Identification and surgical ligation of spinal CSF-venous fistula

Background: CSF-venous fistulas (CVF) may cause incapacitating positional headaches resulting from spontaneous intracranial hypotension/hypovolemia (SIH). Their etiology remains unknown, although unrecognized local trauma may precipitate SIH. In addition, they are diagnostically challenging despite various imaging tools available. Here, we present CVF identification using magnetic resonance myelography (MRM) and elaborate on their surgical management techniques. Methods: Retrospective charts of confirmed and treated CVF patients with attention to their diagnostic imaging modalities and management techniques were further reviewed. Results: Six cases were identified of which three are presented here. There were two females and one male patient. All had fistulas on the left side. Two were at T7-T8 while the third was at T9-T10 level. Two underwent hemilaminotomies at the T7-T8 while the third underwent a foraminotomy at T9 level to access the fistula site. All CVF were closed with a combination of an aneurysm clip and a silk tie. On follow-up, all had complete resolution of symptoms with no evidence of recurrence. Conclusion: Of the various imaging modalities available, MRM is particularly sensitive in localizing CVF spinal nerve level and their laterality. In addition, the technique of aneurysm clip ligation and placement of a silk tie is curative for these lesions.

Successful endoscopic surgical treatment of pleuroperitoneal communication in two infant cases

Background Pleuroperitoneal communication (PPC) is an uncommon, but potentially life-threatening complication of peritoneal dialysis (PD). If a fistula does not close with conservative treatment, surgical repair is required. However, approximately half of these patients are forced to shift from PD to hemodialysis. Although it is important to confirm the site of the fistula to achieve a successful surgical treatment, this identification is more difficult in pediatric patients than in adults. Case presentation We report two infantile cases of severe PPC associated with PD. In both cases, the age at onset was less than 2 years, and right-sided pleural effusion with dyspnea was observed. PPC was diagnosed by the change in color of the pleural fluid after the injection of a dye into the peritoneal cavity. Peritoneal scintigraphy and single-photon emission computed tomography and computed tomography (SPECT/CT) were performed, and these were effective in locating the fistula site. Endoscopic surgery (video-assisted thoracic surgery (VATS) and laparoscopic surgery) was performed. Indocyanine green (ICG), which was injected into the abdominal cavity, showed the exact site of the fistula. The fistula was successfully closed by attaching an absorbable sheet to it from the thoracic side and an autograft (the falciform ligament) to it from the abdominal side in one patient. In the other patient, the fistula site was resected and sutured, and reinforced with an absorbable sheet. In both cases, PD was resumed without any complication. Conclusion We successfully treated two infants of PPC by endoscopic surgery. To identify the fistula site, the ICG navigation method was useful. Even in small infants, PPC can be treated successfully by endoscopic surgical repair if the site of the fistula is identified.

DOZ047.10: Acquired tracheoesophageal fistulas after esophageal atresia repair

Aim Tracheoesophageal fistula (TEF) recurrence is a frequent but challenging complication after esophageal atresia (EA) repair. Although most recurrent TEFs are commonly seen at the original fistula site, long new fistulas localized differently from the congenital TEF sites are called acquired TEFs (acq-TEF). Acq-TEFs are long new fistulas with unusual locations, including fistulas from the esophagus to anywhere on the airway such as the bronchus, trachea, or lung parenchyma. Herein, we aimed to discuss diagnostic and management challenges in different localizations of acquired TEF. Methods The medical records of patients admitted with acq-TEF in the last 5 years were retrospectively evaluated. The demographic features, admission complaints, physical and radiological findings, TEF localization and management were recorded. Results From 16 TEF recurrences, 4 TEFs were acquired fistulas. Admission age ranged from 3 months to 8 years. The female/male ratio was 2/2. The complaints were recurrent respiratory tract infections, choking, and coughing in all cases. Three of the cases had proximal EA + distal TEF; the other case was isolated EA. Primary repair was performed in 3 cases and colon interposition was performed in 1 case. Anastomotic leak and mediastinitis after initial operation were seen in 3 cases. Three acq-TEFs were to the cervical part of the trachea, one was from the colon conduit to the trachea, one was to right bronchus by passing through the intrathoracic abscess cavity, and one was directly to the right bronchus. In all cases the TEFs were shown in sine-esophagography and confirmed with bronchoscopy during operation. TEF was repaired by thoracotomy incision in 3 cases and callor incision in 1 case. The second acq-TEF of Case 1 was closed spontaneously. Muscle flap or pleura was placed between suture lines in all cases. All TEFs were confirmed to be closed with esophagography in all cases at postoperative period. Conclusion Acq-TEF is mostly seen secondary to local or diffuse mediastinitis. Besides its classical location of TEF, acq-TEFs may be seen at unusual rare localizations such as esophagus to right bronchus, esophagus to abscess cavity, and conduit to trachea. They cause both diagnostic and surgical challenge. Clinicians should be aware of these different localizations of Acq-TEFs in order to evaluate and manage these patients more comprehensively.

Coil Embolization of an Iatrogenic Arteriovenous Fistula between the Superior Mesenteric Artery and Vein: A Case Report

Superior mesenteric arteriovenous fistulae are rare. A 32-year-old woman presented with abdominal pain. The angiography showed that the superior mesenteric vein was aneurysmal. The patient underwent coil embolization, during which a balloon catheter was inflated before the fistula for the protection of coil migration with a high blood flow. After the balloon inflation, one 8-mm and two 7-mm coils were deployed at the fistula site. The final angiography showed successful embolization with no visualization of the fistula and the aneurysmal vein

Application of the selective indocyanine green videoangiography in microsurgical treatment of a craniocervical junction dural arteriovenous fistula

Craniocervical junction dural arteriovenous fistula (CCJDAVF) is a rare and unique type of intracranial DAVF with complex neurovascular anatomy, making it difficult to identify the arterialized vein during operation. The authors report the case of a 50-year-old male who presented with symptoms of venous hypertensive myelopathy. Angiography demonstrated a left CCJDAVF. The fistula was successfully disconnected via a suboccipital midline approach. The selective indocyanine green videoangiography (SICG-VA) technique was applied to distinguish the fistula site and arterialized vein from adjacent normal vessels. Favorable clinical and angiographic outcomes were attained. The detailed operative technique, surgical nuances, and utility of SICG-VA are illustrated in this video atlas.The video can be found here: https://youtu.be/GJYl_jOJQqU.

Treatment using diffuse laser energy of cochlear and vestibular fistulas caused by cholesteatoma

ObjectiveTo measure the outcomes of laser treatment of cholesteatoma covering cochlear and vestibular fistulas.MethodsCholesteatoma matrix over the fistula was denatured; the power density was sufficient only to gradually heat, but not vaporise, the keratin-forming matrix. The denaturing speed was controlled so that the integrity of the fistula cover was maintained. The change in bone conduction threshold and the residual rate of cholesteatoma at the fistula were measured.ResultsThirty-six fistulas were assessed. There were seven cochlear fistulas. All were 5 mm or less in maximum length. For the entire group, the average change in bone conduction threshold was −0.3 dB. For cochlear fistulas, the average change in bone conduction was + 0.2 dB. The distribution of hearing results for the entire group was Gaussian; the apparent changes in hearing could be attributed to errors associated with testing. All patients underwent second-stage surgery. In all cases, the cholesteatoma was completely cleared from the fistula site. There were no facial palsies.ConclusionLaser denaturing of cholesteatoma matrix over fistulas measuring 5 mm or less of vestibular apparatus and the cochlea is effective at eliminating cholesteatoma, and is not associated with cochlear hearing loss or facial palsy.

Managing Ureterovaginal Fistulas following Obstetric and Gynecological Surgeries

Background: Iatrogenic ureteric injuries leading to fistula are rare but devastating complications of obstetric and gynecological surgeries. The aim of the study was to review the demography of ureterovaginal fistula (UVF) and its surgical outcome in Kathmandu Model Hospital.Methods: This is a review of 15 patients of ureterovaginal fistula who were referred to department of Obstetrics and Gynaecology of Kathmandu Model Hospital from Feb 2014 to Sept 2017. We reviewed the demography, causesand surgical outcome of ureterovaginal fistula (UVF). Ten patients who had complete blind end at the distal ureter, underwent Lich-Gregoir extravesical ureteroneocystostomy. In other five patients, guide wire was successfully negotiated beyond the fistula site, however retrograde double J stenting could be done in only four patients.Results: All the patients had distal ureteric injury close to vesicoureteric junction leading to ureterovaginal fistula. Among them, majority were due to post-hysterectomy in 60% (n=9) followed by obstetrical procedures in 40% (n=6). Fourteen patients (93%) had successful closure of the fistula with complete preservation of renal function. Retrograde double J stenting was possible in patients who were referred earlier within two weeks of the onset of injury.Conclusions: Iatrogenic injury to the distal ureter during surgery was the leading cause for the ureterovaginal fistula. Endoscopic management with ureteric stents was still possible if the patients were referred earlier following primary surgery.

Hybrid treatment of arteriovenous fistula between popliteal vessels

The authors describe treatment of a patient who presented an arteriovenous fistula between the popliteal vessels more than 20 years after a gunshot wound. The patient underwent endovascular treatment using Viabahn (Gore®) stent grafts, but, because of the large disparity in popliteal artery diameters proximal and distal of the fistula, the endovascular treatment was unsuccessful. The superficial femoral artery was then banded around the stent graft that was deployed previously. This improvised strategy allowed an open surgical approach to be performed far from the fistula site, reducing the risks of operating in a region with anatomic distortions and significant enlargement of the surrounding venous structures, which would certainly have increased the likelihood of iatrogenic injuries.