Case Report 5

(Fistula Closure)





The Medically Compromised Patient


Severe Arterial Disease

A 60 year old patent with both large and small vessel arterial disease underwent resection of a jaw tumour.

A persistent fistula failed to close, following 6 surgical attempts, with various flaps (Figure 1).

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Figure 1


The patient was fed by nasogastric tube for a period of 1 year, (Figure 1).

The fistula was closed with titanium chain mail anchorage with a central titanium diaphragm (Figure 2) in a simple surgical procedure based, on the same principle as hernia repair using mesh. One month following surgery the fistula has closed and oral feeding has been re-established (Figure 3).

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Figure 2 Figure 3




Complication

Figure 4 shows growth of tissue through the chain mail. The fistula remained closed for 6 months post surgery, at which time a small hole recurred at the lower end of the diaphragm / chain mail interface. The patient was however still able to feed orally at 10 months (Figure 5), but gradually the soft tissue retreated from the chain mail and the device was removed at 18 months post insertion, and tube feeding reintroduced.

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Figure 4

Disease free @ 37 months


Figure 5

Fistula Closure @ 10 months


Fistula Closure: Oral feeding maintained for 10 months. Surgical treatment possible in a medically compromised patient

Case Summary

1. Reduction in surgical trauma - increased margins of safety for medically compromised.

2. No second donor surgical site required to effect primary reconstruction.

3. Surgery time - 7 hours in the operating theatre.

4. Post operative intensive care required for 21 hours (related to medical status).

5. Earlier rehabilitation of dentition.

6. Significant morbidity - related to pre-existing arterial disease, poor healing and MRSA infection.

7. No recurrence of tumour occurred in this case.

8. Jaw implant system remained stable following placement.

9. Osseointegration occurred between (THORP) plate fixation screws and bone

10. Significant Cost Savings for Purchasers of Health Care.



Conclusions

It is advocated that stereolithography and customised implant techniques have converted a very difficult and potentially dangerous multistaged reconstruction into a simple single staged procedure, in a medically compromised patient who may not have survived more major surgery.

Whilst caution is required in the interpretation of this outcome, further research and development is advocated as a matter of priority, at a national and international level, in view of the tumour free outcome, in a patient not fit for major surgery; and the demonstration of short term stability in the closure of a fistula, both conventionally with a flap, and secondarily with a chain mail technique.



Comment

It is to be noted that skin inflammation improved with this treatment. Whilst we cannot claim success in the closure of the fistula, this treatment has permitted the maintenance of oral nutrition for a period of 10 months, when all other options had failed; and in this respect the treatment plan has been successful in securing an improved quality of life for the patient.

Further research and development is advocated with respect to this possible method of salvage in medically compromised patients, who may be denied a surgical component to their treatment plan. This evaluation must take place in conjunction with reappraisal of the general principles of reconstructive surgery, and the potential for outcome enhancement with engineering assisted surgery techniques. Associations with more accurate planning, and the potential for the elimination of human error, must be identified and incorporated into clinical practice within the framework of Clinical Governance.





Patient died peacefully @ 53 months following surgery (March 2001)

Tumour Free

R.I.P.

The support and contribution of the patient and her family to this programme is gratefully acknowledged