Aorto-esophageal fistula: the multi-disciplinary team approach to management.

Aorto-esophageal fistula is often a terminal event in many patients. The commonest causes are thoracic aortic aneurysm and esophageal malignancy. To achieve a good outcome in this condition, a MDT approach is required that combines the expertize of vascular surgeons, radiologists, and emergency physicians.

The use of an ex vivo contrast study at the time of surgery to confirm the site of a perforated jejunal diverticulum.

A 63-year-old patient was diagnosed with acute jejunal diverticulitis and possible perforation. The patient was taken to the operating room for an exploratory laparotomy where a suspected segment of small bowel was resected. However, the surgical team was unsure whether the resected segment was the definite location of the perforation. A novel technique; using intraoperative contrast enhanced ex vivo x-ray photographs aided the surgical team in finding the exact location of the perforation and thus allowing the operating team to confidently and safely proceed with closure of the abdomen.

Acute pancreatitis with pancreatic abscess secondary to sealed jejunal diverticular perforation.

Although most cases of acute pancreatitis are attributed to gallstones or alcohol, many remain idiopathic. The authors describe a case of acute pancreatitis in a 75-year-old gentleman who presented with acute epigastric pain, fevers and shortness of breath. Serum amylase was 2164. CT showed free mesenteric air, and a partly cystic/partly gas-containing mass in the uncinate lobe of the pancreas. Gastrograffin meal revealed duodenal and jejunal diverticular disease, but no contrast leak. Further CT analysis pinpointed fine tracts of air leading from a jejunal diverticulum up toward the pancreas, suggesting causation by a sealed jejunal diverticular perforation. He responded well to intravenous antibiotics and conservative management. Although small bowel diverticular disease is linked to chronic pancreatitis, evidence for association with acute pancreatitis is scarce. The authors believe this is the first reported case of jejunal diverticular disease causing acute pancreatitis, and it highlights micro-perforation as a potential disease mechanism.