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Introduction: This study aimed to compare patient characteristics according to the primary aetiology including gunshot wounds in inpatient individuals diagnosed with enterocutaneous fistula (ECF) or enteroatmospheric fistula (EAF) and to evaluate the impacts of these characteristics on all-cause in-hospital mortality., Methods: This is a single-centre hospital-based retrospective cohort study conducted with adult patients who were hospitalised for treatment of ECF or EAF. The patients were allocated to three study groups according to their primary aetiology (surgery-related group, gunshot-related group and other-cause group). The demographics and clinical features of the patients were compared between the study groups, furthermore, the impacts of these characteristics on in-hospital mortality were evaluated using Cox Regression Analysis., Results: Gunshot-related fistulas were more likely to originate from small intestines, whereas surgery-related fistulas originated from all anatomic sites and those related to other aetiologies often originated from large intestines (p = 0.006). Severe malnutrition was more prevalent in the other-cause group (26.1%) (p < 0.001). Sepsis occurred in 24.3%, 68.8% and 47.8% of the patients (p = 0.008); and the median length of stay was 18.0, 45.0 and 32.0 days (p = 0.025) in the surgery-related group, the gunshot-related group, and the other-cause group, respectively. While the surgery-related and gunshot-related groups had similar and low mortality rates (2.7% and 6.7%, respectively), patients with other reasons had the highest mortality (30.4%). The increase in the duration of output (DOO) was associated with decreased mortality [HR (95%CI): 0.55 (0.39-0.79) p = 0.001], whereas being severely malnourished and having an aetiology of other causes were associated with increased mortality [HR (95%CI): 25.29 (5.20-123.09) and p < 0.001, and HR (95%CI): 9.06 (1.11-73.86) and p = 0.040, respectively]., Conclusions: Patient characteristics, clinical manifestations and treatment approach may differ according to primary aetiology in patients with ECF or EAF. Primary aetiology, the decrease in DOO and severe malnourishment have negative impacts on in-hospital mortality., Competing Interests: Declarations. Ethical approval: Ethics approval was obtained from Gulhane Training and Research Hospital Ethics Committee (Ethical approval no:2020 − 364, and approval date: 04-09-2020). Consent to participate: Because of the retrospective nature of the study, informed consent was waived, and this issue was approved by the Ethics Committee. Competing interests: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: To investigate the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) for infectious aortic diseases., Materials and Methods: Patients who underwent TEVAR for infectious aortic diseases including infected thoracic aortic aneurysm, aortobronchial fistula (ABF), and aortoenteric fistula from December 2011 to October 2022 at 4 institutions were retrospectively studied. The primary outcome of the study was overall survival, whereas the secondary outcome was comprehensive adverse events. Comprehensive adverse events were defined as a combination of deaths, aortic events, and infectious adverse events., Results: A total of 28 patients were included in the analysis, with 13 patients having infected thoracic aortic aneurysms, 12 ABFs, and 3 aortoenteric fistulae. Seven patients (25%) underwent additional procedures (abscess drainage, 6 cases; total esophagectomy, 1 case). The mean follow-up period was 30.0 months (SD ± 33.9). The 1-year and 5-year survival rates were 85.7% and 67.9%, respectively. The 1-year and 5-year aorta-related complication-free survival rates were 64.3% and 42.9%, respectively. On univariate analysis, the presence of an ABF was associated with a higher risk of comprehensive adverse events (odds ratio = 11; P = .038)., Conclusions: TEVAR might be a promising treatment for infectious thoracic aortic diseases. Among the infectious pathologies, ABF was considered ominous in terms of late outcomes., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery., Materials and Methods: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005-2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD)., Results: The study encompassed 34,853 patients with a mean age of 77.7 years-56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001)., Conclusion: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.

Background: We assessed feasibility and safety of laparoscopic sigmoidectomy for complicated fistulizing diverticular disease in a tertiary care colorectal center., Methods: A single-center retrospective study of patients undergoing sigmoidectomy for fistulizing diverticular disease between 2011 and 2021 was realized. Primary outcomes were rates of conversion to open surgery and severe postoperative morbidity at 30 days. Secondary outcomes included rates of postoperative bladder leaks on cystogram., Results: Among the 104 patients, 32.7% had previous laparotomy. Laparoscopy was the initial approach in 103 (99.0%), with 6 (5.8%) conversions to laparotomy. Clavien-Dindo grade ≥ III complication rate at 30 days was 10.6%, including two (1.9%) anastomotic leaks. The median postoperative length of stay was 4.0 days. Seven (6.7%) patients underwent reoperation, six (5.8%) were readmitted, and one (0.9%) died within 30 days. Twelve (11.5%) ileostomies were created initially, and two (1.9%) were created following anastomotic leaks. At last follow-up, 101 (97.1%) patients were stoma-free. Urgent surgeries had a higher rate of severe postoperative complications. Among colovesical fistula patients (n = 73), postoperative cystograms were performed in 56.2%, identifying two out of the three bladder leaks detected on closed suction drains. No differences in postoperative outcomes occurred between groups with and without postoperative cystograms, including Foley catheter removal within seven days (73.2% vs. 90.6%, p = 0.08)., Conclusions: Laparoscopic surgery for complicated fistulizing diverticulitis showed low rates of severe complications, conversions to open surgery and permanent stomas in high-volume colorectal center., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes., Methods: We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints., Results: A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome., Conclusions: In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In the present study, we have reported and compared aortoduodenal fistulas (ADFs) after endovascular abdominal aortic aneurysm repair (EVAR) vs after open aortic repair (OAR)., Methods: We retrospectively analyzed the data from patients treated for ADFs from January 2015 to May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoints of the present study were 30-day and 1-year mortality. The secondary endpoints were major postoperative complications., Results: A total of 24 patients (20 men; median age, 69 years; range, 53-82 years) were admitted with ADFs after EVAR (n = 9) or OAR (n = 15). These patients accounted for ∼4.3% of all abdominal aortic aneurysm repairs in our hospital. The median interval from the initial aortic repair and the diagnosis of ADF was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients in the ADF-EVAR group had refused surgical treatment owing to their high surgical risk. One patient in the ADF-OAR group had undergone removal of the aortic prosthesis without replacement. Of the remaining 20 patients, 12 (ADF-EVAR group, n = 4; ADF-OAR group, n = 8) had undergone in situ replacement of the aorta and 8 (ADF-EVAR group, n = 2; ADF-OAR group, n = 6) had undergone extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, no patient had experienced early limb loss. However, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of a ureteroarterial fistula with a homograft (ADF-OAR) had occurred. Overall, the incidence of postoperative complications was significantly greater after ADF-OAR (93% vs 33%; P = .036). The most frequent bacteria involved in the blood cultures were Escherichia coli (25% of patients), and Candida spp. (61%) were the predominant pathogens found on intra-abdominal smears. The in-hospital mortality rates for the ADF-EVAR and ADF-OAR group were 22% and 13%, respectively. The corresponding 1 -year mortality rates were 22% and 33%., Conclusions: Patients with ADFs after EVAR or OAR have limited overall survival. In addition to the similar therapeutic approaches, we found no significant differences in postoperative mortality between these two uncommon pathologic entities. In our study, the overall postoperative morbidity seemed greater for the ADF-OAR group., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF., Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed., Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality., Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The coexistence of an enterocutaneous fistula (ECF) with large abdominal wall defects represent one of the most demanding situations seen by a surgeon. Simultaneous treatment of ECF closure with abdominal wall defect closure has been widely debated. Our objective was to determine if the type of abdominal wall closure was associated with fistula recurrence after definitive surgery for ECF., Materials and Methods: Consecutive patients submitted to fistula resection with primary anastomosis for ECF closure. Among several variables, total abdominal wall closure (primary independent variable) was assessed as a factor related to the recurrence of the ECF (dependent variable). Univariate and multivariate analyses were performed., Results: One-hundred and fourteen patients were included. Fistula recurred in 39 patients (34%). Total abdominal wall closure was done in 37 patients (32%). ECF recurred in 16% (6 of 37 patients) when abdominal wall closure was performed, compared to 43% (33 of 77 patients) when this was not (p < 0.02). After multivariate analyses, abdominal wall closure was found as a protective factor against recurrence (p < 0.02). Patients with total abdominal wall closure had one-fourth of risk for recurrence compared to patients without it. Other factors associated to recurrence of ECF were multiple fistulas (p < 0.05), intraoperative blood loss >325 mL (p < 0.05) and preoperative C-reactive protein >0.5 mg/dL (p < 0.01)., Conclusion: Our results suggest that total abdominal wall closure is a protective factor against fistula recurrence after definitive surgery for ECF.

Background: Previous data reveal that females account for a disproportionate majority of all patients diagnosed with diverticulitis., Objective: This study analyzed the variation in mortality from diverticular disease by sex., Design: This was a nationwide retrospective cohort study., Settings: Data were obtained from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research national registry., Patients: All citizens of the United States who died from an underlying cause of death of diverticulitis between January 1999 and December 2016 were included., Main Outcome Measures: The primary outcome addressed was overall mortality rate of diverticulitis by sex. Secondary outcomes included pattern variances in demographics and secondary causes of death., Results: During the study period, 55,096 patients (0.12%) died with an underlying cause of death of diverticulitis from a total of 44,915,066 deaths. Compared with other causes, females were disproportionally more likely to die from diverticulitis than males (0.17% females vs 0.08% males; p < 0.001). Age-adjusted incidence of death was higher for females compared with males. Female patients were less likely to die within the hospital compared with males (OR = 0.72 (95% CI, 0.69-0.75); p < 0.001). Conversely, female patients were more likely to die either at nursing homes or hospice facilities (OR = 1.64 (95% CI, 1.55-1.73); p < 0.001). In addition, females with an underlying cause of death of diverticulitis were less likely to have a surgical complication as their secondary cause of death (OR = 0.72 (95% CI, 0.66-0.78); p < 0.001) but more likely to have nonsurgical complications related to diverticulitis such as sepsis (OR = 1.04 (95% CI, 1.01-1.05); p < 0.03), nonsurgical GI disorders such as obstruction (OR = 1.16 (95% CI, 1.09-1.24); p < 0.001), or chronic pelvic fistulizing disease (OR = 1.43 (95% CI, 1.23-1.66); p < 0.001)., Limitations: The study was limited by a lack of more specific clinical data., Conclusions: Females have a higher incidence of diverticular disease mortality. Their deaths are more commonly secondary to nonsurgical infections, obstruction, or pelvic fistulae. Female patients represent a particularly vulnerable population that may benefit from more intensive diverticulitis evaluation. See Video Abstract at http://links.lww.com/DCR/B257. ¿EXISTEN VARIACIONES EN LA MORTALIDAD POR ENFERMEDAD DIVERTICULAR POR GÉNERO?: Los datos anteriores revelan que las mujeres representan una mayoría desproporcionada de todos los pacientes diagnosticados con diverticulitis.Este estudio analizó la variación en la mortalidad por enfermedad diverticular por género.Estudio de cohorte retrospectivo a nivel nacional.Los datos se obtuvieron del registro nacional WONDER del Centro de Control de Enfermedades.Se incluyeron todos los ciudadanos de los Estados Unidos que murieron por una causa subyacente de muerte (UCOD por sus siglas en inglés) de diverticulitis del 1 / 1999-12 / 2016.El resultado primario abordado fue la tasa de mortalidad general de la diverticulitis por género. Los resultados secundarios incluyeron variaciones de patrones en la demografía y causas secundarias de muerte.Falta de datos clínicos más específicos.Durante el período de estudio, 55.096 pacientes (0,12%) murieron con un UCOD de diverticulitis de un total de 44.915.066 muertes. En comparación con otras causas, las mujeres tenían una probabilidad desproporcionadamente mayor de morir de diverticulitis que los hombres (0.17% F vs. 0.08% M, p <0.001). La incidencia de muerte ajustada por edad fue mayor para las mujeres que para los hombres. Las pacientes femeninas tenían menos probabilidades de morir en el hospital en comparación con los hombres (OR 0.72, IC 0.69-0.75, p <0.001). Por el contrario, las pacientes femeninas tenían más probabilidades de morir en asilos de ancianos o en centros de cuidados paliativos (OR 1.64, IC 1.55-1.73, p <0.001). Además, las mujeres con una UCOD de diverticulitis tenían menos probabilidades de tener una complicación quirúrgica como causa secundaria de muerte (OR 0.72, CI 0.66-0.78, p <0.001) pero más probabilidades de tener complicaciones no quirúrgicas relacionadas con la diverticulitis, como sepsis (OR 1.04, CI 1.01-1.05, p <0.03), trastornos gastrointestinales no quirúrgicos como obstrucción (OR 1.16, CI 1.09-1.24, p <0.001), o enfermedad fistulizante pélvica crónica (OR 1.43, CI 1.23-1.66, p <0,001).Las mujeres tienen una mayor incidencia de mortalidad por enfermedad diverticular. Sus muertes son más comúnmente secundarias a infecciones no quirúrgicas, obstrucción o fístulas pélvicas. Las pacientes femeninas representan una población particularmente vulnerable que puede beneficiarse de una evaluación más intensiva de diverticulitis. Consulte Video Resumen en http://links.lww.com/DCR/B257.

Background: The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions., Methods: Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively., Results: A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery., Conclusions: Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed., Level of Evidence: Prognostic and Epidemiological Study, Level III.

Background: Postoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality., Methods/design: The NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient's health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled., Discussion: The two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF., Trial Registration: ClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.

Background: The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence., Methods: Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas., Results: Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not., Conclusions: With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question., Material and Methods: A prospective analysis of adult patients enrolled in the IROA., Results: Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence., Conclusion: Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever., Methods: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis., Results: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%)., Conclusions: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Main causes are represented by complicated diverticular disease, colonic and bladder cancer and iatrogenic complications. Diagnosis is often based on patognomonic signs: faecaluria, pneumaturia and recurrent urinary tract infections. Treatment of CVF includes non-surgical and surgical strategy. The non-surgical treatment is reserved to selected patients who are unfit for surgery. Surgery of CVFs is determined by the site of the colonic lesion and patient's comorbidity. However the surgical one-stage approach should be preferred, reserving the multi-stage procedure in patients with a pelvic abscess, or with advanced malignancy, or previous radiation therapy. The sole defunctioning stoma may be an option to improve the quality of life in patients unfit for bowel resection. In open surgery the standard operative management consists in resection and anastomosis of the involved bowel segment and closure of the bladder. Laparoscopic treatment of CVFs is feasible and safe if performed by skilled surgeons. Robotic surgery for CVF treatment is safe and feasible similarly to laparoscopic one and it seems to reduce the conversion rate with respect to laparoscopy. However, further studies are needed to evaluate the advantages of robotic surgery over laparoscopy in the management of CVF. Currently, in Literature it is still debated which is the best surgical approach for CFV treatment due to the lack of RCTs and CCTs, the small sample size and the short follow-up. Further studies with higher quality and larger sample size are necessary to state the gold standard surgical treatment of CVFs.

Background: Despite all advances regarding the surgical treatment of gastric cancer (GC), duodenal stump fistula (DF) continues to negatively affect postoperative outcomes. This study aimed to assess DF regarding its incidence, risk factors, management and impact on overall survival., Methods: We retrospectively analyzed 562 consecutive patients who underwent gastrectomy for GC between 2009 and 2017. Clinicopathological characteristics analysis was performed comparing DF, other surgical fistulas and patients with uneventful postoperative course., Results: DF occurred in 15 (2.7%) cases, and 51 (9%) patients had other surgical fistulas. Tumor located in the lower third of the stomach (p = 0.021) and subtotal gastrectomy (p = 0.002) were associated with occurrence of DF. The overall mortality rate was 40% for DF and 15.7% for others surgical fistulas (p = 0.043). The median time of DF onset was on postoperative day 9 (range 1-75). Conservative approach was performed in 8 patients and surgical intervention in 7 cases. Age (OR 7.41, p = 0.012) and DF (OR 9.06, p=0.020) were found to be independent risk factors for surgical mortality. Furthermore, patients without fistula had better long-term survival outcomes comparing to patients with any type of fistulas (p = 0.006)., Conclusion: DF is related with distal tumors and patients submitted to subtotal gastrectomy. It affects not only the postoperative period with high morbidity and mortality rates, but may also have a negative impact on long-term survival., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF)., Methods: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality., Results: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus , and Klebsiella pneumoniae . Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p  = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group ( p  = 0.016)., Conclusion: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The timing of intestinal failure (IF) surgery has changed. Most specialized centers now recommend postponing reconstructive surgery for enteric fistula and emphasize that abdominal sepsis has to be resolved and the patient's condition improved. Our aim was to study the outcome of postponed surgery, to identify risk factors for recurrence and mortality, and to define more precisely the optimal timing of reconstructive surgery., Methods: PubMed, Embase, and the Cochrane Library were systematically reviewed on the outcomes of reconstructive IF surgery (fistula recurrence, mortality, morbidity, hernia recurrence, total closure, enteral autonomy). If appropriate, meta-analyses were performed. Optimal timing was explored, and risk factors for recurrence and mortality were identified., Results: Fifteen studies were included. The weighted pooled fistula recurrence rate was 19% (95% CI 15-24). Lower recurrence rates were found in studies with a longer median time and/or, at the minimum of the range, a longer time interval to surgery. Overall mortality was 3% (95% CI 2-5). Total fistula closure rates ranged from 80 to 97%. Enteral autonomy after reconstructive surgery, mentioned in four studies, varied between 79 and 100%., Conclusions: Postponed IF surgery for enteric fistula is associated with lower recurrence. Due to the wide range of time to definitive surgery within each study, optimal timing of surgery could not be defined from published data.

Objective: To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period. Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high., Methods: Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998-2013). Data collected included: demographics, mode of admission, pathological grouping and outcome., Results: A total of 286 ECF were identified in 278 patients, mean age 64 years (20-96 years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p = 0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51)., Conclusion: Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.

Background: Aorto-enteric fistulas (AEF) represent a lethal subset of aortic graft infections. The optimal management of AEF remains unclear. We aimed to identify predictors of morbidity and mortality., Study Design: We performed a single-center retrospective review of consecutive AEF repairs. Demographics, comorbidities, and perioperative variables were obtained. Descriptive statistics, chi-square, Kruskall-Wallis, and Cox proportional-hazards modeling were used where appropriate., Results: Between June 1995 and October 2014, 50 patients (30 male; 60%) presented with AEF, with a median age of 70 years (interquartile range [IQR] 61 to 75 years). Median follow-up for the entire cohort was 14 months (IQR 5 to 27 months). Thirty-four (68%) subjects underwent aortic reconstruction with femoral vein; 12 (24%) with extra-anatomic bypass and aortic ligation; 3 (6%) with rifampin-soaked Dacron graft; and 1 (2%) with cryopreserved aortic allograft. The duodenum was the most common location of the enteric defect (n = 40, 80%). Duodenal leak complicated 6 (12%) of the primary enteric repairs, but none of the complex enteric repairs performed with resection and/or bypass. Twenty-three patients (46%) died by 60 days. Advanced age, chronic renal insufficiency, any complications, and gastrointestinal (GI) complications (n = 13, 26%) were all associated with an increase in overall mortality on univariate analysis (p < 0.05). Gastrointestinal complications (hazard ratio [HR] 3.23; 95% CI 1.27 to 8.25; p = 0.015) and advanced age (HR 1.07; 95% CI 1.01 to 1.13; p = 0.01) were the only independent predictors of mortality on multivariable regression models., Conclusions: Over 20 years, approximately 50% of patients with AEF repairs died within 60 days. Gastrointestinal complications increase the risk of mortality more than 3-fold, representing an attractive surgically modifiable risk factor. Future multicenter studies are required to clarify optimal methods of arterial and GI reconstruction in AEF., (Published by Elsevier Inc.)

Aortoenteric fistula (AEF) is one of the most challenging diagnostic and therapeutic entities in vascular surgery. AEF can occur either primarily involving the aorta and the gastrointestinal tract or, more commonly, secondary to previous aortic reconstructive surgery. Traditionally, the treatment of AEF includes graft excision and extra-anatomic bypass surgery or in situ graft replacement. However, recently endovascular repair has emerged as an alternative therapeutic option. In this article, we present published and current evidence for endovascular repair of primary and secondary AEF. When endovascular treatment is applied where appropriate, early outcomes seem to be superior compared to open surgery. This benefit may be lost during long-term follow-up, implying that a staged approach with early conversion to in situ grafting may realize the best patient survival and morbidity. Lifelong administration of antibiotics is associated with a reduction in re-infection. An endovascular approach used as a bridging procedure in unstable patients is recommended, followed by definitive open therapy, if feasible, in patients with good life expectancy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy., (© 2016 International Society for Diseases of the Esophagus.)

Objectives: To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs)., Methods: This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type., Results: Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups)., Conclusions: Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Initial enthusiasm for use of cryopreserved arterial allografts was subsequently tempered by suboptimal long-term outcome. Thrombosis, anastomotic pseudo-aneurysm, allograft disruption, aneurysmal degeneration, recurrent intestinal fistulization, and persistent infection are commonly reported in series with long-term follow-up. The authors reviewed their experience over the past 15 years with the use of cryopreserved arterial allografts as a vascular substitute for vascular prosthetic infection or for primary arterial infection, to investigate allograft-related complications., Material and Methods: A retrospective analysis of prospectively collected data was conducted for 103 cryopreserved arterial allografts inserted in 96 patients between July 2000 and July 2015. There were 78 patients with infected vascular prosthesis (IVP), nine patients with an aorto-enteric fistula (AEF), and nine patients with primary arterial infection (PAI)., Results: The in-hospital mortality was eight out of 78 (9%) IVP patients, three out of nine AEF patients, and zero out of nine PAI patients. Median follow-up was 49 months. Allograft-related re-interventions were necessary in 29% of the patients with IVP and four of the patients with AEF, but none of the patients with PAI. Five-year survival for the IVP, AEF, and PAI patients was 53%, 44%, and 90%, respectively., Conclusion: This series highlights some shortcomings of cryopreserved arterial allografts in the long term, including suboptimal outcome-results and shortage of material. The authors discuss the allograft-related complications and suggest some tricks to minimize their risk., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Massive bleeding in patients with aortoenteric fistula (AEF) may be preceded by minor, intermittent gastrointestinal (GI) blood loss, termed the "herald bleed." The aims of this retrospective study were to: (i) analyze the interval between the herald bleed and onset of major GI hemorrhage and/or diagnosis of AEF and (ii) to evaluate the diagnostic roles of endoscopy and computed tomography imaging., Methods: Analysis of all patients diagnosed with AEF or iliac-enteric fistulas between 1994 and 2013 in a single institution., Results: In 31 of a total of 34 fistula cases, GI bleeding was the presenting symptom. Of these, 17 of 31 presented with herald bleed while 14 of 31 presented with massive GI bleeding. In patients with a herald bleed, median time from first bleeding to diagnosis was 14 (2-137) days. In 5/17 patients, herald bleeding preceded major hemorrhage with a median of 6 (4-92) days before a diagnosis of AEF was made or intervention could be initiated. CT angiography (CTA) showed abnormalities associated with a fistula in 27 (79%) cases, of which in 12 (35%) cases a fistula was actually identified. Esophagogastroduodenoscopy (EGD) demonstrated a fistula in 8 (25%) patients, while 50% of EGDs were completely normal., Conclusions: Any patient with history of aortic surgery and GI bleeding should be considered to have an AEF until proven otherwise. The sensitivity of CTA for detecting AEF is substantially greater than that of EGD. The time interval between herald bleed and subsequent massive hemorrhage associated with AEF is unpredictable but may be as short as 4 days., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR)., Methods: Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR., Results: A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months., Conclusions: Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The open abdomen is a widespread therapeutic resource; however, it is also a source of complications, of which the enteroatmospheric fistulas (EAFs) pose one of the greatest problems. The objective of this study was to describe the implemented strategy for handling enteroatmospheric fistulas, and secondarily, to analyze the differential results based on a change in the conservative local treatment specifically designed for the stated complication., Materials and Methods: From March 2002 to March 2014, patients treated for EAF were retrospectively analyzed. They were divided into 2 groups: Group 1 (G1: 2002 - 2007), treated with an occlusive vacuum device (SIVACO), similar to that used for other enterocutaneous fistulas, and Group 2 (G2: 2008 - 2014), covered in a specific modality for EAF. Results of conservative and surgical treatment were described and then the two groups were statistically compared., Results: Study participants comprised 62 patients. Twelve cases (19.4%) healed with conservative treatment. This was statistically related with a baseline albumin level >3 g/dL, single lesions with no visible mucosa and baseline output <700 mL/d. In G1, the output fall was higher, while G2 required fewer wound dressing changes and enteral nutrition was feasible in a significantly higher number of patients. Forty-seven patients underwent reconstructive surgery. The mortality-associated variables were preoperative hypoalbuminemia and 2 or more anastomoses. Overall mortality was 8% (5 patients). In the multivariate model, only initial output (<700 mL/d) was an independent predictor for spontaneous closure, whereas 2 or more anastomoses and hypoalbuminemia were negative independent predictors., Conclusion: Systematic management of enteroatmospheric fistulas, following a rigorous protocol and a two-step specific treatment, resulted in a practical approach and yielded good results in healing and mortality.

Introduction: The manifestation of enterocutaneous fistulas is varied. They can range from controlled secretion via the abdominal wall to septic disease. The disease is categorised into low-, moderate- and high-output fistulas. Often the only option is surgical treatment. Occasionally, there is spontaneous healing under conservative treatment. The aim of this study was to work out a possible subgroup of patients who benefit from conservative treatment. Material und Methods: Ninety-nine patients were treated for enterocutaneous fistulas from 1 January 1995 to 31 December 2005. Seventy patients underwent surgery, 29 patients were treated conservatively. All data was collected prospectively using an admission form and was analysed retrospectively. Conservative treatment consisted of fasting with parenteral nutrition, while fistulas in the surgical group were treated by suture repair or resection. Additive treatments such as vacuum dressings or TNF-α medication for patients with Crohn's disease were not performed., Results: In our study we achieved a total cure rate of 69%, with an average hospital stay of 38 days. Surgical treatment led to significantly better results compared with conservative treatment (83 vs. 34%). Mortality in the surgical group was distinctly, but not significantly reduced at 7%, compared with 14% in the conservative group. The fistulas that healed after conservative treatment were low-output fistulas only., Conclusion: Enterocutaneous fistulas are diseases associated with long hospital stays and, therefore, expensive treatment. Low-output fistulas may heal spontaneously. The best results are achieved by surgical treatment. More recent treatments such as vacuum therapy and TNF-α medication for patients with Crohn's disease are promising approaches. In the future, many of these will have to be combined with surgical treatment., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To identify the possible predictors of early complications after the initial intervention in acute necrotizing pancreatitis., Methods: We collected the medical records of 334 patients with acute necrotizing pancreatitis who received initial intervention in our center. Complications associated with predictors were analyzed., Results: The postoperative mortality rate was 16% (53/334). Up to 31% of patients were successfully treated with percutaneous catheter drainage alone. The rates of intra-abdominal bleeding, colonic fistula, and progressive infection were 15% (50/334), 20% (68/334), and 26% (87/334), respectively. Multivariate analysis indicated that Marshall score upon admission, multiple organ failure, preoperative respiratory infection, and sepsis were the predictors of postoperative progressive infection (P < 0.05). Single organ failure, systemic inflammatory response syndrome upon admission, and C-reactive protein level upon admission were the risk factors of postoperative colonic fistula (P < 0.05). Moreover, preoperative Marshall score, organ failure, sepsis, and preoperative systemic inflammatory response syndrome were the risk factors of postoperative intra-abdominal bleeding (P < 0.05)., Conclusion: Marshall score, organ failures, preoperative respiratory infection, sepsis, preoperative systemic inflammatory response syndrome, and C-reactive protein level upon admission are associated with postoperative complications.

Aim: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip (OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas., Methods: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients (48.8%) presented with severe upper-gastrointestinal (GI) bleeding, 3 (3.6%) patients with lower-GI bleeding, 7 patients (8.3%) underwent perforation closure, 18 patients (21.4%) had prevention of secondary perforation, 12 patients (14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) and 3 patients (3.6%) had an intervention on a chronic fistula., Results: In 78/84 patients (92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients (89.28%). The overall mortality in the study patients was 11/84 (13.1%) and was seen in patients with life-threatening upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41 (85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases (57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18 (100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen (2%)., Conclusion: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Background: Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome., Methods: We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics., Results: The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time., Conclusions: Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.

Aim: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer., Methods: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed., Results: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d., Conclusion: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.

Purpose: The aim was to evaluate the predictive value of serial serum sodium determination for mortality in enteric fistula (EF) patients complicated with sepsis., Methods: Between January 1(st), 2012 to January 13(th), 2013, we performed a prospective observational study enrolling 162 patients. Patients were divided into survivors group (n = 119) and nonsurvivors group (n = 43) according to 28-day outcomes. Laboratory variables on day 0, day 3, and day 7 after admission were recorded. [Na(+)]0 was defined as serum [Na(+)] value on admission. [Na(+)]3 was defined as serum [Na(+)] value on day 3. Δ [Na(+)]3 was defined as changes from [Na(+)]3 to [Na(+)]0. The definition applied to other parameters. The results were validated in an independent cohort of 116 patients., Results: ROC analysis showed that [Na(+)]7>147.5 mmol/L and ΔNa7>5.2 mmol/L were reliable predictors ([Na(+)]7: 81.2% sensitivity, 87.7% specificity, (area under the curve(AUC):0.872, p < .001; Δ[Na(+)]7: 81.3% sensitivity, 83.6% specificity, AUC:0.836, p < .001) for mortality. The combination form ([Na(+)]7>147.5 mmol/L+ Δ[Na]7>5.2 mmol/L+ ΔPCT7<5.3 ng/ml) had greatest predictive value (AUC:0.899, p < .001). Their predictive values were confirmed in the validation cohort., Conclusions: Serum sodium was a reliable predictor for mortality in abdominal septic patients, which should be paid close attention in the critical care.

Aim: Para-anastomotic aneurysms, leakage due to anastomotic failure, aorto- and arterioenteric fistulas are some of the serious complications after aorto-iliac surgical reconstructions. Treatment of these complications is challenging and is either done by open surgery or by endovascular therapy. The mortality and morbidity is higher compared to the initial treatment. We present twelve patients with these complications which were treated by an endovascular approach., Methods: From January 2008 through January 2013 our radiological records were searched for cases with post surgical vascular complications treated with endovascular intervention. These comprised of anastomotic pseudoaneurysm, suture leakage and arterial enteric fistulas. Patients with limb occlusions were not included in this study., Results: Twelve patients with graft related complications treated with endovascular intervention were recorded. There were four women and eight men with a mean age 75,3 years (range 48-80). At the time of diagnosis, 9 patients (75%) had symptoms and three (25%) was incidentally discovered. Six patients had leakage due to suture failure. All infective parameters were within normal limits. Four patients presented with anastomotic pseudoaneurysms without leak, of which three had proximal anastomotic pseudoaneurysms and one had distal iliac anastomotic pseudoaneurysm. Implanted stent graft were Endurant (Medtronic) bifurcated endoprostheses in three patients and Excluder (Gore) prosthesis in a two cases. Tubular Medtronic endoprosthesis was implanted in one case and in two cases aortic cuff was used. Fluency periphery stent grafts were used in four cases. There was a 100% technical success. Intervention related early mortality was 8%. One patient with pseudoaneurysm died 28 months after endovascular treatment because of cardiac infarct and one patient with previously infected arterio-enteric fistula and advanced malignancy died 7 months after second endovascular treatment. Overall the mortality was 25%. There was no procedure related morbidity or complications during hospitalization and follow-up of mean 12, 3 months (range 1-36 months) in the other 9 patients. There were no complications like endoleaks or limb occlusions., Conclusion: Endovascular treatment of vascular graft related postsurgical complications is a valuable therapeutic option followed by lower mortality and morbidity rates compared with re-operation. Short and midterm follow-up is without severe complications and if it occurs most of them can be treated by endovascular means again.

Background: Various conditions lead to the development of colonic fistulas. Contemporary surgical data is scarce and it is unclear whether advances in surgical care have impacted outcome. The aim of the present study was to review the short- and long-term outcome of patients treated surgically for colonic fistula over an 8-year period at a tertiary institution., Methods: A retrospective review was performed, focusing on the type of operative interventions, short- and long-term complications, length of hospital stay, readmission rate, mortality rate, and fistula recurrence., Results: Forty-five patients were treated for colonic fistula. The most common etiology was diverticulitis (74%). Fistula type was colovesical (58%), colocutaneous (18%) and colovaginal (15%). Laparoscopic resection was performed in 42% of cases. An intraoperative complication occurred in 4%. A primary anastomosis was performed in 96% of patients and 10 (23%) had a temporary stoma. Median length of hospital stay was 6 days. Postoperative complications were common (47%) and wound infection was noted in 20% of patients. The readmission rate was 29% and the 90-day mortality was 4%. All patients healed their fistula with no recurrences noted during a median follow-up of 37 months., Conclusions: Surgical intervention healed the majority of patients with colonic fistula. However postoperative complications were common and readmission occurred in one-third of the cases. Laparoscopic excision was feasible in nearly half of the patients.

Background: An aortoenteric fistula is an abnormal communication between the aorta and the bowel lumen. It is usually caused by previous aortic surgery and involves the duodenum (ADF) in most cases. The treatment of this high-mortality condition is based on the correction of enteric and vascular defects. However, enteric repair indications and impact are unknown., Objective: We sought to characterize the surgical procedures available for duodenal repair in ADF and estimate their impact in mortality., Methods: A literature search was conducted, between the years 1951-2010. Cases (791 from 614 references) were individually registered and analyzed to demography, enteric location, type and cause of fistula, type of surgical procedure, mortality, and cause of death. Risk factors to outcome were estimated by univariate and multivariate analysis., Results: The enteric procedure was described in 331 cases: duodenorrhaphy (with or without omentum interposition; with or without enterostomy) in 266 cases, duodenal resection/reconstruction in 54 cases, antibiotic or abdominal drainage alone in 4 cases, and nothing was done in 7 cases. Vascular treatment was described in 515 cases: extra-anatomic bypass in 207 cases, in situ graft in 197 cases, direct closure of the aortic defect in 52 cases, endovascular procedures in 32 cases, and others arterial reconstructions in 27 cases. Univariate analysis revealed that mortality caused by ADF is directly associated with primary ADF type, direct closure of the aortic defect, and is inversely associated with recent publications, omentum interposition, use of an in situ graft, and endovascular prosthesis. Multivariate analysis revealed that omentum interposition and the use of an in situ graft were independent factors to the outcome, and that omentum use was the strongest factor related to survival. The most common cause of death was ADF recurrence (41.8%), which was significantly high (P = 0.036) in the patients who underwent simple duodenorrhaphy., Conclusions: The literature supports the use of omentum interposition and suggests that duodenal derivation is preferable to the simple closure of fistula. Delayed or avoided enteric repair after endovascular treatment emerged as an option, but needs additional supporting research., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Persistent inflammation-immunosuppression catabolism syndrome (PICS) is a newly proposed concept that has replaced late multiple-organ failure and prolongs surgical intensive care unit (ICU) duration. Enterocutaneous fistula (ECF) is one of the most challenging complications in the practice of surgery. However, no studies have been performed connecting PICS with ECF., Methods: A total of 130 ECF patients admitted to ICU between January 2011 and January 2012 were retrospectively studied. Two residents of our center collected data (including demographics, clinical manifestation, underlying disease, Acute Physiology and Chronic Health Evaluation II score, therapeutic schedules, laboratory test reports, and clinical outcomes) from electronic medical records for each patient. We further investigated the prevalence of PICS in patients with ECF and compared the demographics, disease severity, complications, clinical outcomes, and prognosis between PICS and non-PICS patients., Results: The overall incidence of PICS in ECF was 43.1%. The mortality rates of non-PICS and PICS groups were 7.1% and 28.3%, respectively. Compared with the non-PICS group, the PICS group showed an increased age, a higher fistula output, but a lower body mass index and albumin level. However, the Acute Physiology and Chronic Health Evaluation II score did not differ between the two groups. During the whole treatment course, the PICS group showed a higher risk of developing pneumonia and catheter-related blood stream infection compared with the non-PICS group. Although the overall incidences of sepsis were similarly, the risk of developing sepsis after the first 7 days of admission was significantly higher in the PICS group (67.9% vs. 38.6%, p = 0.002). Moreover, the PICS group experienced longer stays in the ICU, higher hospital charges, and higher probabilities of mechanical ventilation compared with the non-PICS group., Conclusion: PICS is a common manifestation of patients with ECF. ECF provides an excellent clinical model to study PICS owing to the pathophysiologic characteristics of ECF itself., Level of Evidence: Prognostic study, level III.

Introduction: Gallstone ileus is a mechanical bowel obstruction caused by a biliary calculus originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate., Methods: A retrospective review of the Nationwide Inpatient Sample from 2004 to 2009 was performed for gallstone ileus cases treated surgically by enterotomy with stone extraction alone (ES), enterotomy and cholecystectomy with fistula closure (EF), bowel resection alone (BR), and bowel resection with fistula closure (BF). Patient demographics, hospital factors, comorbidities, and postoperative outcomes were reported. Multivariate analysis was performed comparing mortality, morbidity, length of stay, and total cost for the different procedure types., Results: Of the estimated 3,452,536 cases of mechanical bowel obstruction from 2004 to 2009, 3268 (0.095%) were due to gallstone ileus-an incidence lower than previously reported. The majority of patients were elderly women (>70%). ES was the most commonly performed procedure (62% of patients) followed by EF (19% of cases). In 19%, a bowel resection was required. The most common complication was acute renal failure (30.44% of cases). In-hospital mortality was 6.67%. On multivariate analysis, EF and BR were independently associated with higher mortality than ES [(odds ratio [OR] = 2.86; confidence interval [CI]: 1.16-7.07) and (OR = 2.96; CI: 1.26-6.96) respectively]. BR was also associated with a higher complication rate, OR = 1.98 (CI: 1.13-3.46)., Conclusions: Gallstone ileus is a rare surgical disease affecting mainly the elderly female population. Mortality rates appear to be lower than previously reported in the literature. Enterotomy with stone extraction alone appears to be associated with better outcomes than more invasive techniques.

Introduction: Enterocutaneous fistula (ECF) is a distressful problem to the surgeon, patients and relatives. In spite of the medical advances over the years, mortality still remains between 10 and 20%. The objective of this study was to evaluate the management of ECF and its outcome as seen in University of Port Harcourt Teaching Hospital (UPTH)., Patients and Methods: This is a retrospective study of all cases of ECF seen and managed in UPTH over an 8 year period. Relevant data were retrieved and analyzed., Results: Thirty six folders were retrieved and analyzed within the study period. There were 24 females and 12 males. Their ages ranged from 13 to 68 years with the peak age incidence at 51 60 years. The commonest cause was post operative (91.7%) and appendicectomy was the commonest surgical procedure (36.4%). Twenty patients were managed conservatively and 15(75%) had spontaneous closure of their fistulae. Conservative management was satisfactory in most of our patients either alone (93.8%) or conservative followed by surgery (100%) with 1(6.2%) mortality while surgical management had 6 (37.5%) mortalities and 4 (25%) recurrences that were subsequently and successfully managed conservatively. Mortality rate was 19.4%., Conclusion: The commonest cause of ECF is post operative. The modality of treatment should be conservative while surgery be reserved for selected cases.

Aim: To study factors that influenced healing and survival after attempted closure of enterocutaneous fistula., Material and Methods: Retrospective analysis of prospective data concerning 101 patients operated on 132 instances for 110 enterocutaneous fistulae at two hospitals., Results: In all, 96 (87%) of the 110 fistulae healed and 92 (91%) patients survived. A total of 9 patients with unhealed fistula died. Multivariate analysis revealed jaundice as an independent factor for both death and failed closure and operation without anastomosis as an independent positive factor for healing. Failure rate was lower after an operation with stoma without anastomosis (6 of 43, 14%) than after an operation with anastomosis (30 of 89, 34%) p = 0.0213. Of the 36 instances with unhealed fistula, 13 (36%) could be ascribed to inadvertent bowel lesions at the reconstructive operation. In addition, univariate analysis revealed that patients with previous multiple laparotomies or with multiple operations for enterocutaneous fistula healed less likely and had higher mortality. A low serum albumin, high white blood cell count, high C-reactive protein concentration, high fistula output, total parenteral nutrition, and operation for recurrent fistula were associated with death together with long operation time and operative bleeding, both indicators of surgical complexity. Over time, staged surgery avoiding anastomosis increased from 27% to 57%. Mortality decreased from 12% to 6%, and healing increased from 73% to 94%., Conclusions: Chronic inflammation, malnutrition, and liver failure causing an impaired healing capacity are important reasons for failure. Staged operation without primary anastomosis may allow the patient to reverse this condition and improve outcome. The high surgical complexity is a negative factor that requires careful planning of the operation.

Introduction: According to literature, colonic resection with a primary anastomosis and no defunctioning ileostomy is a safe treatment for colovesical or colovaginal fistula of diverticular origin. This study investigates the outcome of surgery for this patient group in a regional hospital., Methods: Patients were obtained from a prospective database in the period 2004-2011. Several variables were investigated for their relation with surgical outcome., Results: A colovesical (n = 35) or colovaginal (n = 5) fistula was diagnosed in 18 men and 22 women. The mean age was 69 years (range, 45-90). A rectosigmoid resection with primary anastomosis was performed in 32 patients. Fourteen patients received a defunctioning ileostomy. Eight patients were treated with a Hartmann procedure. Overall 30-day treatment-related morbidity and mortality was 48 and 8 %, respectively. Major morbidity, because of anastomotic leakage, was mainly observed in the primary anastomosis group without a defunctioning ileostomy. Morbidity and mortality were associated with high body mass index, diabetes, use of corticosteroids, and American Society of Anesthesiologists classification, though not significantly., Conclusions: One should be liberal in the use of a defunctioning ileostomy in case of a primary anastomosis after colonic resection for a diverticular fistula, in order to prevent high morbidity rates due to anastomotic leakage.

Aim: Multi-organ resection for colorectal malignancy is a topic of interest nowadays as it raises the issue of benefits versus increased morbidity. This study aims to identify factors that may influence the development of postoperative complications and death following multivisceral resection., Methods: The study included 107 patients hospitalized in the Surgical Clinic III of Cluj-Napoca, who underwent multivisceral resections for colorectal cancer pathology. This is a retrospective study covering the period between 2006 and 2010. This study compares the morbidity and mortality following multi-organ resections for locally advanced colorectal cancer, with results in patients with uncomplicated colorectal resections. The study also highlights the impact that certain factors have on the development of postoperative complications., Results: This study shows a higher incidence of death and postoperative complications in the case of multiorgan resections. The differences were found to be statistically significant as follows: postoperative complications: 26% after multiorgan resection and 14% after uncomplicated resection respectively (p = 0.001); postoperative death: 11% after multi-organ resection and 3% after uncomplicated resection respectively (p < 0.001). The factors that have influenced in a negative way the postoperative evolution of the patients were: diabetes, personal history of malignant disease, associated heart disease, major abdominal surgery prior enrolling, the number of resected organs and increased intraoperative blood loss (over 500 ml)., Conclusion: In cases of locally advanced colorectal neoplasm, multiorgan resection should become the standard indication, as it offers patients their only chance of survival, comparable to that obtained in less advanced stages of the disease. This indication is underlined by the high resecability rate (R0) accomplished in our service. Preoperative compensation of the associated pathologies, the surgery performed by experienced teams, as well as providing an adequate intensive care are required to reduce the postoperative risks.

Background: Enterocutaneous fistulas are abnormal connections between the skin and gastrointestinal tract that most commonly occur after surgery. Somatostatin analogues have been used in their treatment. The objective of the present study was to determine if somatostatin analogues shorten the time to closure of postoperative enterocutaneous fistulas compared to placebo., Methods: We searched Medline, EMBase, the Cochrane Central Register of Controlled Trials, as well as reference lists of textbooks and relevant articles for randomized controlled trials (RCT) comparing somatostatin analogues to control in the treatment of postoperative enterocutaneous fistulas. We systematically assessed trials for eligibility and validity, and extracted data in duplicate. We pooled data across studies using a random effects model., Results: Our initial search yielded 720 studies, of which eight RCT ultimately met eligibility criteria and were included in this review. Somatostatin analogues significantly decreased the time to closure of fistulas compared to placebo {weighted mean difference (WMD)--6.37 days [95% confidence interval (CI) -8.33, -4.42]}. The duration of hospital stay was also significantly decreased with somatostatin analogue treatment [WMD--4.53 days (95% CI -8.29, -0.77)]. No difference in mortality was identified with somatostatin treatment [RR 0.87 (95% CI 0.49-1.55)]., Conclusions: Somatostatin analogues appear to decrease the duration of enterocutaneous fistulas and duration of hospital stay, but no mortality benefit was identified. The quality of evidence for outcomes in this review ranged from low to moderate. Future large, blinded, RCT would be useful in improving the confidence in the treatment effects identified in this systematic review and meta-analysis.

Objective: To determine the risk of developing complicated colonic diverticular disease (CCDD) with prior episodes of acute diverticulitis and determine the mortality of the spectrum of CCDD., Design: Population-based cohort study., Setting: Computerised records from the General Practice Research Database linked to Hospital Episode Statistics data from the UK., Participants: Patients and controls registered in the General Practice Research Database from 1990 to 2007., Main Outcome Measures: Mortality was calculated and Cox regression modelling used to provide adjusted HRs and 95% CI. Logistic regression was used to model the effect of prior acute diverticulitis on the development of complications., Results: 2950 patients (1872 (63.5%) female) had a diagnosis of CCDD (8739 controls). A total of 1042 (35.3%) patients died compared with 2062 (23.6%) controls. Most excess deaths occurred in the first year after the complication. Patients with a perforation/abscess had a 4.5-fold increase in 1-year mortality (HR 4.55, 95% CI 3.74 to 5.52) compared with the general population, whereas those with a fistula or stricture had a 2.5-fold increase in mortality (fistula HR 2.60, 95% CI 1.47 to 4.62; stricture HR 2.41, 95% CI 1.86 to 3.11). Although most patients (2133 (72.3%)) had suffered no prior episodes of acute diverticulitis, increasing episodes of acute diverticulitis were associated with an increased risk of developing a fistula (two or more prior episodes, OR 1.54 95%, CI 1.08 to 2.19), but there was no clear relationship with stricture or perforation/abscess., Conclusions: Although most patients have experienced no prior episodes of acute diverticulitis, fistula formation is preceded by bouts of inflammation. Excess 1-year mortality across the spectrum of CCDD compared with the general population is substantial.

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.

Background: The open abdomen (OA) is a severe disease pattern accompanied by high morbidity and mortality. It is either result of a surgical dis-ease or approach. The aim of this review article is to provide a systematic overview on the options of a temporary closure of the abdominal wall including early and late consequences in the treatment of an open abdomen based on the current medical literature., Methods: Topic-related, selective, PubMed-based literature search of the last decade including historically relevant references combined with own clinical experiences., Results: The initial course is marked by problems in intensive care. The most frequent causes of -death are ventilatory problems, acute renal fail-ure, persisting infections and sepsis as well as multiorgan failure. Intensive care duration ranges from 13 to 65 days. Perioperative mortality is account-ed for 10-52 %. Specific complications can be seen in surviving patients such as enteroatmospheric fistula (1.3-41 %), ventral hernia (32-100 %), intraabdominal abscess formation (2.1-21 %), intestinal adhesions and digestion disturbances, neurological und psychological problems (approximately 20 %) as well as heterotopic ossification (17-25 %)., Discussion: Application of a temporary abdominal closure aims to avoid those complications. Furthermore, time and effort for care and treatment are recommended to be reduced as patients comfort should be improved, simultaneously. Primary fascial closure is of utmost importance to reach this goal. Procedures with highest fascial closure rate (Wittmann patch, STAR, 75-93 %; dynamic retention sutures, 61-91 %; V.A.C., 69-84 %) have lowest mortality., Conclusion: Type and severity of the various early and late consequences in the treatment of an open abdomen are substantially determined by the complication-inducing causes and the basic disease as well as by the options of an efficient, even in some cases temporary closure of the abdominal wall., (© Georg Thieme Verlag KG Stuttgart ˙ New York.)

Objective: We reviewed the perioperative and long-term outcomes after the surgical management of secondary aortoenteric fistulas., Method: Over a 20-year period (1989-2009), 48 patients (33 men and 15 women; mean age, 64 years) were treated for secondary aortoenteric fistulas (SAEF). Most of the patients presented with symptoms of gastrointestinal bleeding (42 cases), or of serious septicaemia and general septic conditions (19 cases). Twenty-eight patients (58.3%) required an emergency procedure and were admitted with an unstable hemodynamic status. Repairs were accomplished by graft removal and an axillobifemoral bypass (n = 11), in situ reconstruction with a silver-impregnated prosthetic replacement (n = 21), a Dacron graft replacement (n = 7), a cryopreserved homograft replacement (n = 8) or an in situ deep vein replacement (n = 2)., Results: Early perioperative (<30 day) mortality was 45.8%. There was a significant difference in the mortality rates between patients who had an emergency procedure (59.2%) and patients who underwent urgent (38.0%) operations (p < 0.04). The average follow-up period was 48.6 ± 16 months. There were eight late deaths; three of which were related to the SAEF treatment. The cumulative mortality rate was 34% at 3 years. The in situ silver graft replacement group cumulative survival rate was 72% at 3 years. No significant difference was observed in mortality on the complete or partial graft removal. Six late graft failures occurred; four of them resulted in amputation and three of them were associated with a recurrent infection. Freedom from amputation was 76.5% at both 3 and 5 years. Late infections occurred in six patients. Freedom from recurrent infection was 80.8% and 81.4% at 3 years in the whole study group and in the in situ silver graft group, respectively. The infect free rate at 3 years was the same compared the complete or partial graft removal, Conclusion: The long-term outcomes associated with aortoenteric fistula repair might be favourable when silver-impregnated grafts were used as an in situ strategy. The eradication of infection is possible in mid-term follow-up with partial graft replacement, which associated with a lesser operative load.

Background: Abdominal vacuum therapy has simplified the treatment of a laparostoma. But is that all that it can achieve? The role of abdominal vacuum therapy concerning the development of small bowel fistulas is still under discussion. Treatment of the bowel surface seems to be crucial for the prevention of fistulas. As military surgeons, we need a simple, standardised regimen, leading to reproducible good results and low complication rates. The question is: are we able to eliminate small bowel fistula during open abdominal treatment?, Patients and Methods: We analysed 28  consecutive patients with open abdominal treatment in the period of 2004 to 2009. From June 2006 on, we implemented an algorithm, using the KCI V.A.C.® Abdominal Dressing (Kinetic Concepts Inc., San Antonio, Texas, USA) and a vicryl mesh between the non-adherent layer and the foam to prevent fascial retraction. The patients treated -after the installation of the new algorithm were compared to a group treated from 2004 to May 2006 before its installation. Fistula rates, mortality, the fascial closure rate, the number of abdominal dressing changes and the duration of open -abdominal treatment were evaluated., Results: After implementation of our new algorithm, the fistula rate decreased from 45 % to 0 %. The mortality during open abdominal treatment decreased from 45 % to 6 %. In addition, the duration of open abdominal treatment was reduced as well as the number of dressing changes. The primary fascial closure rate was 87 %., Conclusion: We implemented a regimen, which is suitable for our mission in Afghanistan, as well as for medical evacuation and for the treatment of patients in our hospitals in Germany. It ensures a standardised treatment of the open abdominal cavity with an ideal protecting treatment of the bowel surface. Our algorithm utilises the advantages of the laparostoma while minimising the complications. The development of a small bowel fistula was eliminated in the evaluated patient group and mortality was clearly reduced., (© Georg Thieme Verlag KG Stuttgart ˙ New York.)

Introduction: Postoperative peritonitis arising in the upper abdomen requiring reoperative surgery has a mortality rate of up to 50%. One therapeutic modality for these patients is the use of the Hélisonde(®) drain, designed by Levy, the Levy Helical Drain (LHD), but it has not seen widespread use. In this paper, we describe our experience in managing supramesocolic peritonitis with this drain at the University Surgical Center at Amiens and we analyze our results., Patients and Methods: Between 2005 and 2010, we cared for 190 patients with supramesocolic peritonitis in our unit. Of these, 22 patients with gastric or duodenal fistula underwent transorificial intubation with the LHD. There were 12 men and 10 women with a mean age of 66 years. At surgery, the helical drain was screwed into the fistular orifice, two more flat drains were left adjacent to the fistula, and a jejunal feeding tube was placed. The mean interval between the initial surgery and the drainage procedure was 16.1 ± 14 days., Results: The mean APACHE II score was 20 (10-28). The Mannheim score averaged 28 (19-34). The LHD was completely removed at a mean interval of 35.5 ± 11 days. Six patients (27%) died postoperatively. Postoperative complications included intraperitoneal abscess (n = 3), pneumonia (n=1), and evisceration (n = 2). Two patients required reoperation. The average hospital stay was 70.7 days. Four patients had a persistent chronic fistula., Conclusion: The LHD is a useful technical device in the treatment of supramesocolic peritonitis. Its management requires close oversight., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)