Treatment of Lymphatic Complications after Common Femoral Artery Endarterectomy.

BACKGROUND: This study analyzes the outcome of lymphatic complications after a standard vascular procedure. METHODS: This is a retrospective study including patients who had a lymphatic complication after endarterectomy and patch of the common femoral artery in our clinic between March 2007 and June 2018. Therapy of choice was selected according to wound situation and amount of lymphatic liquid. If signs of a wound infection occurred, a surgical therapy was performed; in all other cases a nonsurgical treatment (conservative treatment, radiotherapy) was chosen. RESULTS: We performed 977 index operations, a lymphatic complication occurred in 112 cases (11.5%). In 69 cases the lymphatic complication presented as lymphatic fistula (Group 1), in 43 cases as lymphorrhea from the wound (Group 2). Nonsurgical treatment was done in 66 cases (Group 1: 76.8% vs. Group 2: 30.2%; P < 0.000), and a surgical treatment was necessary in 46 cases (Group 1: 23.2% vs. Group 2: 69.8%; P < 0.000). Indication for surgery was Szilagyi 1 infection in 25 cases, Szilagyi 2 infection in 11 cases, and Szilagyi 3 infection in 10 cases. Patients with Szilagyi 1 infections received negative wound pressure therapy (NWPT). A muscle flap in combination with an NWPT was performed in patients with Szilagyi 2 infections. In Szilagyi 3 infections, the patch was replaced; additionally, a muscle flap and an NWPT were performed. The median hospital stay was 13 days in the nonsurgical group and 22.5 days in the surgical group. We had no bleeding complications and no reinfection during follow-up. The median observation period was 23.0 months. Age ≥80 years was associated with an increased risk for lymphatic complications. CONCLUSIONS: The therapy of lymphatic complications should be done in accordance with clinical symptoms. A nonsurgical treatment is often sufficient. However, in cases of a wound infection different surgical treatments are necessary.

Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen.

BACKGROUND: Open abdomen (OA) in which the abdomen is closed with temporary abdominal closure methods is the most effective in patients who develop severe abdominal sepsis or abdominal compartment syndrome. Major techniques used are Vacuum-Assisted Closure Method (VACM) and non-vacuum assisted closure method (NVACM). In the present study, the effects of different abdominal closure methods on morbidity and mortality were evaluated. METHODS: In the study, the temporary abdominal closure methods of the patients with OA during 2013-2016 were studied retrospectively. OA etiopathologies, mortality prediction scores, final abdominal closure periods and methods, hospitalization periods, complications (enteroatmospheric fistula, mesh infection, and incisional hernia), and mortality rates of patients who underwent VACM and NVACM were determined and compared. RESULTS: The present study included 123 patients who underwent VACM (n=65) and NVACM (n=58). There was no difference between the groups in terms of age, gender, and etiopathogenesis (p>0.05). The mean APACHE 4 and Multiple Organ Dysfunction Score (MODS) scores in the VACM/NVACM groups in treatment period were 47/63 and 11/14, respectively (p<0.05). The mean intensive care and hospitalization periods in the VACM/NVACM groups were 11/16 (days) and 22/28 (days), respectively (p<0.05). The collection and abscess development rates in the VACM and NVACM groups were 46.2% and 77.6%, respectively (p<0.05). The rate of enteroatmospheric fistula (EAF) development in the VACM and NVACM groups were 15.4% and 56.9%, respectively (p<0.05). The mean abdominal closure times in the VACM and NVACM groups were 13 and 17 days, respectively (p<0.05). Mortality rate in the VACM and NVACM groups were 18% (n=18) and 55% (n=32), respectively (p<0.05). CONCLUSION: In patients with OA, the temporary abdominal closure technique VACM has lower complication and mortality rates and shorter hospitalization period than other methods. Therefore, it is an effective and safe method for the treatment of OA.

Characteristics of atrial fibrillation patients suffering atrioesophageal fistula after radiofrequency catheter ablation.

INTRODUCTION: Radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients can cause various complications and atrioesophageal (AE) fistula is one of the most catastrophic complications of RFCA. METHODS AND RESULTS: RFCA registries from 3 cardiovascular centers in the Republic of Korea consisted of 5721 patients undergoing 6724 procedures. Before undergoing RFCA, patients underwent either computed tomography or magnetic resonance imaging. We evaluated clinical, anatomical, and procedural characteristics of patients who developed AE fistula after RFCA. A total of 10 patients developed AE fistula after RFCA (0.15% per procedure). All AE fistulas occurred during first-time RFCA. Eight patients died and mortality rate was 80.0%. No patients had any gastrointestinal symptom at the time of discharge and mean duration time from RFCA to symptom onset was 23.4 days. Six patients (60.0%) had paroxysmal AF. Substrate modification in addition to pulmonary vein isolation was performed in 4 patients (40.0%). Patients with old age, low body weight, and high CHA2 DS2 -VASc score were at increased risk of AE fistula. Baseline imaging evaluation revealed that esophagus had closest contact with LA posterior wall near left inferior pulmonary vein rather than left superior pulmonary vein and all documented AE fistulas were located near left inferior pulmonary vein. CONCLUSION: Posterior wall of LA near left inferior pulmonary vein was the most vulnerable location for AE fistula. Pulmonary vein isolation was the main lesion set associated with AE fistula and old age, low body weight, and high CHA2 DS2 -VASc score were significant risk factors for AE fistula.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis.

PURPOSE: Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings. METHODS: A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis. RESULTS: The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47). CONCLUSIONS: The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Atrioesophageal Fistula: Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes.

BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF. METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047). CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.

[Sleeve lobectomy: perioperative risks and functional results]. / Bronchusmanschettenresektion: Perioperatives Risiko und funktionelles Ergebnis.

Sleeve lobectomy is an established surgical procedure in patients with lung cancer. Usually the only surgical alternative would be a pneumonectomy. This article describes the perioperative risks and functional results in patients after sleeve lobectomy compared to pneumonectomy and typical lobectomy.There were only minor differences with respect to postoperative morbidity comparing the different procedures but the mortality rate was higher following pneumonectomy. Bronchopleural fistula rates were also similar comparing lobectomy and sleeve lobectomy but elevated following pneumonectomy. Bronchovascular fistulas after sleeve lobectomy are potentially life-threatening. Postoperative pulmonary function tests showed similar values for lobectomy and sleeve lobectomy patients and were considerably better than following pneumonectomy.Whenever possible sleeve lobectomy should take preference over pneumonectomy.

Mortality in hypoplastic left heart syndrome: review of 216 autopsy cases of aortic atresia with attention to coronary artery disease.

OBJECTIVES: Aortic atresia (AA) in hypoplastic left heart syndrome (HLHS) has been associated with increased mortality in several prior studies. We reviewed our autopsy series to explore the relationship of coronary abnormalities to anatomic subsets of HLHS with AA. METHODS: We retrospectively reviewed all pathology specimens with AA/MS (mitral stenosis) and AA/MA (mitral atresia) in the Cardiac Registry of Children's Hospital Boston between 1955 and 2009 including autopsy reports, operative notes, and imaging studies. Formalin-fixed hearts were examined, and cases found to have macroscopic coronary artery abnormalities were sectioned at mid-left ventricular level in the transverse plane and at mid-right ventricular level in the longitudinal plane for histologic analysis of coronary arteries using tissue sections stained with hematoxylin and eosin. RESULTS: A total of 216 autopsy cases were identified with AA/MS (134) and AA/MA (82). Coronary anomalies were found in 49 cases, left ventricle-coronary fistula in 39, all in AA/MS, and 10 other coronary abnormalities, all in AA/MA. Histologic study confirmed fistulas only in the AA/MS group with no evidence of fistulas in the AA/MA group. CONCLUSIONS: The occurrence of left ventricle-coronary fistulas appears limited to the AA/MS group, and coronary fistula specimens were disproportionately more prevalent in postoperative specimens. Further clinical studies are required to validate this finding and to identify subgroups that carry a higher mortality risk.

Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts.

Aorto-oesophageal fistula (AEF) is a rare but life-threatening disease with an underlying infective aetiology that can cause serious complications. This study investigated the clinical outcomes of patients with AEF who received in situ cryopreserved aortic allograft replacement. From August 2000 to February 2011, 11 patients with AEF received aortic allografts; 5 for primary AEF caused by ruptured aortic aneurysm and 6 for secondary AEF that comprised 4 cases following thoracic endovascular aortic repair (TEVAR) and 2 after open graft replacement of the thoracic aorta. As for results, 2 cases of primary AEF received TEVAR and then allograft replacement, one for graft infection and the other for bleeding. Three primary AEF cases received allografts directly. Six secondary AEF cases received staged (5) or simultaneous (1) oesophagectomy and allograft replacement. There were 3 in-hospital deaths (27%), 2 because of bleeding and one because of multisystem organ failure. Four patients completed oesophageal reconstruction. There were 2 late deaths, one due to aspiration pneumonia and one of unknown cause. In conclusion, surgical results for repair of AEF using cryopreserved aortic allograft were satisfactory considering preoperative critical condition, and this type of allograft appears to be an ideal graft of choice.

Is POSSUM predictive of morbidity and mortality in laryngectomy patients?

OBJECTIVES: To test the validity of the comparative audit tool of POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) against a cohort of 92 consecutive laryngectomies at a major tertiary referral centre for head and neck cancer. The major outcome measurements were 30-day mortality rates, formation of a pharyngo-cutaneous fistula, and length of hospital stay. METHODS: By means of a prospective and retrospective case note analysis. RESULTS: No significant difference between the mean POSSUM morbidity scores of those patients who did, or did not develop a fistula, was found (p=0.535, 95% C.I. -4.36 to 8.33). No significant correlation was observed between POSSUM predicted morbidity and bed occupancy [r=0.137 (95% C.I. -0.070 to 0.334)]. The Portsmouth POSSUM equation for mortality however did accurately predict the mortality rate (observed to expected ratio of 1.05). CONCLUSION: The authors propose that whilst there are many similar factors linked to mortality between cohorts of general surgical and head and neck patients, there are several highly specific risk factors in open surgery of the upper aero-digestive tract in the head and neck which are linked with wound breakdown and morbidity which are omitted from the POSSUM scoring system. The authors warn against the use of this comparative audit tool in its current state for such surgical procedures and recommend the creation of a specific POSSUM for head and neck cancer surgery.

Long-term results with cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections.

OBJECTIVE: Our purpose was to evaluate our results with CPAs in patients with infected grafts or primary arterial infection with emphasis on long-term durability of these grafts. METHODS: To evaluate the long-term durability of CPAs, clinical outcomes were analyzed following their use for either graft or primary arterial infections at a single institution over a 9-y period (2000-2009). The 30-d mortality rate, 90-d mortality rate, and the cause of early mortality were determined in each case. Among those surviving 90 d, the grafts were evaluated for subsequent failure. RESULTS: From 2000 through 2009, 51 patients with either infected prosthetic grafts (35) or primary arterial infections (15) received CPAs. One patient had infection of a previously placed thoracic allograft. Forty-three graft infections involved either the thoracic or abdominal aorta. Eleven patients presented with fulminant sepsis with systemic inflammatory response syndrome (SIRS), seven of whom died postoperatively. Eight patients presented with aorto-enteric, esophageal, or bronchial fistulae with infected prosthetic grafts. The 30-d mortality rate was 25.5% (11 deaths) seven of which occurred in patients with SIRS. The 90-d mortality rate was 41.4%. There were 10 graft failures, seven occurring in patients with aorto-enteric or bronchial fistulae all of whom had recurrent hemorrhage. The other three graft failures were due to anastomotic hemorrhage in the early postoperative period. Among those surviving 90 d, the mean follow-up was 46.4 mo (range 1-112 mo). No aneurysmal degeneration of the CPAs was noted. Only one subsequent allograft graft failure was noted among those surviving more than 90 d. CONCLUSIONS: CPAs are a suitable option in dealing with cardiovascular infections. Patients with enteric or bronchial fistulae are a difficult group to treat perhaps because of ongoing contamination of the allograft. The operative mortalities are largely determined by patient comorbidities (SIRS). Subsequent degeneration or infection of the CPAs is rare.

Therapeutic option for infected urinary tract fistulas in renal transplantation.

BACKGROUND: Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge. OBJECTIVE: To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair. PATIENTS AND METHODS: The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis). RESULTS: Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%. CONCLUSION: Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

Allograft replacement for infrarenal aortic graft infection: early and late results in 179 patients.

OBJECTIVES: We evaluated early and late results of allograft replacement to treat infrarenal aortic graft infection in a large number of patients and compared the results in patients who received fresh allografts versus patients who received cryopreserved allografts. METHODS: From 1988 to 2002 we operated on 179 consecutive patients (mean age, 64.6 +/- 9.0 years; 88.8% men). One hundred twenty-five patients (69.8%) had primary graft infections, and 54 patients (30.2%) had secondary aortoenteric fistulas (AEFs). Fresh allografts were used in 111 patients (62.0%) until 1996, and cryopreserved allografts were used in 68 patients (38.0%) thereafter. RESULTS: Early postoperative mortality was 20.1% (36 patients), including four (2.2%) allograft-related deaths from rupture of the allograft (recurrent AEF, n = 3), all in patients with fresh allografts. Thirty-two deaths were not allograft related. Significant risk factors for early mortality were septic shock (P <.001), presence of AEF (P =.04), emergency operation (P =.003), emergency allograft replacement (P =.0075), surgical complication (P =.003) or medical complication (P <.0001), and need for repeat operation (P =.04). There were five (2.8%) nonlethal allograft complications (rupture, n = 2; thromboses, which were successfully treated at repeat operation, n = 2; and amputation, n = 1), all in patients with fresh allografts. Four patients (2.2%) were lost to follow-up. Mean follow-up was 46.0 +/- 42.1 months (range, 1-148 months). Late mortality was 25.9% (37 patients). There were three (2.1%) allograft-related late deaths from rupture of the allograft, at 9, 10, and 27 months, respectively, all in patients with fresh allografts. Actuarial survival was 73.2% +/- 6.8% at 1 year, 55.0% +/- 8.8% at 5 years, and 49.4% +/- 9.6% at 7 years. Late nonlethal aortic events occurred in 10 patients (7.2%; occlusion, n = 4; dilatation < 4 cm, n = 5; aneurysm, n = 1), at a mean of 28.3 +/- 28.2 months, all but two in patients with fresh allografts. The only significant risk factor for late aortic events was use of an allograft obtained from the descending thoracic aorta (P =.03). Actuarial freedom from late aortic events was 96.6% +/- 3.4% at 1 year, 89.3% +/- 6.6% at 3 years, and 89.3% +/- 6.6% at 5 years. There were 63 late, mostly occlusive, iliofemoral events, which occurred at a mean of 34.9 +/- 33.7 months in 38 patients (26.6%), 28 of whom (73.7%) had received fresh allografts. The only significant risk factor for late iliofemoral events was use of fresh allografts versus cryopreserved allografts (P =.03). Actuarial freedom from late iliofemoral events was 84.6% +/- 7.0% at 1 year, 72.5% +/- 9.0% at 3 years, and 66.4% +/- 10.2% at 5 years. CONCLUSIONS: Early and long-term results of allograft replacement are at least similar to those of other methods to manage infrarenal aortic graft infections. Rare specific complications include early or late allograft rupture and late aortic dilatation. The more frequent late iliofemoral complications may be easily managed through the groin. These complications are significantly reduced by using cryopreserved allografts rather than fresh allografts and by not using allografts obtained from the descending thoracic aorta.

Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management.

Postoperative aortobronchial and aortopulmonary fistulas are rare and late complications of cardiac surgery. They mostly complicate descending thoracic aortic procedures. Hemoptysis is the main symptom, and may be massive or intermittent. The reported interval between the time of operation and the onset of hemoptysis ranges from 3 weeks to 25 years. Diagnostic examinations are often unable to directly visualize a fistula. Indication for surgical or endovascular repair mostly relies on clinical suspicion and nonspecific diagnostic features. Urgent treatment is based on the association of the following elements: (1) hemoptysis, (2) history of previous cardiac or aortic operation, (3) presence of lung infiltrates on the chest roentgenogram, (4) lung hemorrage on the computed tomographic scan, and (5) and visualization of a pseudoaneurysm. Aortobronchopulmonary fistulas are uniformly fatal if untreated. The overall surgical mortality rate is 15.3%. There is no procedure-related mortality after endovascular stent grafting. A review of the English-language literature from 1947 to October 2002 is presented.

Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy.

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3-2%, but is associated with a hospital mortality between 25-90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high,44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Prosthetic vascular infection complicated or not by aortoenteric fistula: comparison of treatment with and without cryopreserved allograft (homograft).

OBJECTIVES: in patients with vascular prosthesis infection, to compare surgical outcome and long-term results of cryopreserved allograft implantations to conventional surgery. DESIGN: retrospective study. MATERIAL AND METHODS: two asynchronous series of 44 [series I: 1980-1994; 8 patients with aortoenteric fistula (AEF)] and 22 (series II: 1994-1997; 4 patients with AEF) patients were treated for prosthesis infection. All patients had prosthesis excision. In series I, there were 4 in situ reparations, 26 extra-anatomic bypass, 13 excision only, and one death at laparotomy. In series II, in situ cryopreserved allografts were implanted in all patients. RESULTS: operative mortality was 16% in series I and 13.6% in series II. For AEF patients, mortality was 37% in series I and 50% in series II. Among hospital survivors, infection-related late mortality was 13.5% in series I and 5% in series II. For AEF patients, late mortality was 20% in series I and 50% in series II. Incidence of reoperations was 54% in series I and 10.5% in series II (p<0.01). Hospital stay was 47.2+/-26.4 days in series I and 16.6+/-11.5 days in series II (p<0.001). CONCLUSIONS: compared to conventional treatment, incidence of reoperations and length of hospital stay are significantly decreased after cryopreserved allograft implantation. However, closure of aortic stump and extra-anatomic bypass gives better results for patients with AEF.

Prognostic factors and management of civilian penetrating duodenal trauma.

OBJECTIVE: This study was designed to investigate risk factors in the final outcome of patients with civilian penetrating abdominal trauma and duodenal injuries, the value of the different surgical approaches used, and to define when more complex procedures are indicated, instead of the simple primary repair. METHODS: The study design was a retrospective review of prospectively collected data of a 4-year period (July 1992 to June 1996). RESULTS: A total of 167 patients were admitted with penetrating abdominal trauma and duodenal injuries at San Juan de Dios Hospital in Santafé de Bogotá, Colombia. CONCLUSION: The independent and significant risk factors that determine the severity of duodenal injury and need for complex procedures, as identified in this series, are preoperative or intraoperative shock; Abdominal Trauma Index higher than 25; and associated injuries to the pancreas, superior mesentric vessels, and colon. These factors are associated with an increased incidence of septic complications, duodenal fistula, and late mortality.

Death in custody due to a colopericardial fistula.

Death while in custody is a sensitive issue as it has the potential to cause legal ramifications and political fall-out, to embarrass the law enforcement community, and to incite the general population. Studies of deaths while in custody show that natural deaths are much more common than both suicides and homicides combined. Studies also indicate that natural deaths cluster in the older population, while suicides, on the other hand, occur predominantly in the younger population. We present a summary and discussion of a death in custody that is unique in several aspects. Contrary to the norm, death in this 18-year-old male inmate was natural. It was due to a rare complication (colopericardial fistula) of a surgical procedure (colonic interposition) performed roughly 16 years previously. We believe that our case represents the third example of a colopericardial fistula and the first to occur following corrective surgery for esophageal atresia.

[Aorto-duodenal fistula--direct suture and pedicled omentum flap-plasty]. / Aorto-duodenale Fistel--Direkte Naht und gestielte Netzlappenplastik.

Between 1985 and 1993, six patients underwent emergency operation at the Department of General Surgery, Essen University Hospitals, for a secondary aorto-duodenal fistula. In all patients, a Dacron tube- or bifurcation prosthesis has been implanted 1-10 years previously to repair an arteriosclerotic aneurysm of the abdominal aorta. The main symptom of the aorto-duodenal fistula was massive gastrointestinal hemorrhage, with manifest shock in two cases. The most reliable diagnostic procedure, in addition to ultrasonography, was found to be computed angio-tomography. In three cases where there was erosion around the proximal aorto-prosthetic anastomosis, bacterial contamination was found during surgery. Direct reconstruction and pedunculated omentum plasty appear to be a safe method for closing an aorto-duodenal fistula. No patient died in the immediate postoperative period after direct reconstruction. One patient, however, died three months after surgery of myocardial infarction. Two patients suffered from fistula recurrence 1.25 and 3 years respectively after operation and died as a result. One patient died of the sequelae of a chronic obstructive pulmonary disease 3.5 years after the operation. The remaining two patients are still alive and free of complications more than 4 years after operation. Direct reconstruction and pedunculated omentum plasty appear to be a safe method for closing an aorto-duodenal fistula.

[Obturation with an elastic balloon--the authors' procedure for the conservative treatment of external postoperative digestive fistulae]. / Obturarea cu balon elastic--procedeu personal de tratament conservator al fistulelor digestive externe postoperatorii.

UNLABELLED: A personal method for the conservative treatment of the postsurgical external digestive fistulas by means of obturation with an elastic balloon of adjustable pressure, used in Surgical Clinic I Craiova in the past 12 years is presented. Initially conceived as an elective method for the treatment of the fistulas exposed in evisceration, the procedure was later applied as a unique method or in association with other conservative procedure in almost all types of fistulas. 122 patients have been treated by means of our method (3 esophageal, 65 gastro-duodenal and gastro-intestinal, 27 intestinal and 27 colo-rectal fistulas), in 53 cases a unique method and in 69 cases as a therapeutically sequences within the conservative treatment of the fistulas. RESULTS: 115 patients (94.2%) have had a fair evolution; we have registered 7 death, which represent a mortality rate of 5.93%. CONCLUSIONS: Our method offers the following advantages: it considerably reduces the losses of digestive liquids through the fistula; it allows early resumption of normal nourishment; it allows early mobilization of the patients; it prevents the occurrence of new fistulas which are caused by decubitus lesions; it is a simple and economic method, which can be applied in any surgical department.