Plan, Do, Check, Act (PDCA) Cycle Nursing Model Reduces the Risk of Hemangioma in Hemodialysis Patients

Background: We aimed to explore the effect of Plan, Do, Check, Act (PDCA) circulation nursing on the prevention of aneurysm after hemodialysis. Methods: A total of 139 hemodialysis patients from Oct 2018 to Jan 2020 in Nephrology Department of the First People’s Hospital of Lianyungang, China were enrolled. They were randomly divided into control group and PCDA group, including 58 patients in control group and 81 patients in PCDA group. Patients' satisfaction, blood flow in arteriovenous internal fistula and the incidence of post-dialysis vascular-related complications were statistically investigated in the two groups. Results: The satisfaction of patients in PDCA group was significantly higher than that in control group (P<0.001). In addition, when there was no statistical difference in blood flow between the two groups, the probability of complications such as internal fistula obstruction, thrombosis, infection, secondary puncture and aneurysm was lower in patients in the PDCA group, none of which occurred aneurysm. Conclusion: PDCA circulation nursing can effectively improve the quality of care and medical effect of hemodialysis patients with internal arteriovenous fistula, improve patient satisfaction and reduce the incidence of complications.

Confirmation of an internal hydatid bladder fistula using postoperative methylene blue retrograde injection via urinary catheter: a case report

Abdominal hydatidosis resulting in an internal hydatid bladder fistula postoperatively is quite rare and might have serious consequences without timely treatment. A 74-year-old Tibetan woman presented with abdominal distension and was diagnosed with hydatid disease. Cyst contents were removed, and the pericyst was partially resected without contraindication. Furthermore, no internal urinary fistula was found before or during the operation, and the presence of an internal fistula was indicated by methylene blue retrograde injection via urinary catheter after the operation. The use of postoperative methylene blue retrograde injection via urinary catheter is recommended to identify internal hydatid bladder fistula formation.

Rare case of rectovaginal fistula in adults

Rectovaginal fistula is an abnormal epithelial lined connection between the rectum and the vagina. The term anovaginal fistula may also be used when the internal fistula opening is found below the anorectal angle. Bowel contents leak through the fistula, allowing gas or stool to pass through the vagina. It may be congenital or acquired. Congenitally these are the anorectal malformations which affect the females when present since birth. Here, we have discussed the cases of adult rectovaginal fistula which the women had developed after vaginal delivery, the obstetric fistula. Patient presented with passage of stool from the vagina after the delivery. They were examined, assessed was successfully treated in our institution. Depending on the site of fistula formation, decision is taken for surgical approach and various techniques. Here the well-known Martius flap, which is based on bulbocavernosa muscle and pudendal artery has been used in both the cases. This flap is best used to repair fistula in the perineal region when there is no underlying sphincter defect.

P446 Plasma rich in growing factors as treatment for perianal fistulas in Crohn’s disease: unicentre experience

Background Perianal Crohn’s disease (PCD) adds a significant morbidity and reduced quality of life. Complex fistulas occur in up to 20% of patients. The available treatment of PCD includes immunosuppressive drugs, antibiotics, different surgeries but are associated with high recurrence rates. A new alternative using plasma rich in growth factors (PRGF) for the treatment of complex fistulas has emerged from to achieve better healing with the minimum possible complications without affecting anal continence. This study aims to assess the feasibility, safety and efficacy of local injection of PRGF in patients with PCD. Methods Retrospective observational and descriptive study analyzing 6 Crohn′s Disease (CD) patients undergoing complex anal fistula sealing with PRGF from March 2019 to December 2020. All patients underwent endoanal ultrasound and 60% a pelvic magnetic resonance also. The technique consisted of locating the tract without the use of hydrogen peroxide, active curettage of the tract and closure the internal fistulous orifice (IFO) with single stitches Vicryl® 3/0. Subsequently, 50% of the PRGF-rich fraction was injected in the submucosa of the closed internal fistula orifice. The other 50% is injected in the fistulous tract. With PRGF-poor fraction a three-dimensional fibrin matrix is created and filled the previously curetted fistulous tract. We describe the results in terms of demographic variables, outcomes, surgical procedure and complications. Endpoint was fistula closure by physical examination and endoanal ultrasound. Results Sixty seven percent of the patients were female, mean age was 43 (26y SD). The clinical characteristics of the patients are described in table 1. All of the patients had previous abscess drainage surgery. The most frequent fistula was mid-transsphincteric type. 66.7% had seton at the time of surgery and only one patient had no medical treatment at that time. The median follow-up was 30 months. The recurrence rate was 66.7% with no differences with in age, sex, comorbidity, type of fistula, fistula location, medical treatment and whether they had a seton implanted at the time of surgery. No patient presented complications. The median follow-up was 16 months. Conclusion PRGF sealing appears to be feasible, safe and a promising option in the treatment of PCD. Further studies should be carried out to determine the real use of PRGF in PCD.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

Background Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands. Methods Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA. Results In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%). Conclusions Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Evolution of Needling: Preliminary Results of Microinvasive Antiglaucoma Reoperation

Purpose: to assess the efficacy and safety of needling performed by the new scleroconjunctival dissector according to our specific technique.Patients and methods. The study included 60 patients diagnosed with operated subcompensated or decompensated glaucoma. Thirty patients underwent microinvasive reoperation with the help of a sclero-conjunctival dissector. The control group consisted of 30 patients; they underwent repeated sinustrabeculectomy with iridectomy. A standard ophthalmological examination and ultrasound biomicroscopy were performed before the operation and in dynamics (after 1, 3, 6, 9 months).Results: 76.7 % of the experimental group had IOP less than or equal to 15 mm Hg six months after microinvasive reoperation. In the control group, the same mark was 70 %. Hyphema occurred in 23.3 % of the main group, it was stopped by conservative treatment. 10 % of patient developed choroid detachment, it did not require surgical treatment. Hyphema was formed in 36.7 % in the control group and choroid detachment — in 53.3 % of patients. The complications were more manifested and required surgical treatment in the control group. According to the data of ultrasound biomicroscopy, the acoustic density in the control group steadily increased, while the height of the filtration bleb first increased and then decreased. This may indicate significant tissue induration, probably as a result of fibrosis after an operating injury. The intrascleral «lake» height does not differ between the groups when comparing dynamic observations, and the volume of the intrascleral cavity is significantly greater in the main group than in the control group (p < 0.0001) at admission and during dynamic observation. The text of the article describes a clinical case of a patient who underwent microinvasive reoperation.Conclusion. When there are indications for re-surgery, an adequate and thorough diagnosis of the preservation of the surgically created outflow tract, namely gonioscopy and ultrasound biomicroscopy, is important. In patients with intact internal fistula and without pronounced fibrosis of the intrascleral drainage pathways, it is possible to carry out microinvasive reoperation according to our technique using a scleroconjunctival dissector, this allows to reduce the risk of postoperative complications and achieve hypotensive efficacy comparable to repeated filtering surgery.

Parotid Injuries and Fistulae

Successful treatment of parotid injuries depends on early recognition and appropriate early intervention. Sequelae of inadequate diagnosis and treatment include parotid fistula and sialocele formation, which are inconvenient for the patient and more difficult to treat than the initial injury. A parotid fistula is a communication between the parotid gland (glandular fistula) or duct (ductal fistula) and the skin externally (external fistula) or to the oral cavity internally (internal fistula). A sialocele is a collection of saliva beneath the skin that occurs if the duct leaks but no fistula forms, or when the glandular substance, but not the duct, is disrupted. Management options include pressure dressings and use of anti-sialagogues, total parotidectomy, tympanic neurectomy, intra-oral transposition of the parotid duct, radiation therapy, the use of botulinum toxin A, and the use of fibrin glue.