Recurrent aortoduodenal fistula.

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

[Perineo-ano-rectal injuries: clinical experience]. / I traunmi perineo-ano-rettali: esperienza clinica.

Traumatic lesions involving the rectum, perineum and anus are infrequent but difficult to treat, requiring experience with trauma and colo-proctological surgery. The aim of the treatment is to repair the lesions and to minimise the early complications which are the main cause of failure and of late complications and disability. The most complicated lesions present problems concerning either the surgical strategy or the surgical timing, both of which are essential for a successful outcome. The Authors analyse their recent clinical experience with 7 patients with complex traumatic lesions involving the rectum, perineum and anus, excluding those of gynaecological/obstetric origin and those not involving the sphincter. They evaluated the clinical history, causes and types of lesions, as well as treatment, complications and outcomes. Five of the lesions were caused by impalement, one by an explosion and one by a motorboat propeller blade. Six of the patients (85.7%) were treated by direct primary repair and one (14.3%) by secondary repair after a previous colostomy. All 7 patients achieved complete recovery of the lesions. Only two cases (28.6%) of early complications and one case (14.3%) of persistent minimal sphincter dysfunction occurred. On the basis of these good results, the clinical experience and the literature, the Authors suggest that these perineo-ano-rectal lesions, though often complex, may often be cured by early surgery, confining colostomy only to particular cases. In addition to experience with trauma and the timing of colo-proctological surgery, a knowledge of all the available surgical options is mandatory to achieve the best results.

Laparoscopic resection of a large GIST of the stomach: is it preferable in elderly patients? A case report.

Gastrointestinal stromal tumour (GIST) of the stomach is extremely rare in the elderly. Surgical resection of the stomach by partial gastrectomy or wedge resection is the standard treatment. Today the resection can also be performed laparoscopically, especially in the case of small tumours as well as for larger GIST though there are unclearly defined oncological limits. The authors report the successful treatment of a large 7.5 cm GIST of the stomach by laparoscopic wedge resection in a 78-year-old patient. The GIST was almost entirely located intraperitoneally between the stomach and the spleen and could be radically resected with a minimal touch technique. The patient recovered promptly and manifested no recurrence at a 2-year follow-up. The authors focus on the main factors supporting the indication for laparoscopic resection of large gastric GIST, especially in the elderly. The surgical risk/benefit ratios of the different approaches, the surgeon's skills in laparoscopically respecting the rules of oncological surgery, and informed consent of the patient in relation to the limited scientific evidence concerning the main risk factors of recurrence are all important considerations.

Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device.

Colonic perforation during endoscopic diagnostic or therapeutic procedures, represents an uncommon occurrence even if, together with haemorrhage, it is still the most common complication of colonoscopy, with an incidence ranging between 0.1% and 2% of all colonoscopic procedures. The ideal treatment in these cases remains elusive as the endoscopist and the surgeon have to make a choice case by case, depending on many factors such as how promptly the rupture is identified, the condition of the patient, the degree of contamination and the evidence of peritoneal irritation. Surgical interventions both laparotomic and laparoscopic, and other medical non-operative solutions are described in the literature. Only three cases have been reported in the literature in which the endoscopic apposition of endoclips was used to repair a colonic perforation during colonoscopy. Ours is the first case that the perforation itself was caused by the improper functioning of a therapeutic device.