Influence of Achalasia on the Spirometry Flow-Volume Curve and Peak Expiratory Flow.

BACKGROUND: Achalasia is an esophageal motor disorder characterized by aperistalsis and the failure of the relaxation of the lower esophageal sphincter. We want to find out whether external compression or recurrent micro-aspiration of undigested food has a functional effect on the airway. METHODS: The aim of this research was to analyze the influence of achalasia on the peak expiratory flow and flow-volume curve. All of the 110 patients performed spirometry. RESULTS: The mean diameter of the esophagus was 5.4 ± 2.1 cm, and nine of the patients had mega-esophagus. Seven patients had a plateau in the inspiratory part of the flow-volume curve, which coincides with the patients who had mega-esophagus. The rest of the patients had a plateau in the expiration part of the curve. The existence of a plateau in the diameter of the esophagus of more than 5 cm was significant (p 0.003). Statistical significance between the existence of a plateau and a lowered PEF (PEF < 80) has been proven (p 0.001). Also, a statistical significance between the subtype and diameter of more than 4 cm has been proved. There was no significant improvement in the PEF values after operation. In total, 20.9% of patients had a spirometry abnormality finding. The frequency of the improvement in the spirometry values after surgery did not differ significantly by achalasia subtype. The improvement in FEV1 was statistically significant compared to the FVC values. CONCLUSIONS: Awareness of the influence of achalasia on the pulmonary parameters is important because low values of PEF with a plateau on the spirometry loop can lead to misdiagnosis. The recognition of various patterns of the spirometry loop may help in identifying airway obstruction caused by another non-pulmonary disease such as achalasia.

CT and 18FDG-PET/CT findings in progressive mediastinal idiopathic fibrosis as a benign mimicker of esophageal carcinoma: a case report.

Idiopathic mediastinal fibrosis, also called sclerosing or fibrosing mediastinitis, is a very rare and aggressive fibroinflammatory process characterized by fibrous tissue proliferation in the mediastinal region. Herein, we present a rare case of idiopathic mediastinal fibrosis presenting with esophageal obstruction, most likely associated with immunoglobulin G (IgG4)-related disease, affecting the posterior mediastinum with intrapulmonary infiltration. Computed tomography revealed a narrowed lumen and thickened wall of the distal esophagus surrounded by a necrotic mass with infiltration into the nearby structures, suggesting a locally advanced malignant process. Positron emission tomography revealed intense accumulation of 18F-fluorodeoxyglucose, indicating an active inflammatory component, which complicates further differential diagnosis of mediastinal masses. Thoracoscopic biopsy and immunohistochemical analysis confirmed a fibroinflammatory process with perivascular lymphoid cell infiltration that was cluster of differentiation (CD)3 (++) and CD20 (++), with massive numbers of IgG4-immunoreactive plasma cells. Although a benign condition, sclerosing mediastinitis is a close mimicker of esophageal carcinoma, which cannot be differentiated by computed tomography or positron emission tomography and must be considered in a differential diagnosis.

Perforated Appendicitis and Bowel Incarceration within Morgagni Hernia: A Case Report.

Morgagni hernia (MH) is a result of abdominal organ protrusion through the congenital defect in the anterior retrosternal aspect of the diaphragm. The colon and omentum are the most commonly involved organs, followed by the small intestine, stomach and liver. Symptoms of MH may be absent, although the majority of patients will experience mild dyspnea or abdominal discomfort. We present a case of MH complicated with intrathoracic acute perforated appendicitis and intestinal obstruction.

A Surgeon's Role in the Management of Early Esophageal, EGJ and Gastric Lesions.

BACKGROUND: Endoscopic mucosal resection and submucosal dissection (ESD) are indicated in a majority of mucosal esophageal, esophagogastric junction and gastric cancers (GC), and selected cases of submucosal cancers as well. SUMMARY: The presence of lymph node metastases in early esophageal cancer (EC) has been proven in up to 50% of -patients with sm3 cancers treated with surgical resection, and up to 18.5 and 30.5% in sm1 and sm2 cancer respectively. The presence of lymphovascular invasion (LVI), tumor depth >500 µm and poor tumor differentiation seem to be a common predictor of worse outcomes in literature reports. In case of early esophagogastric junction cancer (EGJC) these predictors include LVI, tumor size >3 cm, Barrett's origin of the tumor and ulcerative tumor appearance. Extended indications for ESD in early GC are already adopted in high volume centers with high success rates (up to 98%). Jet, positive resection margins after ESD, LVI and poor tumor differentiation carry high metastatic potential, therefore advocating surgery. Limited resections and cooperative laparoscopic endoscopic approach may be implemented in cases of early EGJC and GC. Key Messages: The presence of LVI, depth of submucosal invasion, and poor tumor differentiation in cases of early EC, EGJC, and GC favor surgical treatment despite improvements in endoscopic techniques.

Alternative therapies for GERD: a way to personalized antireflux surgery.

Gastroesophageal reflux disease (GERD) is a common disorder, known to affect about 20% of the Western population. Although conventional medical or surgical treatment has proven effective, there is certainly room for improvements. As only 10% of GERD patients are finally treated by antireflux surgery, a large therapeutic window exists. This treatment gap consists of patients who are not effectively treated with proton pump inhibitor but do not want to run the potential risks of conventional surgery. During the last two decades, several novel and intriguing options for the surgical treatment of GERD have been introduced and found their way into clinical use. The following summary will give an update of certain alternative therapeutic options to treat GERD or its pathological consequences.

Significance of Nissen fundoplication after endoscopic radiofrequency ablation of Barrett's esophagus.

OBJECTIVE: HALO radiofrequency ablation (RFA) has been proven as safe and efficient in eradication of both non- and dysplastic Barrett's esophagus (BE). Definitive post-RFA treatment is yet to be determined. METHODS: RFA was performed in 56 patients with BE, 38 with intestinal metaplasia (IM) and 18 with low-grade dysplasia (LGD), and repeated in case of residual BE. Length of the BE was classified according to C&M criteria. Follow-up included regular upper GI endoscopies with biopsies 6 months, 1 and 2 years after the complete resolution of BE. Patients were divided into two groups regarding post-RFA treatment: those maintaining proton pump inhibitors (PPI) daily and those submitted to laparoscopic Nissen fundoplication (LNF) at least 3 months after BE eradication or synchronous with RFA. RESULTS: There were no perforations or strictures related to RFA. Complete endoscopic resolution of BE was observed in 83.92 % patients (86.84 % IM and 77.77 % LGD), in 25 that maintained PPI and 22 in whom LNF was done. In PPI group, 2-year follow-up revealed BE recurrence in biopsy samples in 20 % of patients, while in LNF group 9.1 % of patients had recurrent IM. In overall sample of patients, no difference was noted regarding the influence of post-RFA treatment (p < 0.423). LNF proved superiority over PPI treatment in patients with long-segment BE (cutoff C > 4 cm, p < 0.021). CONCLUSION: HALO RFA is a safe procedure, with high rate of success in complete eradication of BE in symptomatic GERD patients. LNF provides good protection for neosquamous epithelium and in selected group of patients could be offered as a first line of treatment after HALO RFA.

Highly selective vagotomy and gastrojejunostomy in the treatment of peptic ulcer induced gastric outlet obstruction.

BACKGROUND/AIM: The incidence of peptic ulcer-induced gastric outlet obstruction is constantly declining. The aim of this study was to present our results in the treatment of gastric outlet obstruction with highly selective vagotomy and gastrojejunostomy. METHODS: This retrospective clinical study included 13 patients with peptic ulcer-induced gastric outlet obstruction operated with higly selective vagotomy and gastrojejunostomy. A 3-year follow-up was conducted including clinical interview and upper gastrointestinal endoscopy on 1 and 3 years after the surgery. RESULTS: The most common preoperative symptom was vomiting (in 92.3% of patients). The mean preoperative body mass index was 16.3 +/- 3.1 kg/m2, with 9 patients classified preoperatively as underweight. There were no intraoperative complications, nor mortality. At a 3-year follow-up there was no ulcer recurrence. Delayed gastric emptying was present in 1, bile reflux in 2, and erosive gastritis in 1 patient. Two patients suffered from mild "dumping" syndrome. CONCLUSION: Higly selective vagotomy combined with gastrojejunostomy is a safe and easily feasible surgical solution of gastric outlet obstruction induced by peptic ulcer. Good functional results and low rate of complications can be expected at a long-term follow-up.

Totally implantable central venous catheters of the port-a-cath type: complications due to its use in the treatment of cancer patients.

PURPOSE: A multidisciplinary approach to the treatment of patients with malignant diseases requires adequate venous access in order to safely administer chemotherapy, blood transfusion and blood products, antibiotics, rehydratation and total parenteral nutrition. The insertion of the central venous catheter (CVC), its use and its maintenance can be accompanied by multiple complications. METHODS: Fifty cancer patients were retrospectively enrolled in this study. The obligatory inclusion criterion was an implanted CVC of the port-a-cath type, inserted for chemotherapy administration. This study included patients who had their catheters inserted in the period from 2001 to 2012. RESULTS: The median patient age was 44 years (range 28- 68). Thirty five patients (70%) were female and 15 (30%) male. The port-a-cath had been used from 1 to 40 months (16.8 ± 9 months on average). Breast cancer was the most frequent malignancy (18 patients, 36%). The overall incidence of reported complications was 38%. The most common complications were infections and thromboembolic events, each with an incidence of 10 %. The malposition and disconnection of the port-a-cath were in second place, each with an incidence of 6%. CONCLUSION: Insertion of the CVC carries the possibility of serious complications (thrombosis, infections, occlusions). However, correct implantation and handling performed by experienced and trained surgical and other medical staff significantly decrease the incidence of these complications. The use of the CVC has greatly improved the quality of life and also decreased the morbidity and mortality of the cancer patients in our study.

Can different subsets of ineffective esophageal motility influence the outcome of nissen fundoplication?

BACKGROUND: Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF). METHODOLOGY: A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N = 38), non-propulsive (NPC, N = 18), and simultaneous low-amplitude esophageal contractions (SC, N = 16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery. RESULTS: Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p = 0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p = 0.390). A longer duration of postoperative dysphagia was noted in the SC group (p < 0.05). Improvement of nadir values of contraction amplitudes in distal esophagus occurred postoperatively in all groups, significantly higher in LAC (p < 0.001). CONCLUSION: Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.

Radiofrequency ablation for Barrett's esophagus high-volume center initial results.

INTRODUCTION: Barrett's esophagus (BE) is a well established precursor of esophageal adenocarcinoma. Both, surveillance and therapeutic strategies have been proposed over the years. Recent deve-lopment of endoscopic radiofrequency ablation (RFA) brought new perspectives in the treatment of BE, with excellent initial results. METHODS: The study of 40 pts with macroscopically visible BE on endoscopy and biopsy proven goblet cells presence, was conducted from January 2010 until March 2012. In all pts a complete symptomatic, endoscopic and manometric evaluation was performed. Initially RFA HALO 90 and 360 were performed in 28 and 12 pts respectively. Repeated treatments were conducted in 7 pts. The overall number was 50, while the mean number of RFA procedures per patient was 1.25. RESULTS: The mean circumferential length and maximal extent of BE were 1.61 and 3.29 cm respectively. We did not encounter esophageal perforation or hemorrhage during the procedure. Complications were transient short-term retrosternal pain (23 pts) and dysphagia (11 pts). Three months after the RFA mean values of cumulative symptom and heartburn score dropped significantly (p < 0.05). Functional diagnostics did not disclose any statistically significant decrease of lower esophageal sphincter pressure or esophageal body contraction amplitudes. One year foIlow-up was obtained in 26 pts and revealed a complete macroscopically visible BE eradication. So far, in 19 pts a laparoscopic Nissen fundoplication was performed up to 3 months after complete RFA BE eradication. CONCLUSION: HALO RFA procedure is safe and very effective in the treatment of pts with BE, does not lead to esophageal function impairment, and produces no long term and serious side effects.

Medical waste management at the Oncology Institute of Vojvodina: possibilities of successful implementation of medical waste regulation in Serbia.

Implementation of National waste management strategy, which included most of Healthcare facilities (HCF) in Serbia, began in 2009. The present study aimed to evaluate the medical waste management strategy protocol at Oncology Institute of Vojvodina, which is the first institution in Vojvodina and one of the first institutions in Serbia which has implemented the recomended medical waste management protocol. Segregation, storage, transportation and treatment were all evaluated and that was all performed according to National strategy. Biohazard generation rate was 0,17 kg/bed/day, which correspods with values in the HCF in Eastern Europe. The results show that the methods for safe management of medical waste are acceptable, affordable, and economically justifable to accomplish the reduction in the financial costs in HCF business, and can serve as representative of proper medical waste management practice for other HCF.

Seed germination and seedling vigour of italian ryegrass, cocksfoot and timothy following harvest and storage / Germinação de sementes e o vigor de plantas jovens de azevem italiano, dactilis e timóteo após a colheita e o armazenamento

During post-harvest maturation, different species vary in the length of dormancy breaking or germination increases. Seed dormancy and slow seedling development often limit establishment of forage grass stands. Seed germination and seedling vigour of Italian ryegrass (Lolium italicum A. Braun, Synonym Lolium multiflorum L.), cocksfoot (Dactylis glomerata L.) and timothy (Phleum pretense L.) were observed after harvest and storage. After harvest in June, seeds were stored under standard storage conditions and sampled every 30 days after harvest (DAH), up to 270 DAH, and then every 60 days up to 990 DAH. At each date, seeds were tested for final germination percentage and for seedling vigour traits. Timothy seeds had a maximum germination (88 percent) and the best seedlings vigour at 90 DAH, which implies that early autumn (September-October) is the best sowing period for freshly harvested seeds of timothy. Timothy seed germination was poor from 270 DAH (73 percent). The best germination and vigour of Italian ryegrass and cocksfoot seedlings were between 270 and 330 DAH, which equates to spring sowing time (March-April) in the succeeding year. Cocksfoot and Italian ryegrass seeds maintained satisfactory germination levels up to 630 DAH (81 percent) and 810 DAH (81 percent), respectively. The data can serve for the determination of a proper storage duration management between harvest and sowing of the tested species under ambient conditions of south-eastern Europe.

Durante o armazenamento, diferentes espécies comportam-se diferentemente quanto à dormência e crescimento de plântulas. A dormência o desenvolvimento lento das plântulas limitam a época do plantio das gramíneas forrageiras plurianuais. A germinação de sementes e o crescimento das plântulas de azevem italiano (Lolium italicum A. Braun sin. Lolium multiflorum L.), Dactilis (Dactilis glomerata L.) e de timoteo (Phleum pratense L.) foi pesquisada durante a maturação pós-colheita e a silagem. Após a colheita, em junho, sementes foram armazenadas em condições tradicionais e analisadas a cada 30 dias após a colheita, até 270 dias e, em seguida, a cada 60 dias até 990 dias. Nessa pesquisa, avaliou-se a germinação final e o vigor das plântulas. As sementes de timoteo obtiveram germinação máxima (88 por cento) e o melhor crescimento das plântulas após 90 dias de armazenamento, indicando que o melhor período para o plantio das sementes colhidas em junho é o inicio de outono (setembro-outubro). A germinação de sementes de timoteo reduziu nos 270 dias (73 por cento) seguintes. A melhor germinação, e crescimento da plântula do azevem italiano e do dactilis ocorreu entre 270 e 330 dias, indicando que a melhor época para plantio é na primavera (março-abril), do ano seguinte. As sementes de dactilis e azevem italiano mantiveram germinação satisfatória até 630 dias (81 por cento) e 810 dias (81 por cento), respectivamente. Essa pesquisa pode servir para determinação de gerenciamento adequado de duração de armazenamento entre a colheita e o plantio das espécies testadas em condições de armazenamento no sudeste da Europa.

Is there an association between hiatal hernia and ineffective esophageal motility in patients with gastroesophageal reflux disease?

INTRODUCTION: The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal hernia and to determine if herniation is a factor related to esophageal dysmotility in patients with gastroesophageal reflux disease. METHODS: The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional diagnostics. Hiatal hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamocolumnar junction and esophageal dysmotility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus as <30 mmHg and/or less than 80% of effective contractions. For univariate statistical analysis, the patients were divided into two groups: with and without hiatal hernia. Poisson regression models were used to estimate crude and adjusted prevalence ratios (PR) of esophageal dysmotility according to hiatal hernia. RESULTS: Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). Patients with hiatal hernia also showed a higher frequency of erosive esophagitis (47.5% versus 24.2%, p < 0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001), and higher frequency of individuals with abnormal pH-metry values (p < 0.001). The crude PR for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (confidence interval (CI), 1.04-3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry, and altered low esophageal sphincter (adjusted PR, 1.69; CI, 0.68-4.15; p = 0.257). CONCLUSION: Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between these variables in individuals with gastroesophageal reflux disease disappeared when controlling for age, esophagitis, altered pH-metry, and altered low esophageal sphincter, leading us to believe that in these patients, hiatal hernia is not an independent risk factor for dysmotility.

Acinetobacter spp. colonization and infection risk factors in surgical patients.

INTRODUCTION: The results of numerous studies carried out over the last two decades have increasingly important cause of intrahospital infections (IHI). The aim of the study was to determine potential differences in distribution of individual risk factors between the group of patients in whom multiresistant Acinetobacter spp. was isolated and the group of patients in whom it was not. MATERIAL AND METHODS: A prospective cohort study of 64 patients hospitalized with recorded IHI at the University Hospital for Digestive Surgery, Clinical Center of Serbia in the period between January and July 2011. The subjects were divided into two groups: patients with IHI in whom multiresistant Acinetobacter spp. was isolated from the biological material samples, and those with IHI without the presence of Acinetobacter spp. RESULTS: Univariate data analysis indicated presence of statistically significant difference in distribution of certain types of surgeries (esophageal, pancreatic and hepatobiliary) among the two groups of subjects, distribution of CVC placement, application of mechanical ventilation and nasogastric tube placement, length of stay in ICU, lethal outcomes and administration of third generation cephalosporins. The results of multivariate analysis indicated that length of hospitalization in ICU (> 7 days), CVC, mechanical ventilation, esophageal, pancreatic and hepatobiliary surgeries as well as administration of third generation cephalosporins are independent risk factors for colonization and infection of patients with Acinetobacter spp. CONCLUSION: Colonized or infected patients with Acinetobacter spp. play a major role in contamination of hands of the medical staff in the course of care and treatment, while inadequate hand hygiene of the staff leads to cross transmission of the causative organism to infection-free patients. Selective antibiotic pressure, particularly administration of quinolones and broad-spectrum cephalosporins, favor onset of multiresistant species of Acinetobacter spp., and therefore appropriate prophylaxis and treatment represent basic preventive measures against the onset and spreading of the causative organisms.

Significance of limited hiatal dissection in surgery for achalasia.

INTRODUCTION: It is speculated that postoperative pathologic gastroesophageal reflux after Heller's myotomy can be diminished if the lateral and posterior phrenoesophageal attachments are left intact. The aim of this study was to evaluate the effectiveness of limited hiatal dissection in patients operated due to achalasia. METHODS: Prospective, randomized, 3 years follow-up of 84 patients operated due to achalasia. In 26 patients, Heller-Dor with complete hiatal dissection was done (G1), limited hiatal dissection combined with myotomy and Dor's procedure was performed in 36 patients (G2), and with Heller's myotomy alone in 22 (G3). Stationary manometry and 24 h pH study were performed in regular postoperative intervals. RESULTS: Postoperatively, higher median values of lower esophageal sphincter resting pressures were marked in G2 and G3, while patients in G1 were presented with higher median values of pH acid score (p < 0.001). Abnormal DeMeester score 3 years after surgery was present in 23.1% of patients in G1 and 8.5% and 9.1% in G2 and G3 accordingly. There was no statistical difference between the groups concerning postoperative dysphagia recurrence. CONCLUSION: Indicating further long-term studies, 3 years after the operation limited hiatal dissection compared to complete obtains better reflux control in achalasia patients, regardless of Dor's fundoplication.

Hemodynamic and cardiovascular problems during modified hyperthermic intraperitoneal perioperative chemotherapy.

BACKGROUND/AIMS: Cytoreductive surgery and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) significantly improves patients survival with peritoneal carcinomatosis especially in low-grade tumor e.g. ovarian and appendiceal adenocarcinoma, peritoneal pseudomyxoma and grade I gastric and colorectal cancer. METHODOLOGY: During a period of nine years, hemodynamic and cardiac functions combined with urinary output during hyperthermic intraoperative intraperitoneal chemotherapy were prospectively measured in 60 patients. RESULTS: Statistically significant hemodynamic and cardiac parameters were characterized by an increased heart rate and cardiac output as well as decreased systemic vascular resistance associated with an increased body temperature and decreased effective circulating volume. The tendency of urinary output was to decrease as the therapy progressed. CONCLUSIONS: HIPEC induces a hyperdynamic circulatory state requiring increased intravenous fluid administration, which avoids changes because of increased intra-abdominal pressure. Documented by normal blood pressure and adequate urinary output hemodynamic and intravenous fluids, titrated to frequent urinary output determination, can achieve cardiac stability.

Popliteal traumatic arteriovenous fistulas.

BACKGROUND: The purpose of this report is to analyze the clinical presentation, diagnosis, and outcome of surgical treatment in patients with popliteal arteriovenous fistulas (AVFs) in order to make trauma surgeons aware of the various issues patients with popliteal AVFs might present. METHODS: From 1991 to 2000, 49 patients were treated for traumatic AVF. Among these patients, seven suffered from popliteal AVF of various durations. The patients were men and ranged in age from 17 to 27 years, with a mean age of 22.4 years. The time from injury to admission to our institutions varied from 5 days to 2 years. A diagnosis of popliteal AVF was made after clinical examinations revealed thrill and bruit over the injury sites. The diagnosis was confirmed in four of the patients after they underwent angiography. Patients with long-standing popliteal AVF underwent cardiology examinations to check for signs of heart failure. All patients with popliteal AVF received surgical treatment. Five patients had major blood vessels reconstructed, one patient had a minor blood vessel ligated, and another patient had a minor blood vessel reconstructed. RESULTS: Five of the seven patients experienced no postoperative difficulties. No serious heart failure occurred; however, there were signs of cardiac overload in three of the five patients. The two remaining patients of the seven underwent leg amputations. However, one of the two patients had a gangrenous foot at admission to our institution, and vascular reconstruction on the other patient was unsuccessful. For all seven patients, the average hospital stay in the vascular surgery department was 16.2 days and the follow-up ranged from 2 to 44 months, with a mean of 21.5 months. CONCLUSION: Trauma of the popliteal space requires special attention, since blood vessel injuries in that zone might result in serious complications. Popliteal traumatic AVFs result in a high rate of leg amputation and long-standing fistulas produce cardiac overload. The presence of thrill and bruit over the injury site should alert the examiner to consider the existence of AVF. Angiography is a reliable diagnostic tool, and should be used in all vitally stable patients. Surgical or nonsurgical closure of AVF will prevent local and systemic complications that might be irreversible in long-standing fistulas.