Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations

PurposeA complication of the surgical management of anorectal malformations (ARMs) is a retained remnant of the original fistula (ROOF) formerly called a posterior urethral diverticulum (PUD). A ROOF may have multiple presentations or may be incidentally discovered during the work-up of ARM after previous surgery. We sought to define the entity and the surgical indications for excision of a ROOF when found.MethodsWe performed a retrospective cohort study of all male patients who presented to our center following previous repair for ARM at another institution, who came for evaluation of problems with urinary and/or fecal continence, from 2014 to 2017. Charts were reviewed for symptoms, original type of malformation, preoperative imaging, treatment, and postoperative follow-up.ResultsOf 180 referred male patients, 16 had a ROOF. 14 underwent surgical repair to address this and for other redo indications, and 2 did not require intervention. 13 patients had an additional reason for a redo such as anal mislocation or rectal prolapse. Indications for ROOF excision were urinary symptoms (e.g. UTI, dribbling, passage of mucous via urethra, stone formation), to make a smoother posterior urethra for intermittent catheterization, or for prophylactic reasons. Patients were repaired at an average age of 4.2 years, using a PSARP only approach with excision of the ROOF for all except one patient who needed a laparotomy due to abdominal extension of the ROOF. No patient needed a colostomy. The original ARM repairs of the patients were PSARP (9), laparoscopic assisted (4) and abdominoperineal pullthrough (3). Preoperative evaluation included pelvic MRI, VCUG, and cystoscopy. The ROOF was visualized on 14 of 16 MRIs, 10 of 14 VCUGs, and 14 of 15 cystoscopies. Urinary symptoms associated with a ROOF and ease of catheterization were improved in all repaired cases.ConclusionPatients not doing well from a urinary or bowel standpoint post ARM pull-through need a complete evaluation which should include a check for a ROOF. Both modalities MRI and cystoscopy are needed as a ROOF can be missed on either alone. A VCUG was not reliable in identifying a ROOF.Excision is needed in patients to improve urinary symptoms associated with these lesions and to minimize the small but theoretical oncologic risk present in a ROOF.Level of evidenceLevel III.     

Incidence and significance of gastroesophageal reflux following repair of esophageal atresia and tracheoesophageal fistula and the need for anti-reflux procedures.

Patients with esophageal atresia and/or tracheoesophageal fistula are known to have disordered esophageal motility, but the incidence of significant gastroesophageal reflux requiring anti-reflux surgery remains undocumented. We have studied a series of patients from 2 wk to 13 yr post-repair, utilizing manometric motility and acid reflux techniques. All demonstrated abnormalities of esophageal motility, including aperistalsis, low amplitude contraction, and simultaneous contractions. Lower esophageal sphincter pressures ranged from 7 to 50 mm Hg. Fourteen patients demonstrated signifcant reflux and six patients required anti-reflux surgery for recurrent pneumonia or recurrent stricture. The incidence of significant gastroesophageal reflux requiring antireflux surgery appears significant following repair of esophageal atresia and/or tracheoesophageal fistula.     

Value of random mucosal biopsies in the management of superficial bladder cancer.

115 newly diagnosed patients with Ta-T1, G1-G2 superficial transitional cell carcinoma of the bladder underwent four quadrant biopsies of normal-looking bladder mucosa, in addition to the endoscopic treatment of the primary tumour or tumours. In 88 (77%) patients all the biopsies were normal; in the other 27 (23%) at least one biopsy revealed dysplasia or carcinoma in situ or G1-G2 carcinoma. 88 patients presented with a single tumour, of which 14 (16%) had abnormal biopsies compared to 13 (48%) of the 27 presenting with multiple tumours. The difference between the 2 groups was statistically significant (p < 0.01). The incidence of freedom from new tumours at 5 years was 68% in patients with normal biopsies compared to 33% in patients with abnormal biopsies (p = 0.002). In patients presenting with multiple tumours and in those with single tumours and abnormal biopsies, the incidence of freedom from new tumours was significantly lower than in those presenting with single tumours and normal mucosal biopsies (p = 0.002). The study shows that the exercise of performing random mucosal biopsies is particularly useful in patients presenting with single tumours, in order to identify those who are more likely to develop new tumours over the longer term. Such patients could be offered early prophylactic intravesical chemotherapy. The study did not substantiate tumour implantation as a factor for new tumour development in superficial bladder cancer.     

Value of percutaneous diagnosis and therapeutic procedures in obstructive uropathy following kidney transplantation

Postrenal obstruction is a severe complication after renal transplant. To evaluate side effects and effectiveness we analyzed 71 ategrade pyeloureterographies (AP) and 30 percutaneous and open nephropyelostomies. AP shows a sensitivity of 93% and proved thereby its superiority to alternative diagnostic procedures. Also percutaneous pyelostomy proved its reliability in therapy of obstructive disease. Comparing side effects to those in normal kidneys we found a higher incidence of bleeding (17%). There was no severe complication with loss of graft. In 6 cases of obstructive disease we could prevent an operation by temporary percutaneous nephrostomy. Long term nephrostomy allows to evaluate the function of the kidney accurately which may not be possible until after 1-2 months.     

胆道良性狭窄金属支架置入术后并发症及其处理

目的探讨金属支架置人治疗胆道良性狭窄的并发症。方法随访5例胆道良性狭窄应用金属支架治疗的病人，由于反复出现寒战发热，合并支架内结石形成，胆管阻塞，其中4例行手术取出支架。结果4例病人手术取出金属支架，术中见金属支架被胆泥堵塞，胆管壁黏膜破坏，支架取出困难；行胆肠吻合胆管内置管引流。2例病人因置人金属支架后反复胆管炎，胆汁性肝硬化，肝功衰竭死亡。结论金属支架不适合应用于良性胆道狭窄。     

经尿道前列腺剜除加膀胱小切口治疗高龄大体积前列腺增生合并膀胱结石

目的 总结评价经尿道前列腺剜除后经膀胱卵圆钳取出治疗高危、大体积前列腺增生合并膀胱结石的临床疗效.方法 本组60例75岁以上大体积前列腺增生合并膀胱结石患者,均行经尿道前列腺剜除术后,卵圆钳经膀胱腺体及结石一期取出,回顾性分析其临床资料及随访情况.结果 患者年龄83.5±9.2(75 ～95)岁.经直肠B超测量前列腺大小为120.8±52.1(76 ～320)mL;合并膀胱结石长径3.47±1.2(1.7 ～6.0)cm;最大尿流率(5.4±2.1) ml/s、国际前列腺症状评分(30.7±4.2)分.60例手术均顺利完成,无中转开放术,无术中输血者;无闭孔神经反射、经尿道电切综合征(TURS)及死亡病例;手术时间50.9±15.3(40～85)min;术中出血30.3±10.5(20-100)mL.术后3个月复查尿流率、国际前列腺症状评分、生活质量评分均较术前明显改善;无尿失禁、迟发出血、尿道狭窄等发生.结论 经尿道前列腺剜除后经膀胱卵圆钳取出术治疗高龄大体积前列腺增生合并膀胱结石安全可行、效果肯定.     

Sequelae and functional reintegration following prolonged post-traumatic sub-reactivity (study of 100 cases)

Summary Within a large series of head injuries (around 800 cases hospitalized every year), the most severely ill patients are studied in a prognostic computer programme. An analysis has been carried out of one hundred unselected cases of severe head injury with deep degrees of subreactive state (more than 1 to 4 days in degrees III and II respectively, and an average of 40 days) with a late follow up of between 8 months to 7 years.Neurological and psychological studies, as well as adaptation to family life and previous work, were carefully assessed. There is a close correlation between the duration of the subreactive state (S.R.S.) and post-traumatic amnesia (P.T.A.). Below 30 years of age one day of S.R.S. corresponds to two days of P.T.A. Above 40 years of age the correlation is one day of S.R.S. to about three days of P.T.A. Residual defects in memory, attention and concentration depend also on the duration of S.R.S. as expressed by length of P.T.A., as well as on the age of the patient.Psychometric studies (Wais test, etc.) followed the same patterns. Full scale I.Q. was lower than 70 in 12 per cent of the cases. Manipulative I.Q. was significantly lower than verbal scores, and Digit symbol and Object assembly were the most severely affected subtests. All these deficits were more evident in those patients with the longer P.T.A.Readaptation to work was related to the duration of the P.T.A. together with the age of the patient. Below 40 years of age 40 days of P.T.A. seemed to be the upper limit for a full return to work. Altogether only 15 of our 100 patients resumed their previous working status. Family inadaptation was the rule in patients aged more than 50 years and in younger ones only after 60 days of P.T.A.Finally, some conclusions are reached concerning E.E.G. findings and other less frequent symptoms.Paper presented at the V World Congress of Neurological Surgery, Tokyo, October 1973.     

Aorto-enteric fistula development secondary to mycotic abdominal aortic aneurysm following intravesical bacillus Calmette–Guerin (BCG) treatment for transitional cell carcinoma of the bladder

INTRODUCTIONIntravesical BCG-instillation for bladder cancer is considered safe but is not without risk. While most side-effects are localised and self-limiting, the development of secondary vascular pathology is a rare but significant complication.PRESENTATION OF CASEA 77-year-old male presented with a mycotic abdominal aortic aneurysm and associated aorto-enteric fistula 18 months after receiving intravesical BCG-instillations for early stage transitional cell carcinoma.DISCUSSIONResponse rates to intravesical BCG for early stage transitional cell carcinoma are high. The procedure produces a localised inflammatory response in the bladder but the exact mechanism of action is unclear. The treatment is generally well tolerated but BCG-sepsis and secondary vascular complications have been documented.Mycotic abdominal aortic aneurysm with associated aorto-enteric fistula secondary to BCG is very rare. Few examples have been documented internationally and the extent of corresponding research and associated management proposals is limited.Surgical options include in situ repair with prosthetic graft, debridement with extra-anatomical bypass and, occasionally, endovascular stent grafting. Recommended medical therapy for systemic BCG infection is Isoniazid, Rifampicin and Ethambutol.CONCLUSIONCurrent screening methods must be updated with clarification regarding duration of anti-tuberculous therapy and impact of concomitant anti-tuberculous medication on the therapeutic action of intravesical BCG. Long-term outcomes for patients post graft repair for mycotic aneurysm are unknown and more research is required regarding the susceptibility of vascular grafts to mycobacterial infection.Recognition of the risks associated with BCG-instillations, even in immunocompetent subjects, is paramount and must be considered even several months or years after receiving the therapy.     

Blood circulation in the lungs during prolonged occlusion of the principal branches of the pulmonary artery and following restoration of their patency in experimental conditions

The results of experiments on 36 dogs showed that in a lung with a ligated pulmonary artery the vascular network is maintained and the circulation of blood occurs through the bronchial arteries and their anastomoses with the pulmonary artery. The blood flow and total vascular bed increase in a functioning lung and the pulmo-arterial resistance diminishes. Desobliteration of the pulmonary artery leads to restoration of the main blood flow in it and the gas-exchange function of the lung which had been operated on, and to normalization of hemodynamics in the contralateral functioning lung.     

膀胱肿瘤抗原临床应用效果与评价（附112例报告）

为探讨膀胱肿瘤患者早期诊断的有效方法，对１１２例怀疑或确诊为膀胱肿瘤的患者进行膀胱肿瘤抗原（ＢＴＡ）测定。结果ＢＴＡ诊断膀胱肿瘤的敏感性为７７．４％略低于膀胱镜检查（９６．４％）但明显高于尿脱落细胞学检查（１１．５％）同时ＢＴＡ的阳性率随着肿瘤的分级增加而增高。认为ＢＴＡ测定是膀胱肿瘤早期诊断，预后监测较为灵敏的指标，并具有快速，安全，无创伤的特点，值得在临床上推广应用。     

Histological grading of transitional cell tumours of the bladder. Value of histological grading (WHO) in prognosis.

Mortality among 139 patients with transitional cell tumour of the bladder was studied. Tumours were reevaluated according to the grading system recommended by WHO. The absolute 5-year survival of histologically benign papilloma cases was 68%, of grade I carcinoma cases 64%, of grade II carcinoma cases 42% and of grade III carcinoma patients 34%. Clinical staging (UICC), however, would have been more effective than histological grading (WHO) for prognostic purposes. 3 of the 14 patients with histologically benign papilloma in this study developed grade I carcinoma during follow-up periods of between 4.5 and 24 years. Following radical treatment all recurrences were papillomas. The study suggests that histological grading should be used to complement clinical staging in prognosis and that with half-yearly check-ups and elimination of any tumours thus detected, patients with papilloma rarely develop carcinomas of higher grade than grade I.     

Feasibility of the application of a resorbable polyglycolic-acid mesh (Dexon mesh) to prevent complications of radiotherapy following gynaecological surgery.

The first ten applications of an absorbable polyglycolic-acid mesh to keep small bowel from descending into the pelvis during postoperative radiation treatment, are described. Two of the ten patients developed mild symptoms of (sub)ileus that could be treated conservatively. In two patients GI tract series revealed that a small bowel loop had slipped outside the sling and had descended into the pelvis. To prevent this condition an interlocked running suture to adjust the mesh is recommended. It is concluded that this intestinal sling procedure is a feasible surgical method causing only mild postoperative complaints or no symptoms at all. The sling procedure is effective to keep the small bowel out of the pelvis following surgery in patients who may require postoperative radiation treatment for pelvic malignancy.     

Simple mastectomy and axillary node sampling (pectoral node biopsy) in the management of primary breast cancer.

Axillary node sampling was introduced as a means of defining those patients whose primary breast cancer was treated by simple mastectomy in whom postoperative radiotherapy could be avoided safely. The authors have initiated controlled randomized trials in Cardiff and Edinburgh which have indicated that, provided that nodes are identified for histologic examination, simple mastectomy, node sampling, and selective radiotherapy give equal survival rates to routine radical treatment, whether this is by surgery or radiotherapy. Provided sampling of nodes is adequate and histologically proven, locoregional control also is satisfactory. A current randomized trial comparing this policy with Patey mastectomy has allowed comparative studies of axillary node status. These and follow-up data indicate that for a valid assessment, three to four nodes should be identified by the surgeon for histologic examination, the false negative rate being less than 10%.     

A review of pancreatico-pleural fistula in pancreatitis and its management.

Pancreatico-pleural fistula is a rare condition in which pancreatic enzymes drain directly in to the pleural cavity, most commonly from an enlarging pseudocyst. We review the literature on the causes, investigations and treatment of pancreatico-pleural fistulae and compare this with our own experience of the case of a 41 year old man with a left sided pancreatico-pleural fistula associated with pancreatic duct obstruction. The fistula could not be demonstrated by USS, CT or ERCP, and after these investigations the patient was managed conservatively. However, deterioration in the patients' condition led to an urgent but not emergency laparotomy and operative pancreatogram. This demonstrated the distally obstructed pancreatic duct, with associated pleural fistula for which aggressive surgical intervention was indicated. The patient subsequently completely recovered.     

Experience with a low-pressure colonic pouch (Mainz II) urinary diversion for irreparable vesicovaginal fistula and bladder extrophy in East Africa

Introduction and hypothesis  

We report our experience with a low-pressure colonic pouch for urinary diversion in women with irreparable vesicovaginal fistulas and bladder extrophy.