Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula.

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17-81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.

Management of pseudoaneurysm of the splenic artery: report of two cases.

BACKGROUND: Splenic pseudoaneurysm is an uncommon disease. It occurs as a consequence of injury to the vascular wall, mostly inflammatory. The main symptom is gastrointestinal bleeding. The objective of this paper is to present the case of two patients with splenic pseudoaneurysm. CASE REPORTS: The first case we present is a 26-year-old male with a history of idiopatic pancreatitis, pancreatic abscess and colonic fistula 3 years prior. The second case is a 20-year-old male with a history of chronic kidney disease with peritoneal dialysis interrupted due to fungal (Candida albicans) peritonitis. Both patients presented with signs of lower gastrointestinal bleeding. Endoscopic examinations (upper endoscopy and colonoscopy) were inconclusive. Tomographic studies showed the lesion. Arteriography with embolization was performed and was satisfactory in one case and partially satisfactory in the other case. Surgery was done with proximal and distal ligation of the lesion with splenectomy. Postoperative evolution was satisfactory. During the follow-up for 6 and 12 months, neither patient has presented signs of recurrent bleeding. CONCLUSIONS: This is a very rare lesion usually presenting after a history of pancreatitis or abdominal trauma. This lesion must be ruled out in patients with obscure gastrointestinal bleeding. Arteriography with embolization is the best diagnostic and probably therapeutic procedure. Surgery is warranted for hemodynamically unstable patients, embolization failure or rebleeding.