Post-thyroidectomy hypoparathyroidism, what should we keep in mind?

AIM: Hypoparathyroidism and the resulting hypocalcemia is a common iatrogenic complication following surgical procedures to the neck, and commonly, to the thyroid gland. The aim of this study was to review the available literature to summarize current data related to the development of hypoparathyroidism after thyroid surgery. MATERIALS AND METHODS: An analysis of the surgical literature was performed using the search engine EMBASE and PubMed with particular reference to the principal risk factors related to the post-thyroid surgery hypoparathyroidism. Moreover the medical records of 345 patients, who underwent thyroid surgery at the Section of Endocrine Surgery - Department of Medical and Surgical Sciences, Advanced Technologies "G. Ingrassia" University of Catania, Italy, were also examined. RESULTS: The definition of hypoparathyroidism varies widely in literature. There is a wide range of reported incidences of transient and permanent postoperative hypoparathyroidism in literature. Extensive surgery, malignant disease and concomitant central and/or lateral neck dissection, autoimmune or Grave's' disease and re-operation represent the most recognized risk factors. A wide consensus exists about transplanting a parathyroid gland when it seems to be nonviable. DISCUSSION: Although many improvements have been done in surgical technique, hypoparathyroidism seems to be one of the most common complication after total thyroidectomy. In this study we discuss the diagnosis methods and the importance of its early prediction regardless it is transient or permanent. Recovery time is under discussion: some author consider a gland permanent injury if restoring functionality does not occur within 6 months other 12 months. To assess the parathyroid gland function some authors have been using postoperative PTH level as a useful tool for predicting hypocalcemia. CONCLUSIONS: Many efforts are required to address the problem of a consensus on best define these complications. An early low PTH level after total thyroidectomy is associated with a high risk of permanent hypoparathyroidism and normal levels usually exclude long-term parathyroid glands dysfunction. However, the cost of the PTH assay may limit its widespread application. Despite the reassuring presence of new therapeutic strategies, intra-operative preservation of the parathyroid glands is the best prophylaxis to avoid postoperative hypocalcemia after total thyroidectomy. KEY WORDS: Hypoparathyroidism, Thyroid surgery.

Epigastrium: unusual site of incisional hernia from a 5 mm trocar.

The observation of an unusual case of incisional hernia, found in the epigastric zone at the site of a 5 mm trocar incision for a cholecystectomy, has caused us to describe it and to review the literature. C.A. is a male aged 59 and He came to our attention in 2014, complaining about the presence, for about three months, a swelling in the epigastric area, without occlusive symptoms. An objective examination showed an epigastric mass at the scar of the insertion site of a 5mm trocar during the cholecystectomy operation. The patient was hospitalized and underwent traditional surgery: incision at the scar; isolation of the extruded fatty tissue, which had no sac, identified as part of the round ligament, herniated through the residual incision of the previous operation. Based on experience acquired it is useful to make careful sutures of 5 mm incisions repairing peritoneal laceration. KEY WORDS: Epigastrium, General surgery, Incisional hernia, Laparoscopy, Trocar.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly.

OBJECTIVE: The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients. MATERIALS AND METHODS: A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients. RESULTS: Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients. CONCLUSIONS: Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

The thyroid disease in the elderly: Our experience.

INTRODUCTION: The number of elderly people in Italy is growing, so it is important to study the presentation of diseases in these subjects. MATERIALS AND METHODS: We selected 1362 patients who underwent thyroidectomy for different thyroid diseases from January 2008 to December 2014. The patients weredivided into two groups, according to the age. The patients aged 65 years and over were included in the group A, and the patients under the age of 65 years were included in the group B. DISCUSSION: Thyroid diseases in the elderly often present with atypical symptoms which are very similar to symptoms of the aging process. In elderly hypothyroidism occurs frequently sub-clinically and hyperthyroidism is often presented with cardiovascular symptoms. In our study we evaluated the differences in incidence of thyroid diseases in the elderly and in the younger groups of patients. CONCLUSION: The data analyzed in this study showed that in the elderly we have a reduced secretion and metabolization of thyroid hormones. The symptomatology in the elderly is nonspecific and can create a delay in the correct diagnosis.

Non-mycotic anastomotic pseudoaneurysm of renal allograft artery. Case Report.

UNLABELLED: Vascular complications after kidney transplantation are uncommon, and in most cases they present in the early post-transplant period. Anastomotic pseudo-aneurysms usually involve the renal transplant artery anastomosis and in most cases are the consequence of a mycotic contamination during organ recovery or handling of the graft. We report the case of a 61 year-old woman, who presented, eight months after successful kidney transplantation from a deceased donor, with mild pain in the right iliac fossa. Graft sonography and computed tomography scan demonstrated a 33-mm pseudo-aneurysm of the transplant renal artery at the anastomotic site with the external iliac artery. The patient underwent an emergent surgical intervention with resection of the pseudo-aneurysm. Renal transplant artery was re-perfused with a by-pass with the internal iliac artery, while the common iliac artery was revascularized through an autologous vein by-pass between the proximal external iliac artery and the common femoral artery. Postoperative course was complicated by inguinal lymphorrea, with complete resolution on postoperative day 22. Histopathologic examination of the pseudo-aneurysm wall did not reveal any sign of mycotic infection. At 6-month follow-up, graft function was stable and graft sonography demonstrated the patency of iliac-femoral by-pass and a normal renal graft perfusion. In conclusion, pseudo-aneurysm of the renal transplant artery is a rare but potentially life-threatening complication of kidney transplantation, occurring even in the late post-transplant period. Surgical resection of the pseudo-aneurysm, although challenging, may be a valuable option for definitive treatment of the pseudo-aneurysm, while preserving the renal graft function. KEY WORDS: Aneurysm, Deceased donor, Kidney transplantation, Pseudo-aneurysm, Renal artery Surgery, Vascular complications.

First Case Report of Acute Renal Failure After Mesh-Plug Inguinal Hernia Repair in a Kidney Transplant Recipient.

Acute renal failure due to ureter compression after a mesh-plug inguinal repair in a kidney transplant recipient has not been previously reported to our knowledge. A 62-year-old man, who successfully underwent kidney transplantation from a deceased donor 6 years earlier, was admitted for elective repair of a direct inguinal hernia. The patient underwent an open mesh-plug repair of the inguinal hernia with placement of a plug in the preperitoneal space. We did not observe the transplanted ureter and bladder during dissection of the inguinal canal. Immediately after surgery, the patient became anuric, and a graft sonography demonstrated massive hydronephrosis. The serum creatinine level increased rapidly, and the patient underwent an emergency reoperation 8 hours later. During surgery, we did not identify the ureter but, immediately after plug removal, urine output increased progressively. We completed the hernia repair using the standard technique, without plug interposition, and the postoperative course was uneventful with complete resolution of graft dysfunction 3 days later. Furthermore, we reviewed the clinical features of complications related to inguinal hernia surgery. An increased risk of urological complications was reported recently in patients with a previous prosthetic hernia repair undergoing kidney transplantation, mainly due to the mesh adhesion to surrounding structures, making the extraperitoneal dissection during the transplant surgery very challenging. Moreover, older male kidney transplant recipients undergoing an inguinal hernia repair may be at higher risk of graft dysfunction due to inguinal herniation of a transplanted ureter. Mesh-plug inguinal hernia repair is a safe surgical technique, but this unique case suggests that kidney transplant recipients with inguinal hernia may be at higher risk of serious urological complications. Surgeons must be aware of the graft and ureter position before proceeding with hernia repair. A prompt diagnosis with graft sonography and abdominal computed tomography scan and emergency surgery may avoid the need for nephrostomy and may resolve graft dysfunction more rapidly.

Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature.

INTRODUCTION: The majority of neuroendocrine tumors (NET) are located in the gastrointestinal tract (67.5%) and in the bronchopulmonary (25.3%). CASE REPORT: CA, female, 42 years old, profuse diarrhea about two months, cramping for increased peristalsis, vomiting and weight loss. The patient, diagnosed with ileal neuroendocrine tumor, by colonoscopy with biopsy of lesion, therefore came in our unit to be subjected to surgical therapy. Plasma assay Chromogranin A was performed: 160 ng / ml (nv: 15-100 ng / ml). The patient underwent surgery of right hemicolectomy. DISCUSSION: Neuroendocrine tumors although are rare diseases, have an increasing impact, probably by virtue of improved diagnostic methods. In case of profuse diarrhea should be suspected a neuroendocrine tumor. Certainly the diagnosis of certainty is given by histological examination (biopsy or resected nodule). CONCLUSION: After surgical excision is necessary to perform the follow-up of chromogranin A, and, if not executed, perform nuclear medicine examinations such as Octreoscan and PET. KEY-WORDS: Chromogranin A, Neuroendocrine tumor, Octreoscan.

Cystic pancreatic neuroendocrine tumors: To date a diagnostic challenge.

OBJECTIVE: Cystic PNETs are an uncommon neoplasms increasingly detected in current clinical practice which often present a diagnostic challenges to both the experienced radiologist and pathologist. The aim of this study was to review the available literature to summarize current data that compare and evaluate both the clinical and pathologic features of cystic pancreatic neuroendocrine tumors. MATERIALS AND METHODS: A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting on cystic pancreatic neuroendocrine tumors. The MeSH search terms used were "cystic pancreatic neuroendocrine tumors", "endocrine neoplasms", and "pancreatic cysts". Multiple combinations of the keywords and MeSH terms were used. RESULTS: The clinical evaluation of cystic pancreatic lesions appears to suffer from same limitations despite the improvement in the diagnostic tools. Subsequently, we highlight diagnostic pitfalls and differential diagnosis of these cystic tumors. In this review we discuss current advances in the application of the imaging modalities and characteristics features with special emphasize on endoscopic ultrasound (EUS), and EUS guide fine needle aspiration (EUS-FNA). CONCLUSIONS: Cystic neuroendocrine tumor in the pancreas underlines the clinical impact of endoscopic ultrasound in the work-up of patients with unclear lesions in the pancreas. EUS-FNA cytology and cyst fluid analysis is a useful adjunct to abdominal imaging for the diagnosis of pancreatic cystic lesions. Due to the evident diagnostic difficulties, we hypothesize that cyst fluid characteristics, including cytomorphological features, is the most accurate test to achieve a preoperative diagnosis and to provide a basis for prognostic prediction.

Laparoscopic cholecystectomy and concomitant diseases Effectiveness of the single step treatment.

AIM: With the expanded use of laparoscopy, the options for combined surgical procedures have also increased and can be a modality of choice for coexisting pathologies in the abdomen. In our study we evaluate the safety and the efficacy of a number of surgical procedures combined with laparoscopic cholecystectomy and report our results. MATERIAL OF STUDY: We conducted a retrospective study on 19 consecutive patients who underwent laparoscopic cholecystectomy simultaneously with other operations. RESULTS: No conversion to open surgery was necessary. Postoperative complications occurred in three patients. The mean postoperative hospital stay was 3 days (range 2-4) and a few patients required more than 48 hours postoperative hospitalization. The perioperative mortality rate was 0%. DISCUSSION: Concomitant surgical procedures result in longer operating time, but certainly the patient benefits from a single exposure to anesthesia, single hospital stay, and single period of absence from work. CONCLUSIONS: Combining surgeries does not significantly alter the outcome of the procedure, proved to be a safe and feasible and present an interesting alternative to two separate operations. Prospective studies with long-term follow-up are required to better understand the implications of simultaneous operations. KEY WORDS: Laparoscopic combined procedures, Minimally invasive surgery.

Incisional hernia in the elderly: risk factors and clinical considerations.

OBJECTIVE: Ventral incisional hernia is a common complication of abdominal surgery. The marked improvements in medical technology and healthcare, lead to an increasing number of elderly patients to take advantage of even complex surgical procedures. The objective of this literature review was to analyze the risk factors for ventral incisional hernia in elderly patients and to identify measures that might decrease the incidence of this complication. MATERIALS AND METHODS: An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with particular reference to elderly patients using the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention. RESULTS: In our opinion the risk factors for incisional hernia should be separately considered. First those related to the patients and to the abdominal surgery and, in addition, those related to the surgery of the abdominal wall defects. CONCLUSIONS: Reparative surgery of the abdominal wall, to date uniquely characterized by the use of the mesh, should be considered an additional risk factor for the occurrence of incisional hernia. However, the low incarceration risk, the risk of recurrence, the relevant rate of postoperative pain and discomfort and complications associated with mesh repair, as small bowel obstruction, mesh infection, and entero-cutaneous fistula, suggest that the general indication for surgical treatment of incisional hernias, in a symptomatic or oligosymptomatic elderly patients, should be critically reconsidered in order to avoid unnecessary surgery.

Kidney transplantation from donors with hepatitis C infection.

The increasing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led to most transplant centers developing protocols that allow safe utilization from donors with special clinical situations which previously were regarded as contraindications. Deceased donors with previous hepatitis C infection may represent a safe resource to expand the donor pool. When allocated to serology-matched recipients, kidney transplantation from donors with hepatitis C may result in an excellent short-term outcome and a significant reduction of time on the waiting list. Special care must be dedicated to the pre-transplant evaluation of potential candidates, particularly with regard to liver functionality and evidence of liver histological damage, such as cirrhosis, that could be a contraindication to transplantation. Pre-transplant antiviral therapy could be useful to reduce the viral load and to improve the long-term results, which may be affected by the progression of liver disease in the recipients. An accurate selection of both donor and recipient is mandatory to achieve a satisfactory long-term outcome.

Appendix stump closure with endoloop in laparoscopic appendectomy.

AIM: To address the question of the appendix stump closure in laparoscopic appendectomy and evaluate the incidence of intraoperative and postoperative complications after application of endoloops. MATERIAL OF STUDY: Data included age and gender, ASA score, co-morbid illness, prior abdominal surgery, clinical presentation, operative time, conversion rate and reasons for conversion, postoperative morbidity and mortality rates, pathologic diagnosis, and length of hospital stay. RESULTS: Laparoscopic appendectomy with stump closure using endoloops was performed in 35 consecutive patients. Postoperative complications occurred in three patients. The mean postoperative hospital stay was 2 days. The perioperative mortality rate was 0%. DISCUSSION: The treatment of appendiceal stump closure in laparoscopic appendectomy represents the main technical aspect and it is an important step for its potentially serious postoperative complications due from an inappropriate management. Endostapling, hem-o-lok clips and intracorporeal knotting are the most commonly recommended methods. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. CONCLUSIONS: From our experience we can confirm that the endoloop can be safely used and should be the preferred modality in treating the appendiceal stump, especially for low-grade appendicitis. Alternative methods should be used in case of phlegmonous or gangrenous appendicitis, perityphlitic abscess or simultaneous operation for Meckel's diverticulum. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure. KEY WORDS: Appendiceal stump closure, Laparoscopic appendectomy.

Can laparoscopic cholecystectomy be safety performed in the elderly?

AIM: To assess the suitability of laparoscopic cholecystectomy in elderly patients, although early reports have questioned the efficacy of this procedure in that patient group. MATERIAL OF STUDY: Retrospective study evaluating the medical records of the elderly patients who underwent laparoscopic cholecystectomy in our surgical unit. Data included age and gender, American Society of Anesthesiologists (ASA) score, comorbid illness, prior abdominal surgery, presentation, operative time, conversion rate, postoperative morbidity, and mortality rates and length of hospital stay. RESULTS: Fifty consecutive patients age 70 or older who underwent laparoscopic cholecystectomy were studied Postoperative complications occurred in five patients. DISCUSSION: Many Studies have shown that the incidence of complicated gallstone disease in the elderly is higher when compared with that of younger patients and gallbladder disease is particularly virulent in the elderly, with high rate of acute cholecystitis, biliary tract disease, increased morbidity, and prolonged hospital stay. This poor outcome has been attributed to the presence of severe co-morbid factors associated with the aging process. Compared to open cholecystectomy, laparoscopic cholecystectomy may cause less postoperative depression of respiratory function and cell-mediated immunity. In our study perioperative mortality rate was 0%. CONCLUSIONS: Laparoscopic cholecystectomy in elderly patients is a relatively safe procedure that can be accomplished with acceptable low morbidity. In this series of geriatric patients, there was no evidence of any increased risk for conversion to an open cholecystectomy, delayed recovery, or prolonged hospitalization.

Two-as-one monolateral dual kidney transplantation.

OBJECTIVES: Dual kidney transplantation (DKT) of marginal kidneys could offer transplant candidates a very satisfactory kidney transplantation in terms of renal function. However, DKT might be considered a major surgical procedure and, in older recipients, has a potentially greater risk of surgical complications compared with single kidney transplantation. Because of these findings, some transplant centers have replaced the classic bilateral placement of 2 kidneys with the monolateral placement of both kidneys. METHODS: In a group of 35 DKTs performed during a 5-year period, we applied a new technique of monolateral placement of DKT in 10 recipients. In these 10 patients, the arteries and veins of the 2 kidneys were joined through a running suture, and the joined kidneys were anastomosed into the external iliac vessels in the recipient. RESULTS: The delayed graft function rate was 20%. No surgical complications developed in the entire series. One patient experienced late rejection with ureteral stricture. The graft and patient survival rate at a median follow-up of 30 months was 90%. CONCLUSIONS: To reduce the surgical risk and morbidity rate, the monolateral placement of both kidneys seems the safest method to perform DKT. The joined monolateral DKT, by reducing the cold ischemia time and the surgical trauma, could represent a step forward in the delicate treatment of these patients.

Could a high resectability rate improve the long-term survival of patients with proximal bile duct cancer?

BACKGROUND AND OBJECTIVES: This retrospective study was undertaken to evaluate if high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer. METHODS: Between 1985 and 2001, 50 patients (34 male and 16 female) with proximal bile duct cancer were treated. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent nonsurgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-en-Y cholangiojejunostomy with two or three divided segmental hepatic ducts; in 10 patients, the cholangiojejunostomy was performed with four or five divided segmental hepatic ducts. Three patients were treated by palliative transtumoral intubation with Kehr tube. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins. RESULTS: There was no operative mortality. Postoperative morbidity was 25%. Overall 1-, 3-, and 5-year survival of the entire surgical group was 61%, 22.5%, and 9%, respectively. In the 19 patients treated with curative intent the survival at 1, 3, and 5 years was 63.1%, 31.5%, and 15.8%, respectively, while in the group that had palliative treatment it was 45%, 15%, and 0%, respectively. CONCLUSIONS: Only margins free from tumor can guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better long-term survival.

[Antibiotic prophylaxis in laparotomic and laparoscopic cholecystectomy]. / La profilassi antibiotica nella colecistectomia laparoscopica e laparotomica.

Antibiotic prophylaxis in biliary surgery, when correctly used, has led to the minimisation of postoperative infections. Conventional cholecystectomy, and particularly laparoscopic cholecystectomy give rise to a very complicated issue concerning the use of antimicrobial prophylaxis, especially in relation to low-risk patients. The authors describe their experience with the use of short-term prophylaxis in biliary surgery based on a hundred consecutive laparoscopic cholecystectomies. In addition, the literature on this topic strengthens the authors' conviction that antimicrobial prophylaxis may be indicated in all surgical cholecystectomy procedures, also in view of the difficult management of postoperative infection risk factors.

Rare surgical complications of Crohn's disease. Clinical and therapeutic considerations.

We present our clinical experience in the management of rare surgical complications in Crohn's disease. Two hundred and eight patients affected by Crohn's disease were treated surgically between January 1992 and September 2001, at the Department of Surgical and Gastroenterological Sciences of the University of Padua. Rare surgical complications were identified in 17 patients (6.2%): 4 with small intestine adenocarcinoma, 5 with massive gastrointestinal bleeding, 5 with free peritoneal perforation and 3 with psoas abscesses. The very substantial clinical variability of Crohn's disease is a constant challenge to researchers. In particular, the high incidence of associated pathologies and complications related to Crohn's disease makes this pathology extremely disabling. In addition, this disease quite often appears to occur together with a rare complication which, though in most cases its course tends to remain unknown, at times may be potentially life-threatening. For this reason, it is crucial to suspect the occurrence of these pathologies, especially in patients responding poorly to therapy or in those whose symptoms suddenly become acute. Early diagnosis and treatment are therefore fundamental for the most appropriate treatment to be administered.

[Laparoscopic treatment of benign ovarian cysts]. / Trattamento laparoscopico della patologia ovarica cistica benigna.

Laparoscopic surgery is the most frequent indication for the management of benign ovarian cysts in the obstetric and gynaecological field. On the basis of their experience the authors address the clinical classification of benign ovarian pathology and the surgical laparoscopic procedures utilised in the treatment of adnexal cysts. Forty-two patients underwent laparoscopic surgery after a preoperative clinical and biological evaluation and imaging in order to exclude the presence of ovarian malignancies. All surgical procedures were carried out laparoscopically, with a conversion index of 0%. The morbidity was 2.3% (one case of haematoma of the umbilical trocar site) and there was no mortality. No late complications were observed. In conclusion, laparoscopic surgery in the management of ovarian cysts is technically feasible. On the basis of these findings laparoscopic surgery is the treatment of choice for adnexal cystic tumours after careful exclusion of malignancy.

Poorly differentiated jejunal adenocarcinoma in a patient with coeliac disease: a case report.

It is well known that coeliac disease increases the risk of gastrointestinal lymphomas, whereas adenocarcinoma is a rare complication. The authors report a case of a poorly differentiated jejunal adenocarcinoma complicating coeliac disease in a 40-year-old female and discuss the clinical, diagnostic and therapeutic aspects.

[Role of nutritional support in the treatment of enteric fistulas]. / Ruolo del trattamento nutrizionale nelle fistole enteriche.

Enteric fistulas are nowadays considered an important therapeutic challenge. Artificial, total parenteral and enteral nutrition have allowed an improvement in the healing of these fistulas and a lower incidence of mortality. Fourteen patients with enteric fistulas (10 men, 4 women; mean age: 64.4 years; range: 20-80 years) were observed. The fistula was located in the large bowel in 11 patients, in the ileum in 2, and in the jejunum in 1. Thirteen patients received enteral nutrition. The patient with the jejunal fistula received total parenteral nutrition for 30 days and then enteral nutrition. The fistulas were successfully treated in 11 patients. One patients underwent surgery after 6 weeks of treatment with enteral nutrition because of lack of improvement of the symptomatology. In two patients, with advanced cancer of the colon and stomach, respectively, only a reduction of the fistula output was achieved. Nutritional support in the treatment of enteric fistulas is an effective procedure widely utilised to restore adequate nutritional status and bowel rest, which are two important targets for achieving fistula closure. Nutritional support is also useful in the management of patients undergoing surgery in order to reduce the postoperative complication rate.