Acute management of aortoesophageal fistula and tracheoesophageal fistula treated by thoracic endovascular aortic repair and esophageal endoprosthesis: a case misdiagnosed as esophageal cancer.

Aortoesophageal fistula is rare but fatal if untreated. Open thoracic surgery is associated with high operative mortality and morbidity. We report a case of a 77-year-old man who, treated with thoracic endovascular aortic repair (TEVAR) for descending thoracic aneurysm in another center, after an acute episode of hematemesis and melena was referred to our center. The total body computed tomography scan showed the presence of reperfusion of the descending thoracic aneurysm sac (8.8 cm in diameter) in the proximal and distal TEVAR landing zone (endoleak type I) without clear signs of fistulous tract with the esophageal lumen. The patient underwent new TEVAR inside previous implantation with proximal landing very close to left subclavian artery and distal landing just above celiac trunk. For the presence of a tracheoesophageal fistula, an esophageal endoprosthesis was implanted few days later, and a jejunostomy was performed. At 30 days, patient was in good general condition, but he died at 3 months' follow-up. Aortoesophageal fistula is a rare and usually fatal condition; early recognition and TEVAR treatment prevent immediate exsanguination in patients, but after deployment of the endograft, most patients are at risk for infectious complications. Cessation of bleeding and restoration of circulation is of paramount urgency, but infectious diseases and esophageal repair remain open problems.

Hybrid open and endovascular repair of recurrent visceral aortic patch aneurysmal expansion after previous thoracoabdominal aortic aneurysm repair: case report and description of technique.

The rate of morbidity and mortality in patients undergoing open repair for thoracoabdominal aortic aneurysm (TAAA) still remains too high, ranging from 2% to 40%. In recent years "hybrid" techniques have been developed (EVAR and retrograde surgical revascularization) for the treatment of TAAA. This procedure has proved to be more effective to reduce the high risks of complication related to this kind of operation resulting in a lower morbidity and mortality rates when compared to traditional surgical techniques. A 77-year old patient who had previously been undergone surgical exclusion of a TAAA by using a straight aorto to aortic bypass graft (end to end fashion) with visceral patch, was referred to our behalf for the presence of a recurrent Crawford Type IV aortic aneurysm expansion of 10.5 cm length on diameter. Considering the serious co-morbidities of the patient and the high risk of mortality related to the traditional redo surgery, the hybrid technique was considered to repair this recurrent aneurysm by using a surgical debranching of the visceral and renal arteries from the aorta associated to the their retrograde revascularization before to perform the endovascular exclusion of the aneurysm at the same time in a single operation. Over a period of 12 months the patient was alive in good health, a follow-up by computed tomography (CT) scan confirmed the correct position of the endograft, without endoleaks, the patency of the bypasses and the reduction on diameter of the aneurysmal sac. The combined hybrid procedure (endovascular and open surgical approach) for treatment of complex TAAA is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required either to validate this procedure or to get a more significant and statistical comparison to the traditional approach.

[Splenic artery aneurysm. Two successfully operated cases]. / Gli aneurismi dell'arteria splenica. Su due casi operati con successo.

The splenic artery aneurysms usually have an asymptomatic course; their rupture is associated with high mortality. The clinical history and the treatment of two patients with splenic artery aneurysm are reported. Of the two cases, one was asymptomatic, diagnosed with upper abdomen ultrasound, the other one was treated as an emergency because presented with shock. Both patients underwent surgical procedure; ligature of the splenic artery and splenectomy were performed. Early diagnosis is important in these lesions because the progressive enlargement and eventual rupture are the natural history. Ultrasonography (US) and computed tomography (TC) are very helpful as diagnostic tools, however angiography represents the method of choice since it could be the first step of the embolization treatment. If the diameter is more than 2.5 cm surgical treatment must be performed. Ruptures are treated with emergency operations, when possible. In high-risk patients non operative management by selective embolization may be a suitable alternative.

[Postoperative intra-abdominal adhesions: prevention and treatment]. / Le aderenze intraddominali postoperatorie. Prevenzione e trattamento.

The formation of adhesions after abdominal surgery is a very frequent event, often burdened by complications. Different techniques and materials have been tested in order to reduce peritoneal damage and the onset of adhesions. While the introduction of improved surgical techniques has been decisive, the use of drugs and irritating solutions has not produced significant results. Promising results have been obtained by the use of barrier systems that allow the peritoneal surfaces to be mechanically separated during healing and re-epithelialization: Interceed (TC7)--Absorbable Adhesion Barrier--appears to be the most appropriate material for this purpose at present, given that it has been demonstrated to be of use in reducing both the incidence and extent of adhesions. The use of this material in general surgery over the past to years or so appears to the authors to be indicated in the event of secondary abdominal surgery with detachment and extensive peritoneal damage, and in more restricted surgery performed on the true pelvis in women of child-bearing age.