[Jejunobronchial fistula as a complication after an alloplastic diaphragm substitute]. / Jejunobronchiale Fistel als Komplikation nach alloplastischem Zwerchfellersatz--Ein Fallbericht.

CASE REPORT: In a 60-year-old patient with an inflammatory pseudotumour due to a penetrating gastric ulcer, extended gastrectomy and partial diaphragm resection were carried out 7 years ago. The diaphragmatic defect was closed with a prosthetic patch (polytetrafluoroethylene, PTFE). The patient currently complains about cough during eating, fever and weight loss. By means of fluoroscopy after barium swallow, an enterobronchial fistula was detected. Intraoperatively, a 10-cm long, dead-end piece jejunum was found after end-to-side oesophagojejunostomy. The torn-out PTFE patch was seen in a subphrenic empyemic cavity, which communicated with the dead-end length of jejunum and the peripheral bronchi of the lower lobe via a fistula. After resection of the dead-end length of jejunum and extensive debridement of the residual parts of the diaphragm as well as oversewing of the bronchial fistula, the diaphragmatic defect was covered with a distally pedicled flap of the latissimus dorsi muscle. There were no postoperative complications. CONCLUSION: In case of potential infections the implantation of alloplastic material must be excluded. The reversed latissimus dorsi muscle flap proved to be ideal autologous material for reconstruction of the hemidiaphragm. The dead-end length of jejunum in the end-to-side oesophagojejunostomy should be short to prevent any retention of food. Pulmonary resection is not absolutely necessary in the case of enterobronchial fistulation.

"Hemosuccus pancreaticus"--primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection.

There is a broad spectrum of causes for upper gastrointestinal (GI) bleeding that can be stopped by various approaches. On the basis of the report of an extraordinary case, the favorable minimally invasive approach of applying fibrin glue and histoacryl/lipiodol to the vascular basis of a bleeding pseudoaneurysm leading to "Hemosuccus pancreaticus" as a rare cause of recurrent bleeding in the upper GI tract and dangerous complications in the case of chronic pancreatitis is described. There were recurrent bleeding episodes within the upper GI tract in a 40-year-old female patient. Her medical history was significant for chronic pancreatitis and pseudocyst. Abdominal ultrasound plus duplex ultrasonography revealed a pseudoaneurysm within the tail of the pancreas as the cause of "Hemosuccus pancreaticus". Ultrasound guidance was used to repeatedly apply 2 ml of fibrin glue and 2 x 2 ml of the mixture of lipiodol and histoacryl to the basis of the pseudoaneurysm which led to complete and permanent cessation of the bleeding. Immediate and follow-up control duplex ultrasonographies (up to one year) demonstrated sufficient exclusion of the pseudoaneurysm but a preservation of the lienal artery with no disturbance of the blood perfusion in the splenic parenchyma. In conclusion, this is one of the first reports of the successful cessation of recurrent bleeding into a pseudocyst out of pseudoaneurysm ("Hemosuccus pancreaticus") by an ultrasound-guided transcutaneous fibrin glue and histoacryl/lipiodol application, which 1. is recommended as an alternative but feasible and safe therapeutic tool, 2. can provide sufficient and permanent cessation of bleeding but preserve the perfusion of the natural vessel as an initial step in the possible therapeutic algorithm, and 3. can avoid, in case of success, more invasive approaches such as angiography-guided embolization with coils or implantation of a prosthesis and even open surgical intervention, in particular, in high-risk patients.