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Anti-acid secretion activity of drugs cimetidine, ranitidine, tiotidine D 15,144 in dogs fixed with gastric fistulae

Ridzwan BH, Waton NG, Jais AM

Gen. Pharmacol., 1989;20(2):133-6.
PMID: 2565846

1. Acid secretion for each dog has reached a near maximum (100%) at the 6th samples, 90 min after the intravenous infusion of histamine (10 mu ghr-1, or approximately equal to 0.3 mghr-1). 2. 0.5 mgkg-1 Cimetidine had produced a mean inhibition of 47% on the stomach. 3. 0.1 mgkg-1 Ranitidine (D 14,951) could only inhibit a maximum of 28%, and the secretion had return to normal in just 30 min. 4. 0.025 mgkg-1 Tiotidine (D 15,104) had inhibited 53% acid secretion within 15 min of exposure. Recovery was quite similar to that of Cimetidine, at 150 min. 5. At a dosage one fifth of Cimetidine (0.1 mgkg-1) D 15,144 had depressed 35% of acid secretion at the first 15 min. The inhibition is gradually increased to about 43% (at 30 min), and was maintained for the next 105 min.

Matched MeSH terms: Gastric Fistula/physiopathology
The tampered implant. Intra-medullary nailing of the femur for fracture of the shaft-unusual difficulty in extraction: case report

Subramanian N

Med J Malaysia, 1973 Dec;28(2):123-4.
PMID: 4276229
Matched MeSH terms: Fistula/etiology
Fulltext Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization

Henry TCL, Huei TJ, Yuzaidi M, Safri LS, Krishna K, Rizal IA, et al.

Chin J Traumatol, 2020 Feb;23(1):29-31.
PMID: 31744657 DOI: 10.1016/j.cjtee.2019.10.001

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of <1%. This is due to the advancements and wide availability of ultrasound to guide its insertion. Formation of arteriovenous fistula after arterial puncture is an unexpected complication. Till date, only five cases (including this case) of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture. The present case is a 26-year-old man sustained traumatic brain injuries, chest injuries and multiple bony fractures. During resuscitative phase, attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery. Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula. The catheter was removed successfully and common carotid artery was repaired. Postoperatively, the patient recovered and clinic visits revealed no neurological deficits. From our literature review, the safest method for removal is via endovascular and open surgical removal. The pull/push technique (direct removal with compression) is not recommended due to the high risk for stroke, bleeding and hematoma formation.

Matched MeSH terms: Arteriovenous Fistula/etiology*
Fulltext Case Report: Severe Hyponatremia in Infants With Urinary Tract Infection

Abu Bakar K, Jalaludin MY, Zainal N, Woon SL, Mohd Zikre N, Samingan N, et al.

Front Pediatr, 2021;9:655010.
PMID: 34026690 DOI: 10.3389/fped.2021.655010

Introduction: Many reports on investigations and treatments in UTI, however little, have been mentioned with regard to electrolyte abnormalities. Secondary pseudohypoaldosteronism (PHA) in UTI, though less common, is a known association. Features include hyponatremia and concomitant hyperkalemia. Objectives: We aim to highlight these uncommon sequelae in UTI to avoid incorrect diagnosis and unnecessary investigations. Study Design: Clinical data of patients admitted and referred to a pediatric nephrologist at the University Malaya Medical Center between May 2019 and October 2020 were collated and elaborated. Results and Discussion: We report three infants with hyponatremia and hyperkalemia during UTI episodes. Two infants were known to have posterior urethral valve (PUV) before the onset of UTI and one infant had UTI, which led to investigations confirming the diagnosis of bladder vaginal fistula. The electrolyte derangements were temporary and resolved within 48 to 72 h of treatment with intravenous fluid and appropriate antibiotic therapy. Out of three, only one had a hormonal study, which confirms PHA. Reduced aldosterone activity could be due to absolute reduction in aldosterone titer or lack of aldosterone responsiveness at tubular (other tissues) level. In the latter, aldosterone titer is elevated. The infant in our cohort who had hormonal evaluation had the mentioned electrolyte abnormalities with a markedly elevated aldosterone titer. This demonstrated defective action of the hormone at the level of mineralocorticoid receptor. Although the remaining two infants had no confirmatory hormonal study, all of them recovered within 48 h of hospital admission, after receiving appropriate management for the primary problem, which was UTI. We observed a slower recovery of hyponatremia in relation to hyperkalemia, but none of these infants required salt replacement upon discharge. Conclusion: Infants with severe UTI and deranged electrolytes should be screened for structural abnormality and vice versa. Not all infants require hormonal screening, but those who required prolonged salt replacement or showed involvement of other systems warrant further evaluation.

Matched MeSH terms: Urinary Bladder Fistula; Vaginal Fistula
Fulltext Feasibility of a bilateral regional sternocleidomastoid muscular flap in the closure of a persistent acquired tracheopharyngeal fistula

Goh LC, Santhi K, Arvin B, Mohd Razif MY

BMJ Case Rep, 2016 Aug 26;2016.
PMID: 27566213 DOI: 10.1136/bcr-2016-216676

An acquired persistent tracheopharyngeal fistula secondary to an infected tracheopharyngeal voice prosthesis is a common cause of recurrent aspiration pneumonia in a postlaryngectomy patient. We report a case of a successfully treated tracheopharyngeal fistula whereby both the sternocleidomastoid muscles were used as muscular flaps to close the defect and its outcome.

Matched MeSH terms: Fistula/surgery*
A comparison of arteriovenous fistula failure between Malaysian and Australian and New Zealand participants enrolled in the FAVOURED trial

Hudson R, Pascoe EM, See YP, Cho Y, Polkinghorne KR, Paul-Brent PA, et al.

J Vasc Access, 2024 Jan;25(1):193-202.
PMID: 35686506 DOI: 10.1177/11297298221099134

AIM: To describe and compare de novo arteriovenous fistula (AVF) failure rates between Australia and New Zealand (ANZ), and Malaysia.
BACKGROUND: AVFs are preferred for haemodialysis access but are limited by high rates of early failure.
METHODS: A post hoc analysis of 353 participants from ANZ and Malaysia included in the FAVOURED randomised-controlled trial undergoing de novo AVF surgery was performed. Composite AVF failure (thrombosis, abandonment, cannulation failure) and its individual components were compared between ANZ (n = 209) and Malaysian (n = 144) participants using logistic regression adjusted for patient- and potentially modifiable clinical factors.
RESULTS: Participants' mean age was 55 ± 14.3 years and 64% were male. Compared with ANZ participants, Malaysian participants were younger with lower body mass index, higher prevalence of diabetes mellitus and lower prevalence of cardiovascular disease. AVF failure was less frequent in the Malaysian cohort (38% vs 54%; adjusted odds ratio (OR) 0.53, 95% confidence interval (CI) 0.31-0.93). This difference was driven by lower odds of cannulation failure (29% vs 47%, OR 0.45, 95% CI 0.25-0.80), while the odds of AVF thrombosis (17% vs 20%, OR 1.24, 95% CI 0.62-2.48) and abandonment (25% vs 23%, OR 1.17, 95% CI 0.62-2.16) were similar.
CONCLUSIONS: The risk of AVF failure was significantly lower in Malaysia compared to ANZ and driven by a lower risk of cannulation failure. Differences in practice patterns, including patient selection, surgical techniques, anaesthesia or cannulation techniques may account for regional outcome differences and warrant further investigation.

Matched MeSH terms: Arteriovenous Fistula*
Abdominal wall reconstruction after resection of an enterocutaneous fistula with an island pedicled anterolateral thigh perforator flap. Case report

Ali F, Safawi EB, Zakaria Z, Basiron N

Clin Ter, 2013;164(5):413-5.
PMID: 24217827 DOI: 10.7417/CT.2013.1605

Entero-cutaneous fistula resulting from a locally invasive large bowel carcinoma is a difficult surgical challenge. En-bloc resection of the involved organs and the entero-cutaneous fistula tract with a healthy tissue margin will result in a composite abdominal wall defect that requires closure. Reconstructive surgical options include primary closure, components separation and the use of local, regional or free flaps with or without prosthetic mesh. We report a case of an abdominal enterocutaneous fistula secondary to a locally invasive sigmoid carcinoma, which was reconstructed with a pedicled antero-lateral thigh perforator (ALT) flap. To our knowledge, this is the first case of a malignant entero-cutaneous fistula, which was reconstructed with an ALT flap.

Matched MeSH terms: Intestinal Fistula/etiology; Intestinal Fistula/surgery*
Fulltext Unusual mediastinal lymph node uptake and peritoneopleural fistula demonstrated on Technetium-99m macro-aggregated human serum albumin (Tc-99m MAA) peritoneal scintigraphy in a patient with portal hypertension

Tan CJ, Thang SP, Lam WW

Med J Malaysia, 2016 04;71(2):69-71.
PMID: 27326945

Peritoneal radionuclide scan is an established imaging modality for evaluating peritoneopleural communications. In this case report, unusual mediastinal lymph node radiotracer uptake is seen in a patient with portal hypertension on peritoneal scintigraphy. This was suspected to be due to marked lymphatic enlargement from longstanding portal hypertension since childhood, permitting passage of the large Tc-99m MAA particle. The nodes were morphologically benign on CT. Mediastinal lymph node uptake on peritoneal scintigraphy is rare but should not raise undue clinical concern, particularly in a patient with chronic portal hypertension. Anatomic correlation with SPECT-CT can provide reassurance.

Matched MeSH terms: Fistula
Fulltext Nutritional management of enterocutaneous fistula: a retrospective study at a Malaysian university medical center

Badrasawi MM, Shahar S, Sagap I

J Multidiscip Healthc, 2014;7:365-70.
PMID: 25187726 DOI: 10.2147/JMDH.S58752

Enterocutaneous fistula is a challenging clinical condition with serious complications and considerable morbidity and mortality. Early nutritional support has been found to decrease these complications and to improve the clinical outcome. Location of the fistula and physiological status affect the nutrition management plan in terms of feeding route, calories, and protein requirements. This study investigated the nutritional management procedures at the Universiti Kebangsaan Malaysia Medical Center, and attempted to determine factors that affect the clinical outcome. Nutritional management was evaluated retrospectively in 22 patients with enterocutaneous fistula seen over a 5-year period. Medical records were reviewed to obtain data on nutritional status, biochemical indices, and route and tolerance of feeding. Calories and protein requirements are reported and categorized. The results show that surgery was the predominant etiology and low output fistula was the major physiological category; anatomically, the majority were ileocutaneous. The spontaneous healing rate was 14%, the total healing rate was 45%, and the mortality rate was 22%, with 14% due to fistula-associated complications. There was a significant relationship between body mass index/serum albumin levels and fistula healing; these parameters also had a significant relationship with mortality. Glutamine was used in 50% of cases; however, there was no significant relationship with fistula healing or mortality rate. The nutritional status of the patient has an important impact on the clinical outcome. Conservative management that includes nutrition support is very important in order to improve nutritional status before surgical repair of the fistula.

Matched MeSH terms: Intestinal Fistula
Fulltext Aorto-oesophageal fistula and aortic pseudoaneurysm caused by a swallowed fish bone

Sia KJ, Ashok GD, Ahmad FM, Kong CK

Hong Kong Med J, 2013 Dec;19(6):542-4.
PMID: 24310662 DOI: 10.12809/hkmj133668

We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.

Matched MeSH terms: Esophageal Fistula/etiology*; Esophageal Fistula/pathology; Esophageal Fistula/surgery
Endonasal endoscopic repair of anterior skull-base fistulas: the Kuala Lumpur experience

Gendeh BS, Mazita A, Selladurai BM, Jegan T, Jeevanan J, Misiran K

J Laryngol Otol, 2005 Nov;119(11):866-74.
PMID: 16354338

The purpose of this retrospective study is to determine the pattern of cerebrospinal fluid (CSF) rhinorrhoea presenting to our tertiary referral centre in Kuala Lumpur and to assess the clinical outcomes of endonasal endoscopic surgery for repair of anterior skull base fistulas. Sixteen patients were treated between 1998 and 2004. The aetiology of the condition was spontaneous in seven and acquired in nine patients. In the acquired category, three patients had accidental trauma and this was iatrogenic in six patients (five post pituitary surgery), with one post endoscopic sinus surgery (ESS). Imaging included computed tomography (CT) scan and magnetic resonance imaging (MRI). Endoscopic repair is less suited for defects in the frontal sinuses with prominent lateral extension and defects greater than 1.5 cm in diameter involving the skull base. Fascia lata, middle turbinate mucosa, nasal perichondrium and ear fat ('bath plug') were the preferred repair materials in the anterior skull base, whereas fascia lata, cartilage and abdominal fat obliteration was preferentially used in the sphenoid leak repair. Intrathecal sodium flourescein helped to confirm the site of CSF fistula in 81.3 per cent of the patients. Ninety per cent of the patients who underwent 'bath plug' repair were successful. The overall success rate for a primary endoscopic procedure was 87.5 per cent, although in two cases a second endoscopic procedure was required for closure. In the majority of cases endoscopic repair was successful, and this avoids many of the complications associated with craniotomy, particularly in a young population. Therefore it is our preferred option, but an alternative procedure should be utilized should this prove necessary.

Matched MeSH terms: Fistula/diagnosis; Fistula/etiology; Fistula/surgery*
Fulltext Diagnostic dilemma of dural carotid cavernous fistula

Noorlaila B., Zunaina E., Raja Norliza R.O., Nor Fadzillah A.J., Alice, G.K.C.

Journal of Biomedical and Clinical Sciences, 2017;2(1):38-41.
MyJurnal

We report a case of dural carotid cavernous fistula (CCF) pose a diagnostic dilemma with initial symptoms of the arteriovenous shunt. A 56 year-old man presented with right eye diplopia, thensubsequently developed ptosis, congestion of conjunctiva, dilated episcleral vessels, and gradual rise in intraocular pressure. Initial diagnosis of pseudotumour was made based on negative finding of CCF by computed tomography angiography (CTA). In view of persistent clinical manifestations in spite of steroid therapy, and with the presence of new ocular signs; cock-screw conjunctival vessels, dilated retinal veins, and proptosis, digital subtraction angiography (DSA) was performed and confirmed the diagnosis of dural CCF.The ocular symptoms resolved completely post embolization of the fistula.

Matched MeSH terms: Arteriovenous Fistula
Fulltext Outcome of core out fistulectomy and the ligation of anal fistula tract: A single center experience in Malaysia

C. Z. M Salehudin, Azmi Md Nor, Razman Mohd Rus

IIUM Medical Journal Malaysia, 2020;19(1):55-59.
MyJurnal

Fistula-in-ano is a benign anorectal disease which always poses a big dilemma to the surgeons
because of their significant recurrent rate following surgery. Materials and Methods: A cross-sectional study
involving 42 patients undergoing core out fistulectomy in the Hospital Tengku Ampuan Afzan, Kuantan,
Pahang, Malaysia were included in this study. Demographic data of patients were assessed. Endoanal
ultrasound (EAUS) was done prior to the surgery to determine types of fistula and classified using Park’s
classification. Follow up was made post-operatively at 4th week, 2nd month, 3rd month, 4th month, 5th month
and 6th month to look for the duration of healing or recurrence. Results: 5 out of 42 patients were lost to
follow up leaving 37 patients available for the analysis. Mean age of the patient was 38.4 (13.8) years old.
Transphincteric and intersphincteric type of fistula accounted for 54.5% and 40.1%, respectively. 62.2%
(n=23) of patients achieved primary healing after the procedure. The mean for healing duration was 3.7
(3.1) months. Recurrence of the disease was seen only in 37.8% (n=14) of the patients. Conclusions: Even
though we managed to achieve significant success rate cumulatively, recurrence of fistula still impose a
significant challenge toward patient’s management. Therefore, further prospective study with a bigger
sample size is recommended to look into this method to reduce recurrence of fistula.

Matched MeSH terms: Rectal Fistula
Common proctological conditions

Monro JK

Journal of the Malaya Branch of the British Medical Association, 1940;3:396-9.

Matched MeSH terms: Rectal Fistula
Fulltext The blue man who presented with a stroke

Koh KC, Wong MH

Malays Fam Physician, 2011;6(1):29-31.
PMID: 25606217 MyJurnal

A 19-year-old man presented with sudden onset of right eye ptosis, diplopia and giddiness. He had no previous medical illnesses with negative history of exertional dyspnoea, epistaxis, haemoptysis, palpitations, chest pain and chronic cough. Examination revealed central cyanosis, digital clubbing, polycythaemia, partial ptosis of right eye, diplopia on right gaze and dilated right pupil. Examination of the chest revealed pectus excavatum but no cardiac murmurs were heard. Investigations revealed a solitary right pulmonary arteriovenous malformation with two feeder vessels which were successfully embolized surgically.

Matched MeSH terms: Arteriovenous Fistula
Fulltext Pre-auricular sinus: an uncommon presentation

Ng JWS, Chew YK, Tan KL, Chong AW

Malays Fam Physician, 2011;6(1):32-33.
PMID: 25606218 MyJurnal

An infected pre-auricular sinus presenting as a post-auricular swelling is commonly misdiagnosed as an infected dermoid or sebaceous cyst. It may even mimic a mastoid abscess leading to further unwarranted investigations and interventions. We present a case of a 25-year-old Malay man who was initially diagnosed with recurrent infected dermoid cyst. At presentation, a right post-auricular inflamed swelling was noted with an overlying old incision and drainage scar. An auricular pit was found at the crus of helix. Using a blunt probe inserted along the sinus tract pus was drained without the need for further surgical incision. Six weeks after the acute episode, patient underwent excision of the pre-auricular sinus with no evidence of recurrence at three months follow up. Awareness by the attending physician of this ‘variant type’ of pre-auricular sinus at patient’s first presentation may negate the need for unnecessary incision and drainage which may subsequently impact the outcome of surgical excision and reduce the risk of recurrence.

Matched MeSH terms: Fistula
A modified technique of pancreaticogastrostomy with short internal stent: A single surgeon's experience

Yap PY, Hwang JS, Bong JJ

Asian J Surg, 2017 Mar 10.
PMID: 28286020 DOI: 10.1016/j.asjsur.2017.01.003

BACKGROUND/OBJECTIVE: Postoperative pancreatic fistula (POPF) remains an important cause of morbidity and mortality after pancreaticoduodenectomy. Pancreaticogastrostomy (PG) as a reconstruction method after pancreaticoduodenectomy is a safe and optional surgical technique in decreasing the risk of POPF. In this study, a retrospective analysis was carried out to evaluate a new modification of PG technique that uses a two-layer anastomoses with an internal stent.
METHODS: Forty-seven patients underwent this newly modified PG technique between February 2012 and August 2016. Demographics, histopathological findings, type of surgery performed, perioperative parameters, postoperative length of stay, postoperative complications and interventional procedures, follow-up, and mortality data were collected and analyzed. Clavien-Dindo classification was used to grade the complications' severity.
RESULTS: Postoperative mortality was 4.25%, unrelated to POPF, and postoperative morbidity was 44.68%. Thirteen patients had severe (>Grade IIIa) complications, according to Clavien-Dindo classification. As classified in accordance to the International Study Group of Pancreatic Fistula, 24 (51.06%) patients developed Grade A POPF, and no occurrence of Grade B/C POPF was noted. All patients recovered uneventfully with successful treatment interventions.
CONCLUSION: The reported PG anastomotic technique is a safe and dependable reconstruction procedure with acceptable morbidity and mortality.

Matched MeSH terms: Pancreatic Fistula
Fulltext Transposed Basilic Vein Fistula: A Credible Option

Leong BD, Zainal AA, Hanif H, Tajri HM, Govindarajantran N, Pillay K, et al.

Ann Vasc Dis, 2018 Jun 25;11(2):223-227.
PMID: 30116415 DOI: 10.3400/avd.oa.18-00018

Objective: Native fistula creation for hemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. We review our experience in transposed basilic vein fistula (BVT) creation and its usage for hemodialysis. Materials and Methods: We analyzed the hospital operative registry from January 2009 till June 2012 to identify the total number of BVT created in our center. Medical records of all patients were traced, and patients were interviewed using a standard proforma. In our center, BVT is performed as a two-stage procedure. All patients were routinely assessed with duplex scan preoperatively and postoperatively. Results: Two hundred thirty-nine patients were recruited in the study. Of these patients, 50.6% were male and 49.4% were female. Mean age was 53.4 years. Of these patients, 81.2% had history of other previous fistula creation. Risk factors profile includes diabetes mellitus in 59.8%, hypertension in 86.2%, and smoking in 13.0%. Of these patients, 84.5% had no operative complication. Commonest complication was wound infection, 6.3%, followed by hemorrhage or hemotoma required surgical intervention, 5.9%, and pseudoaneurysm, 1.3%. Primary and secondary patencies were at 84.2% and 86.1% at 1 year and 67.7% and 70.5% at 3 years, respectively. Conclusion: BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Preoperative ultrasound assessment improves patient selection and outcome of BVT.

Matched MeSH terms: Fistula
Fulltext Resolution of pleura-peritoneal fistula via transient daytime ambulatory peritoneal dialysis regime (DAPD) - 8 years follow up

Lim TS, Thong KM

Pak J Med Sci, 2016 11 25;32(5):1302-1304.
PMID: 27882041 DOI: 10.12669%2Fpjms.325.11096

Pleural effusion or hydrothorax is a relatively rare but well-recognized complication associated with peritoneal dialysis (PD). We describe the successful long term resolution of a patient who developed pleural effusions after starting continuous ambulatory peritoneal dialysis (CAPD), by altering the PD prescription to normal volume daytime ambulatory peritoneal dialysis (DAPD) transiently before resuming the usual CAPD exchanges four months later. After 8 years of follow up, there is no sign of recurrence of the effusion. Normal volume DAPD present as an attractive alternative and cheap method for resolution of pleura-peritoneal fistula.

Matched MeSH terms: Fistula
Extra-anatomical veno-venous surgical bypass for central vein occlusion in patients with ipsilateral arterio-venous fistula (AVF) for haemodialysis - A single centre experience

Saravana KS, Zainal AA

Med J Malaysia, 2017 02;72(1):3-6.
PMID: 28255132 MyJurnal

OBJECTIVE: Central vein occlusion is a common complication related to central vein catheter insertion for haemodialysis which can be unmasked by an ipsilateral fistula creation, leading to a dysfunctional arteriovenous fistula (AVF). We describe an extra-anatomical venous bypass surgical procedure performed to maintain vascular access and reduce the symptoms of swelling of the ipsilateral upper limb, neck and face.
MATERIALS AND METHODS: We report 20 consecutive patients with end-stage renal failure (ESRF) who had central vein occlusion and were not amenable to endovascular intervention. They underwent extra-anatomical vein to vein surgical bypass. The axillary and iliac or femoral veins were approached via infraclavicular and extraperitoneal groin incisions respectively. In all the patients, an externally supported 6 or 8 mm polytetrafluoroethylene (PTFE) graft was used as a conduit and was tunnelled extra-anatomical. All patients had double antiplatelet (Aspirin and Clopidogrel) therapy post-operatively.
RESULTS: Substantial improvement in the facial, neck and upper limb swelling was noticed following this diversion surgery. The vein to vein bypass was patent at 12 months in 10 out of 20 patients. Graft infection occurred in two (10%) cases. Re-thrombectomy or assisted patency procedure (stent/plasty) was done in four (20%) cases. The patients with preoperative fistula flow rate of more than 1500 ml/min and post-operative graft flow rate of more than a 1000 ml/min were patent at 12 months (P=0.025 and p=0.034 respectively).
CONCLUSION: Axillary to iliac/femoral vein bypass can salvage functioning ipsilateral fistula threatened by occluded upper central vein.

Matched MeSH terms: Arteriovenous Fistula

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