d内1例患者发生吻合口瘘,1例患者术后4-7 d发生吻合口瘘,两组吻合 口发生率差异有统计学意义（x2=3.880,P＜0.05）。经过护理和治疗后,观察组患者吻合口瘘愈合时间明显短于对照组（t=4.026,P＜ 0.05）。对照组SAS 阳性率69.23%,观察组50.00%,二者之间具有统计学差异（x2=5.186,P＜0.05）;对照组SDS阳性率61.54%,观 察组40.00%,二者之间具有统计学差异（x2=4.978,P＜0.05）。结论：合理有效的综合护理措施可以减少吻合口瘘和医患矛盾的发 生,提高患者对治疗的满意度,促进医患关系的和谐。     

Pleural Effusion with Pancreaticopleural Fistula

Three patients with pleural effusion were found to have pancreaticopleural fistulas passing through an opening in the diaphragm are reported. In one case the effusion was purulent and originated from an abscess of the pancreas. Retrograde pancreatography during operation defined the course of the fistula. In two other cases the fistula was demonstrated by radiography after intrapleural injection of contrast medium. The diagnostic importance of injecting contrast medium early into the pleural cavity in cases of effusion rich in amylase, before lung expansion obscures the fistula, is emphasized. Cases of pancreaticopleural fistula may be commoner than supposed.