Endovascular Therapy for Tracheoinnominate Artery Fistula: A Temporizing Measure

Tracheoinnominate artery fistula remains an uncommon, highly fatal complication of tracheostomy and peritracheal pathology. Endovascular placement of a covered stent can provide control of the fistula. Depending on the conditions of the trachea and peritracheal tissues, the fistula may heal or the stent may become infected and/or further erode into the trachea. We report on a case of a patient with a tracheoinnominate artery fistula related to peritracheal tumor invasion, radiation therapy, and tracheostomy. The fistula was initially excluded with a covered stent, but a few weeks later hemoptysis recurred secondary to deep tracheal erosion by the covered stent.     

Weichgewebesarkome an Unterarm und Hand

Radical tumor resection (R0) is the main therapeutic goal in the treatment of sarcomas of the forearm and hand. Plastic reconstructive procedures play a key role in limb salvage by coverage of complex defects. Sophisticated reconstructive techniques are required with the forearm and hand. Twenty patients with soft-tissue sarcomas of the hand and forearm were treated in our department between January 1995 and January 2005. Eleven were male and nine were female. The average age was 48 years. The most common tumor was myxoid fibrous histiocytoma, followed by synovial cell sarcoma. Six patients received free microvascular transplantations to cover their defects. Mesh graft or primary closure was possible in three cases; one patient received a local flap and one a pedicled flap. In nine cases preserving the limb was not possible. Ten patients received radiation and four got chemotherapy (two with neoadjuvant chemotherapy). In 18 cases histologic R0 resection was possible, in two cases R1 resection. Two patients suffered from tumor reccurrence after R0 resection. The average follow-up-time was 42 months. These results show the necessity of plastic surgical reconstruction of the forearm and hand as an integral component of modern sarcoma therapy. Multidisciplinary cooperation is mandatory for adequate treatment.     

Anaplastic (undifferentiated) thyroid carcinoma (ATC)

BACKGROUND: Old age, reduced general condition and far advanced tumor stage associated with poor prognosis induced the belief that, apart from verifying the diagnosis of anaplastic thyroid carcinoma (ATC) by biopsy, no additional surgery would be justified. However, in some cases, an ultraradical approach was recommended in order to improve the quality of life and survival. METHODS: These are the results of a retrospective analysis involving 120 patients subjected to restricted radical surgery (excising as much as possible of the tumor and local metastases, foregoing ultraradical removal of vital organs such as esophagus, larynx and trachea). RESULTS: Irrespective of the surgical approach used, 6+/-2% of the patients were alive after 5 years (median survival time: 3.1 months). Patients without tumor residues (R0-resections; extending to soft tissue only; Kaplan-Meier estimate - cumulative survival 15+/-5%) had a significantly better prognosis than patients with tumor residues (R1/R2-resections; no patient survived 5 years; P<0.001). Tumor morphology (spindle cells, giant cells, mixed cells) or differentiated parts of the tumor as well as lymph-node involvement had no statistically significant impact on the prognosis. CONCLUSIONS: In ATC, the objective should be to remove as much of the carcinoma as possible (in the ideal case, a thyroidectomy); if lymph nodes are affected, neck dissection should be the goal, if possible (restricted radical approach, improving quality of life). Ultraradical surgery to include segmental resection of larynx, trachea or esophagus do not seem to be indicated, as prolonged survival is questionable and quality of life is certainly diminished.     

Indication of the use of pedicled omentum in chest surgery

The omentum has been known to have a remarkable power of repair through neovascularization and scavenger function. Nine patients have been treated with the pedicled omentum. In 4 patients the omentum was used to obtain healing in the presence of infection. Bronchial fistulas were successfully closed in 3 patients with lung cancer and bronchial anastomotic leakage was repaired in one patient who received carinal reconstruction. In 5 patients, all of them had simultaneous resection of thoracic esophagus, the preventive use of omentum made a good result in two tracheoplasties, one pneumonectomy and one terminal tracheostomy. But one patient with esophago-tracheofistula after irradiation to esophageal cancer developed tracheal necrosis postoperatively. The omentum is useful in the case of postoperative empyema with bronchial fistula especially in patient with lung cancer. In the case of tracheobronchial resection after radiation therapy or with resection of thoracic esophagus, the suture line should be wrapped by omentum to prevent anastomotic leakage.     

Zervikoviszerale Resektionen beim organüberschreitenden Schilddrüsenkarzinom

About 6% of patients with thyroid cancer present with life-threatening tumor invasion of the trachea and/or esophagus. The extent of resection depends on tumor diagnosis and stage (indication only in differentiated and perhaps medullary thyroid cancer without extrapulmonary metastases), extent of aerodigestive invasion, and general health state of the patient. After complete tumor resection, 5-year and 10-year survival rates of 40–75% can be achieved. Incomplete tumor resection however has a negative effect on prognosis. Tangential tumor resection (shaving) is indicated if no transmural invasion of trachea/esophagus has occurred. Tracheal resection can be subdivided into six standard procedures – types 1 and 2: laryngotracheal or tracheal window resection; types 3 and 4: circular resection with primary reconstruction infraglottic or tracheal; and types 5 and 6: laryngectomy and cervical evisceration.     

Repair of Inflammatory Tracheoesophageal Fistula

Benign acquired tracheoesophageal fistula is uncommon. Erosion of the membranous wall of the trachea and the anterior esophageal wall by the high-pressure cuff on a tracheostomy tube, often against the anvil of a nasogastric tube, may produce such fistulas. Techniques for closure have included patching the tracheal defect with muscle and, often, multiple staged procedures, planned or unplanned.Since any cuff lesion severe enough to cause a fistula necessarily damages the trachea circumferentially at the same level, definitive correction must include circumferential tracheal resection as well as closure of the fistula. Five patients with tracheoesophageal fistula due to cuff perforation had repair by such a single-stage procedure. Through an anterior approach the involved trachea was resected, primary anastomosis was done, and the esophagus was closed in layers. In 3 of these 5 patients muscle was interposed for added security. One patient had undergone a prior attempt at repair elsewhere. One required a second resection of trachea for subsequent stomal stenosis. Repair in 2 additional patients with fistulas of complex origin related to direct trauma, sepsis, and foreign body involved adaptation of the basic technique to the special problem; 1 of these procedures was necessarily staged. Results in all 7 patients have been good.     

Successful surgical treatment of aortogastric fistula after an esophagectomy and subsequent endovascular graft placement: Report of a case

An aortogastric fistula is a rare but fatal complication after an esophagectomy and intrathoracic esophagogastric anastomosis. A 54-year-old man underwent an esophageal resection due to carcinoma in his lower esophagus. The alimentary tract continuity was restored by intrathoracic esophagogastric anastomosis. Forty-six days later, he suffered a massive hematemesis due to an aortogastric fistula which had formed at the esophagogastric suture line. The fistula was surgically obliterated twice, but each operation was followed by pseudoaneurysm formation. The patient was finally successfully treated with an endovascular stent graft placement. This is the first report of a patient surviving after developing this complication.     

Malignant esophagorespiratory fistula: management options and survival.

The development of a malignant esophagorespiratory fistula is a devastating complication. Data comparing various treatment options in a large group of patients are sparse. To assess the results of therapy, we reviewed our experience in 207 patients with malignant esophagorespiratory fistula. Records of 207 patients admitted to our institution with malignant esophagorespiratory fistula from 1926 to 1988 were reviewed and results of management analyzed. Age ranged from 21 to 90 years (median, 59 years); the male/female ratio was 3:1. Primary tumor site was esophagus in 161 (77%), lung in 33 (16%), trachea in 5 (2%), metastatic nodes in 4 (2%), larynx in 3 (1%), and thyroid in 1. Symptoms and signs of malignant esophagorespiratory fistula included cough in 116 (56%), aspiration in 77 (37%), fever in 52 (25%), dysphagia in 39 (19%), pneumonia in 11 (5%), hemoptysis in 10 (5%), and chest pain in 10 (5%). Respiratory location of fistula included trachea in 110 (53%), left main bronchus in 46 (22%), right bronchus in 33 (16%), lung parenchyma in 13 (6%), and multiple sites in 5 (2%). The percentage of patients alive at 3, 6, and 12 months by treatment modality was 13%, 4%, and 1% for supportive care (n = 104); 17%, 3%, and 0% for esophageal exclusion (n = 29); 21%, 14%, and 0% for esophageal intubation (n = 14); 30%, 15%, and 5% for radiation therapy (n = 20); and 46%, 20%, and 7% for esophageal bypass, respectively. Patients treated with radiation therapy and esophageal bypass had a significantly prolonged survival compared with patients treated with the other modalities.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae.

OBJECTIVE: To evaluate surgical options of treatment in combined tracheo-esophageal injuries and their sequelae and elaborate new ones. METHODS: The overlooked diagnosis of combined tracheo-esophageal injury would lead to severe stenosis of the esophagus and trachea with tracheo-esophageal fistula. This condition requires a complex surgical intervention to be performed with non-standard procedure in every single case. Forty patients with combined tracheo-esophageal injuries were treated in our institution. Nine patients were urgently operated while others were transferred to us from other hospitals with chronic sequelae of the initial trauma. RESULTS: In the majority of cases the cause of the injury was penetrating (17 patients) or iatrogenic (13 patients) trauma followed by blunt neck and chest trauma (six patients) and caustic burn (four patients). Three patients had total cut off of the esophagus and trachea, which were repaired with end-to-end anastomoses. Another six patients had tracheal and esophageal disruptions within one-half to three-quarters of circumference. In these cases both the trachea and esophagus were mobilized within wall laceration and sutured by interrupted Vicryl 4/0. One of them died due to pre-existing disease. Thirty-one patients with sequelae of the trauma were also operated on. In spite of the complexity and extent of the tracheo-esophageal stenosis and fistula the surgical treatment was aimed to one-stage reconstruction of both the esophagus and trachea. For this purpose we performed an originally developed surgical intervention, which was to be modified in accordance with patients diagnosis. The main point of the procedure is that after mobilization of the trachea and esophagus we resect an involved part of the trachea, but preserve a pedicled flap fashioned from the tracheal membrane. Then we remove the mucosa from the flap, resect an involved esophageal wall, repair esophageal mucosa and replace the defect of the muscular layer of the esophagus with the tracheal flap. Then a tracheal or laryngo-tracheal anastomosis is established. There were no postoperative mortality and complications among patients with the sequelae. CONCLUSION: Combined tracheo-esophageal injury requires the precise preoperative diagnosis and well organized plan of surgical treatment, which may be unique for every single patient. The main purpose of the treatment is to restore the continuity of both the esophagus and trachea in one-stage intervention.     

Surgical treatment of esophageal carcinoma complicated by fistulas.

OBJECTIVES: The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas. METHODS: Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients. RESULTS: The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies. CONCLUSIONS: The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.     

Complications in bronchoplastic surgery of benign and malignant lung neoplasms]

Out of 1629 patients who were hospitalised 1963 to 1973 for diagnosis and treatment of bronchogenic tumors, 731 underwent resection. 20 patients could be operated upon by lobectomy or bilobectomy and bronchial resection (Sleeve-resection). In two other patients the tumor could be resected through a bronchotomy. Postoperative complications were frequent (n = 6) on patients with malignant tumors (n= 15). We saw 3 times a bronchopleural fistula (2 patients had to be reoperated, 1 death), once a fatal empyema, once a fatal pneumonia of the contralateral side and once a bronchial stenosis of 50% of the lumen. On the patients with a benign tumor (n = 7) we saw in one patient a bronchopleural fistula and in another endobronchialgranulomas due to non resorbable suture material. Methods to prevent or cure these complications are presented consisting in the use of absorbable suture material and long lasting intrathoracic suction.     

围手术期伊马替尼治疗在可切除原发中高危胃肠间质瘤患者中的应用

目的探讨围手术期应用伊马替尼对可切除原发中高危胃肠间质瘤（GIST）患者凡切除率及预后的影响。方法回顾性分析2001年12月至2012年2月在北京大学肿瘤医院诊断为可切除中高危GIST、并进行手术切除加围手术期伊马替尼治疗的48例患者的临床资料．根据伊马替尼治疗方式分为新辅助治疗组（术前加术后伊马替尼治疗,15例）及辅助治疗组（术后伊马替尼治疗,33例）。比较两组患者R。切除率、术后并发症发生率、无病生存率及总体生存率。结果新辅助治疗组的肿瘤最大径（11．2cm）和平均径（9．1em）均明显大于辅助治疗组（7．7cm和6．2cm,P．0．005和P=0．014）。新辅助治疗组术前治疗疾病控制率为93．3％（14／15）。新辅助治疗组和辅助治疗组患者R0切除率分别为86．7％（13／15）和84．8％（28／33）（P=1．000）。手术并发症发生率分别为13．3％（2／15）和9．1％（3／33）（P=-0．642）。两组患者术后3年无病生存率分别为55％和41％,5年总体生存率分别为83％和75％,差异均无统计学意义（P=0．935,P=0．766）。结论对于可切除的原发中高危GIST,围手术期应用伊马替尼的治疗模式具有潜在优势。     

1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes

Background

Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal neoplasms; however, most ESD articles report small series, with short-term outcomes performed by multiple operators on single organ. We assessed short- and long-term treatment outcomes following ESD for early neoplasms throughout the gastrointestinal tract.

Methods

We performed a longitudinal cohort study in single tertiary care referral center. A total of 1,635 early gastrointestinal neoplasms (stomach 1,136; esophagus 138; colorectum 361) were treated by ESD by single operator. Outcomes were complication rates, en bloc R0 resection rates, and long-term overall and disease-specific survival rates at 3 and 5 years for both guideline and expanded criteria for ESD.

Results

En bloc R0 resection rates were: stomach: 97.1 %; esophagus: 95.7 %; colorectum: 98.3 %. Postoperative bleeding and perforation rates respectively were: stomach: 3.6 and 1.8 %; esophagus: 0 and 0 %; colorectum: 1.7 and 1.9 %. Intra criteria resection rates were: stomach: 84.9 %; esophagus: 81.2 %; colorectum: 88.6 %. Three-year survival rates for lesions meeting Japanese ESD guideline/expanded criteria were for all organ-combined: 93.4/92.7 %. Five-year rates were: stomach: 88.1/84.6 %; esophagus: 81.6/57.3 %; colorectum: 94.3/100 %. Median follow-up period was 53.4 (range, 0.07–98.6) months. Follow-up rate was 94 % (1,020/1,085). There was no recurrence or disease-related death.

Conclusions

In this large series by single operator, ESD was associated with high curative resection rates and low complication rates across the gastrointestinal tract. Disease-specific and overall long-term prognosis for patients with lesions within intra criteria after curative resection appeared to be excellent.     

Prognostic significance of tumor ploidy and histomorphological parameters in adenocarcinoma of Barrett's esophagus.

BACKGROUND: Despite recent advances in surgical and multidisciplinary treatment, the prognosis for patients with adenocarcinoma of Barrett's esophagus remains poor. The low prognostic accuracy of even surgical pathologic TNM staging suggests that additional parameters are necessary in determining the prognosis. METHOD: In a retrospective analysis of 50 patients who underwent transhiatal or transthoracic esophageal resection due to adenocarcinoma of Barrett's esophagus, a quantitative DNA analysis using image cytometry was performed in addition to the TNM classification and usual morphological criteria. At the time of DNA analysis the histomorphological parameters and survival time were not known. RESULTS: The main prognostic parameter was the curativity (R classification) of the operation. Considering only patients after R0 resection, a multivariate analysis identified the DNA ploidy, the depth of tumor infiltration and distant metastases of prognostically independent factors. Furthermore, within pT2 and pT3 tumors, which account for 80% of all the tumors, DNA ploidy allows an additional prognostic differentiation which is not possible with pT stage alone. CONCLUSION: Patients with a diploid or tetraploid tumor without distant metastasis and a tumor stage pT1-pT3 should have curative (R0) resection. In case of an aneuploid DNA content or a pT4 tumor resection alone shows no advantage as compared to palliative nonoperative procedures.     

Bronchopleural fistula after pulmonary resection of lung cancer

From 1977 to 1988, 390 cases of lung cancer were resected in our hospital. In 12 patients (3.1%) a postoperative bronchopleural fistula developed. This complication occurred more commonly after right pulmonary resection than left and most common after right pneumonectomy. Moreover, that had occurred following right pneumonectomy was most fatal. After right middle and lower lobectomy, this complication occurred at the same rate as after pneumonectomy and also caused a fatal result. On the other hand, after the resection of single lobe, the rate of the occurrence of a bronchopleural fistula was lower. And, even if it had developed, the fistula sometimes could be healed by a conservative treatment only. In one of our cases the fistula was successfully treated by intra-bronchial gluing through a bronchofiberscope.     

Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome

OBJECTIVE: To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ). SUMMARY BACKGROUND DATA: While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial. METHODS: Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy). RESULTS: From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R1 resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found >3.8 cm to be the ex vivo proximal margin length (approximately 5 cm in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >or=15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with >3.8 cm margin was limited to patients with T2 or greater tumors and 相似文献   

Surgical complications and treatment during resection for malignancy of the high bile duct

From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.     

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE: To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction. SUMMARY BACKGROUND DATA: Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial. METHODS: In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors. RESULTS: There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients. CONCLUSION: The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.     

A case of tracheoesophageal fistula cured by surgical therapy after blunt trauma received 38 years ago]

We experienced a case of tracheoesophageal fistula successfully cured by surgical therapy after blunt trauma received 38 years ago. A 71-year-old man was injured blunt trauma at right chest by traffic accident in 1960, and was treated for pneumothorax and ribs fracture. In April, 1998, the patient came to the hospital for hemoptysis. Tracheoesophageal fistula at membranous wall 3 cm upper from the carina was diagnosed and operation was performed. Severe adhesion at 3 cm upper from carina was thought to be fistula. Incision was made at lateral esophageal wall and the fistula was confirmed at the esophageal anterior wall and the esophagus was cut in a circle around the fistula. Trachea was closed 1 layer sutures using esophageal all layers and esophagus was closed with 2 layer sutures. A pedicled 4th intercostal muscle was interposed between the tracheal and esophageal suture lines. Prevention of tracheal stenosis was possible without resection of fistula and closure of trachea using esophageal all layers. This operation was seemed to be effective. This case is supposed to be the longest delay between time of injury and its repair in the world.     

Duodenocaval Fistula: A Late Complication of Retroperitoneal Irradiation and Vena Cava Replacement

Duodenocaval fistula (DCF), an unusual pathology, is associated with a 40% mortality rate in the 36 patients previously reported. Although migrating or ingested foreign bodies, trauma, and peptic ulcer disease are often described etiologies, 11 patients have been described who developed DCF after resection of retroperitoneal tumors, 9 of whom also had postoperative radiotherapy. We report two patients who developed DCF after resection of retroperitoneal tumors followed by radiation therapy. The first patient, a 56-year-old female, presented with upper gastrointestinal hemorrhage requiring transfusion caused by a duodenoprosthetic caval fistula 7 years after successful resection of a retroperitoneal leiomyosarcoma and replacement of the inferior vena cava followed by radiation and chemotherapy. The second patient, a 37-year-old male who had previously undergone resection of a retroperitoneal sarcoma followed by external radiotherapy, developed massive upper and lower gastrointestinal bleeding secondary to a duodenocaval fistula. The etiology, diagnosis, and treatment of DCF are analyzed with an emphasis on DCF following resection and irradiation of retroperitoneal tumors. In most patients, spontaneous DCF have occurred as a late complication of high-dose radiation for carcinoma of the right kidney or retroperitoneal structures. Presented at the Annual Meeting of the Southern California Vascular Surgical Society, Carlsbad, CA, April 11-13, 2003.