Colocutaneous Fistula Research Articles

Operative management of diverticulitis in a tertiary care center

Abstract Background Diverticulitis has become a medically managed disease process; the indications and timing of surgical intervention have evolved. Methods We retrospectively reviewed all patients who underwent surgical intervention due to diverticular disease by the Division of Colon and Rectal Surgery from 2012 to 2014. Results Ninety-eight surgeries were performed. Indications included colovesicular fistula, multiple recurrences of diverticulitis, medically refractory diverticulitis, stricture, abscess, colocutaneous fistula, and colovaginal fistula. Average length of stay was 5.7 ± 5.9 days (range, 1 to 51). Eighteen patients (18%) required an ostomy. Postoperative complications occurred in 18% of patients, including anastomotic leak (3.3%), wound infection (7.1%), acute kidney injury (5.1%), and urinary tract infection (2.0%). Thirty-day readmission rate was 7.2%; unplanned 30-day reoperation rate was 3.1%. There were no deaths. Conclusions The type of patient undergoing surgery for diverticulitis has changed, with selection bias toward chronic, advanced disease due to the proliferation of medical management strategies.

Roturas de malla: una causa poco frecuente de recidiva herniaria

The central mesh rupture is a rare cause of hernia recurrence. We analyze our experience. Material and methodsRetrospective search in our database of surgery of the abdominal wall, from 02/2008 to 10/2014, looking for cases with a diagnosis of «recurrent hernia» or «recurrent ventral hernia». Afterwards, the surgical report is reviewed to identify any mesh breakage. ResultsCase 1 Obese patient with giant ventral hernia. Treatment: retromuscular ventral hernia repair with polypropylene mesh (60g/m2) without closing the anterior sheet. At 32 months hernia recurrence appears with central defect of 3×3cm.Case 2 Patient with giant ventral hernia. Treatment: anterior components separation with onlay polypropylene mesh (48g/m2). At 16 months appears hernia recurrence with central defect 7×5cm.Case 3 Obese patient with 8 previous surgeries of ventral hernia, presenting colocutaneous fistula and ventral hernia. Treatment: retromuscular polypropylene mesh (35g/m2) without closing the anterior sheet. It is reoperated three days after due to septic shock, five zones of mesh rupture were found.Case 4 Obese patient with giant incisional hernia after open abdomen 20 years ago. Treatment: ventral hernia repair with retromuscular polypropylene mesh (28g/m2) without closing the anterior sheet. At 20 days central rupture mesh appears about 5cm in diameter. ConclusionsCentral mesh rupture appears especially in obese patients with large hernias or with multiple previous surgeries on the abdominal wall. In these patients, especially if we cannot close the anterior myofascial layer we should avoid using lightweight meshes.

A Case of Sigmoid Colocutaneous Fistula due to the Mesh Plug Repair for an Inguinal Hernia

A Case of Sigmoid Colocutaneous Fistula due to the Mesh Plug Repair for an Inguinal Hernia

The Over-The-Scope-Clip Device: An Indispensable Tool in Interventional Endoscopy. A Case Series

Introduction: The Over-The-Scope Clip (OTSC) is a novel device designed for tissue approximation. It offers an effective endoscopic approach for fistula closure, luminal perforation, and GI bleeding. We report successful use of this device in a series of patients (Table 1).Table 1: Summary of CasesCases: 1) 53-year-old male with history of (h/o) prior feeding tube, presented with (p/w) a nonhealing gastro-cutaneous fistula that was successfully closed using one OTSC. 2) 64-year-old male with h/o chronic pancreatitis underwent ERCP with stent placement for CBD stricture. He presented 6 weeks later with perforation of the lateral duodenal wall by the stent. The stent was removed and the perforation was successfully closed using one OTSC device. 3) 67-year-old male with h/o cirrhosis p/w a massive GI bleed. Evaluation with EGD and angiogram x2 failed to reveal a source. Push enteroscopy showed a bleeding duodenal varix. Ethanolamine injection and band ligation were ineffective. Deployment of the OTSC resulted in immediate hemostasis. 4) 49-year-old male p/w hematemesis. EGD revealed a 2 cm duodenal bulb ulcer with a >2 mm bleeding vessel. Attempt to cauterize with a heater probe was unsuccessful. Epinephrine was injected and an OTSC was deployed with successful hemostasis. 5) 57-year-old male with h/o a prior PEG tube was referred for a non-healing gastro-cutaneous fistula. Successful fistula closure was achieved with placement of two OTSC devices. 6) 68-year-old male with h/o esophageal cancer s/p remote esophagectomy, p/w a non-healing gastro-pulmonary fistula. Two OTSC devices were placed in contiguity to close the fistula. Post-EGD the tracheal secretions became clear with no further bilious output*. The patient ultimately required surgery. 7) 73-year-old female with h/o cirrhosis underwent endoscopic submucosal dissection of a 4 cm Type 0-IIa gastric adenocarcinoma. A 4 mm focal perforation of the muscle layer was successfully closed using one OTSC. 8) 36-year-old male with a colo-cutaneous fistula was referred for endoscopic closure. The OTSC device successfully closed the fistula. The patient was lost to follow-up. Discussion: The OTSC device is an excellent tool for treating GI tract hemorrhage, small perforations, and post-op fistulae. We describe a case series of patients in which the OTSC device was used for a variety of challenging indications.

Mo1707 The Effect of Pentadecapeptide BPC 157 on Colovesical Fistula Healing

Introduction. A colovesical fistulas present an important clinical problems. They usually occur as a complication of diverticulosis, IBD or malignant process. The pentadecapeptide BPC 157 , in clinical trials for IBD therapy, has already shown the effectiveness in healing colocutaneous fistulas ( J. Pharmacol Sci 2008 ) , gastrocutaneous fistulas ( Dig Dis Sci 2009 ). Therefore we suggest it as a possible therapy of colovesical fistulas. Matherials and methods. Wistar Albino rats were randomly assigned, at 5 cm from anocutanous borderline, with the diameter of 3 mm. The surgical procedure was performed according to rules brought by the Local Ethical Committee. Medication of BPC 157 (10ug/kg, 10ng/kg) was per-orally, in drinkingwater and intraperitoneally, once daily, the first dose immediately after the operation, the last dose at 24 h before sacrifice, at 7, 15, 30 post-operative day, with the biomechanical, functional, macroscopic and microscopic assessment. Results. Biomechanical analysis :we measured pressure of the fistulas rupture for all groups of animals with the system for central venous pressure assesment .In the control group pressures for fistulas rupture were similar for every experimental period : ≤1mL H2O, 1mL±0,3 mL, 2 mL±0,5 ml H2O. In the second group( BPC per-orally in drinking water 10ug/kg and 10ng/kg ) water pressures were 1mL±0,3; 2mL±0,3 and 5mL±0,5 but without fistulas rupture at the and of 30 days experimental period.In the third group( BPC intraperitoneally 10ug/kg and 10ng/kg ) water pressure was increased from 2mL±0,5mL until 5 mL±0,5 at the and of 15 days experimental period. In most animals fistulas were healed at the end of 30 days experimental period. Macroscopic analysis: We measured diameters of fistulas on the colonic and the bladder side.In the control group diameters of fistulas were similar for both sides for all experimental periods : 3mm ±0.5mm on the colon and bladder side,3mm±1mm and 2,5±0,5mm. In the second group fistulas diameter was 3±0,2 mm for both sides ( 7 days ),2mm±0,5 mm for colon and 2,5±0,5 mm for bladder ( 15 days ), 1,5mm±0,5 for colon, 2mm±0,5 mm for bladder side ( 30 days ). In the third group fistulas were reduced : 2,5mm±0,2mm colon, 3mm±0,5 bladder ( 7 days ), 1,5mm±0,5mm colon; 2mm±0,5mm bladder ( 15 days ) and at the end oft he 30 days experimental period in most animals fistulas were healed er reduced diameter at 1mm±0,3mm for both sides.. Conclusion. According to these results the pentadecapeptide BPC 157 could present a new possible pathway in therapy of colovesical fistulas.

Mo1708 Serum-Derived Bovine Immunoglobulin/Protein Isolate Attenuated DSSInduced Colitis in a Defined Floral Model

Introduction. A colovesical fistulas present an important clinical problems. They usually occur as a complication of diverticulosis, IBD or malignant process. The pentadecapeptide BPC 157 , in clinical trials for IBD therapy, has already shown the effectiveness in healing colocutaneous fistulas ( J. Pharmacol Sci 2008 ) , gastrocutaneous fistulas ( Dig Dis Sci 2009 ). Therefore we suggest it as a possible therapy of colovesical fistulas. Matherials and methods. Wistar Albino rats were randomly assigned, at 5 cm from anocutanous borderline, with the diameter of 3 mm. The surgical procedure was performed according to rules brought by the Local Ethical Committee. Medication of BPC 157 (10ug/kg, 10ng/kg) was per-orally, in drinkingwater and intraperitoneally, once daily, the first dose immediately after the operation, the last dose at 24 h before sacrifice, at 7, 15, 30 post-operative day, with the biomechanical, functional, macroscopic and microscopic assessment. Results. Biomechanical analysis :we measured pressure of the fistulas rupture for all groups of animals with the system for central venous pressure assesment .In the control group pressures for fistulas rupture were similar for every experimental period : ≤1mL H2O, 1mL±0,3 mL, 2 mL±0,5 ml H2O. In the second group( BPC per-orally in drinking water 10ug/kg and 10ng/kg ) water pressures were 1mL±0,3; 2mL±0,3 and 5mL±0,5 but without fistulas rupture at the and of 30 days experimental period.In the third group( BPC intraperitoneally 10ug/kg and 10ng/kg ) water pressure was increased from 2mL±0,5mL until 5 mL±0,5 at the and of 15 days experimental period. In most animals fistulas were healed at the end of 30 days experimental period. Macroscopic analysis: We measured diameters of fistulas on the colonic and the bladder side.In the control group diameters of fistulas were similar for both sides for all experimental periods : 3mm ±0.5mm on the colon and bladder side,3mm±1mm and 2,5±0,5mm. In the second group fistulas diameter was 3±0,2 mm for both sides ( 7 days ),2mm±0,5 mm for colon and 2,5±0,5 mm for bladder ( 15 days ), 1,5mm±0,5 for colon, 2mm±0,5 mm for bladder side ( 30 days ). In the third group fistulas were reduced : 2,5mm±0,2mm colon, 3mm±0,5 bladder ( 7 days ), 1,5mm±0,5mm colon; 2mm±0,5mm bladder ( 15 days ) and at the end oft he 30 days experimental period in most animals fistulas were healed er reduced diameter at 1mm±0,3mm for both sides.. Conclusion. According to these results the pentadecapeptide BPC 157 could present a new possible pathway in therapy of colovesical fistulas.

Laparoscopic incisional hernia repair in an ambulatory surgery–extended recovery centre: a review of 259 consecutive cases

The high prevalence of incisional hernias and an average stay of 3-10 days for open procedures have made this pathology both a health problem and an economic issue. A protocol was developed for performing this procedure in an Ambulatory Surgery Center (ASC) with extended recovery. From January 2000 to December 2011, data about all laparoscopic incisional hernia repairs were gathered prospectively. The patients' clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied. A total of 259 patients have been operated for incisional hernia (185) or recurrent hernioplasty (74) in our ASC. Laparoscopic repair was successful in 254 patients (98.07 %). Conversion to open surgery was necessary in five patients (1.93 %). A total of 50 patients (19.69 %) in whom surgery was completed laparoscopically were discharged the same day of surgery, 179 (70.47 %) at 24 h and 25 (9.84 %) required a stay of over 24 h. Postoperative pain was severe in 10 % of patients, moderate in 40 %, and mild in 50 %. Complications, mostly minor and self-limiting, were observed in 25 patients (9.84 %) during hospital stay. Five major complications that occured were: bile peritonitis, an acute peritonitis, due to an inadvertent intestinal perforation, and one intestinal obstruction by partial detachment of the mesh, an intra-abdominal hematoma and a colo-cutaneous fistula. There were no deaths in the series. The mean follow-up of patients was 29.35 months (range 12-129 months). The recurrence rate was 7.03 % (n = 18). Four trocar-site hernias were detected. It is essential to create a protocol with selection criteria that take into account the patient, his entourage, the anesthetic-surgical procedure, and a team dedicated to surgical laparoscopic surgery in an ASC with extended recovery to achieve good results in terms of morbidity and patient safety.

Unusual colocutaneous fistula from intussuscepted paediatric descending colon lymphoma: A very rare pathology

Occurrence of Non-Hodgkin lymphoma in the colon of children is extremely rare. Ignorance, nonavailability of experts and poverty affect management of affected patients. Descending colon and sigmoid colon are very uncommon sites for the involvement of Non-Hodgkin lymphoma and less than 10 cases involving children have been described in world literatures. A 13 year old Kanuri boy presented with 3 years of recurrent abdominal colics and distension and eventual spontaneous enterocutaneous fistula 4 days prior to presentation. Patient was chronically ill looking and grossly wasted. The abdomen was soft with a non tender suprapubic mobile mass measuring 10cm x 14 cm. There was diagnostic dilemma which was not assisted by cheap ultrasonography and patient could not afford the sophisticated CT scan and contrast enema. Exploratory laparotomy revealed colocutaneous fistula and descending colon intussusception with a huge fungating mass as the lead point confirmed histologically to be a Non-Hodgkin's lymphoma. The challenge of lack of fund affected prompt presentation and also limited decision taken on investigation and management of the patient. High index of suspicion and meticulous management of the patient in spite of the challenges led to a good outcome. This probably might be the first reported case of a descending colon lymphoma from this subregion or even in Africa.Keywords: Abdominal masses in children, acute abdomen, enterocutaneous fistula, lymphoma, poverty, ignorance and neglect, scarcity of specialists,

Colocutaneous Fistula as a Result of Chronic Hidradenitis Suppurativa

Introduction: Hidradenitis suppurativa is a chronic inflammatory disease affecting the skin of the axillae, groin, and perineum. It has many known sequelae including psychological stress, lymphedema, scarring, and fistula formation. Case Presentation: TS is a 56-year-old male with a long history of hidradenitis affecting all of the classic areas. He has had excision and skin grafting of his axillae. He has also suffered from extensive involvement of his groin and perineum. Approximately 5 years ago he developed a spontaneous colocutaneous fistula at his umbilicus that eventually required surgical management. Discussion: This is a new and unique presentation of hidradenitis that highlights the extensive morbidity caused by the disease. There are no other reports of hidradenitis affecting intra-abdominal tissues. Hidradenitis can be chronic and indolent, or it can be devastating. While multiple medical therapies exist, surgery is the only true cure.

Laparoscopy-Assisted Percutaneous Endoscopic Gastrostomy in a Patient with Distorted Anatomy

Percutaneous endoscopic gastrostomy (PEG), which was first introduced in 1980, was quickly adopted for use in pediatric and adult patients. However, problems such as severe kyphoscoliosis, interposed organs, or other forms of distorted anatomy, may prevent effective and safe PEG tube placement. In such cases, laparoscopy-assisted PEG (LAPEG) is a useful optional procedure for patients with distorted anatomy and an initial unsuccessful PEG attempt. Furthermore, less invasive measures are preferable over surgical gastrostomy. We present a 27-year-old-male patient with severe kyphoscoliosis and a history of PEG-related complications with a colocutaneous fistula appearing 10 months earlier in whom a feeding tube was successfully placed by LAPEG. There were no LAPEG-related complications in the perioperative period, either technical or metabolic. After discharge, the patient was effectively fed using the bolus method. (Korean J Med 2014;87:318-322)

Treatment of Lower-GI Post-Surgical Fistulas With the Over-the-Scope Clip

Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase morbidity and mortality. Over-the-scope clip (OTSC) application, introduced in clinical practice in 2007, represents an innovative technique to seal the visceral wall for acute and chronic colorectal post-surgical leaks and fistula management. Endoscopic closure of colorectal post-surgical leaks and fistulas with OTSC is a safe technique that accomplishes a high success rate in both acute and chronic cases, including rectovaginal, rectovesical, and colocutaneous fistulas. Overall success rate is higher than 80%, as reported in the literature, in both acute and chronic situations. No OTSC-related complications have been described in the lower gastrointestinal tract so far. This article is part of an expert video encyclopedia.

Clipping for endoscopic perforations: initial success but late complication requiring surgery

This response discusses the article by Kim and colleagues entitled "endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients". Iatrogenic colonoscopic perforation, although uncommon, implies serious management problems for endoscopists and surgeons. Nonoperative treatment currently is recommended under certain conditions, and endoscopic clips can primarily close iatrogenic perforations, helping to avoid surgery. Of the 27 colonoscopic perforation cases presented in the article by Kim and colleagues, 16 were managed by endoscopic clipping closure and 11 by primary surgery. Conservative treatment failed for three patients. Only perforation size obtained statistical significance among the nine variables contrasted between the 11 cases with primary surgery and the 13 cases with successful endoscopic clipping. The results for the three patients whose endoscopic closure failed are not reported. The authors of this letter think it would have been interesting if these three patients had been included in the analysis due to the high importance of discovering factors that can predict failure of endoscopic clipping for perforations. To call attention to possible late complications requiring surgery even when initial conservative management of endoscopic perforation succeeds, the authors of this letter present a case of a colocutaneous (actually, sigmoid-scrotal) fistula in a patient 2weeks after an apparently successful closure of colonoscopic perforation with an "over-the-scope" clip.

Mo1828 Estimating the Relationship Between Diclofenac Drug Dosage and Risk of Gastrointestinal Toxicity: Meta-Regression Based on a Systematic Literature Review

Aim. The pentadecapeptide BPC 157, presently at the end of phase II in clinical trials, has shown its effectiveness in healing different organic lesions including newly formed colocutaneous fistulas (J Pharmacol Sci 2008). In this study we assessed its activity onto the chronic lesions which cannot heal spontaneously. We performed a 16 months long follow up in order to estimate the incidence of possible recurrences.Methods. A colocutaneous fistula has been created according to previously described model (J Pharmacol Sci 2008) at 80 male Wistar Albino rats. After the 4 weeks period without any therapy, the animals whose fistula healed spontaneously were excluded (20/80). Others were randomly assigned into 3 groups of 20 animals: the control group which started to receive the saline (5mL/ kg, i.p.). Two other groups started to receive BPC 157 (10 μg/kg i.p.; 10 ng/kg i.p.) for 4 weeks. The animals were followed up through another 16 months and then sacrificed and assesed (J Pharmacol Sci 2008). Results. Animals treated with BPC 157 started to expose the morphological and functional recovery from the 3rd post treatment day and through 2 weeks of treatment fistulas were closed and animals started to defecate only through anus. In control animals fistula remained and they defecated through it. Animals treated with BPC 157 did not develop recurrences during whole follow up period of 16 months. In addition, during 16 months of follow up at control animals none of the fistulas closed. Conclusions. BPC 157 heals both chronic and newly formed colocutaneous fistulas.

Mo1827 The Pentadecapeptide BPC 157 Heals Chronic Lesions and Prevents Recurrences At the Colocutaneous Fistulas Model in Rats

Aim. The pentadecapeptide BPC 157, presently at the end of phase II in clinical trials, has shown its effectiveness in healing different organic lesions including newly formed colocutaneous fistulas (J Pharmacol Sci 2008). In this study we assessed its activity onto the chronic lesions which cannot heal spontaneously. We performed a 16 months long follow up in order to estimate the incidence of possible recurrences.Methods. A colocutaneous fistula has been created according to previously described model (J Pharmacol Sci 2008) at 80 male Wistar Albino rats. After the 4 weeks period without any therapy, the animals whose fistula healed spontaneously were excluded (20/80). Others were randomly assigned into 3 groups of 20 animals: the control group which started to receive the saline (5mL/ kg, i.p.). Two other groups started to receive BPC 157 (10 μg/kg i.p.; 10 ng/kg i.p.) for 4 weeks. The animals were followed up through another 16 months and then sacrificed and assesed (J Pharmacol Sci 2008). Results. Animals treated with BPC 157 started to expose the morphological and functional recovery from the 3rd post treatment day and through 2 weeks of treatment fistulas were closed and animals started to defecate only through anus. In control animals fistula remained and they defecated through it. Animals treated with BPC 157 did not develop recurrences during whole follow up period of 16 months. In addition, during 16 months of follow up at control animals none of the fistulas closed. Conclusions. BPC 157 heals both chronic and newly formed colocutaneous fistulas.

Surgical Management of the Trauma-Induced Colocutaneous Fistula in a Horse

There are few published reports of equine enterocutaneous fistulae, and they are almost always related to umbilical hernias. Colocutaneous fistula as a result of a penetrating wound has not been reported in horse. In this case report, surgical treatment of a traumatic colocutaneous fistula in an 8-year-old stallion is described. Under inhalation anesthesia, the fistula was removed completely, and the resultant defect on the left ventral colonic wall was closed. The defect of abdominal wall was closed routinely. The horse regained his previous performance, and no surgical complication was observed at 1 year’s follow-up.

Spontaneous enterocutaneous fistula due to colonic malignancy: A rare case report

Spontaneous colocutaneous fistula is a rare clinical entity usually associated with diseases like diverticulitis, crohn's disease and post radiotherapy treated malignancy. This case illustrates the challenges of diagnosis and management of such patients. We present a 60-year old lady who had a lump in left lumbar region which started discharging feculent material ten day prior to presentation. There was history of progressively worsening constipation and weight loss but no rectal bleeding or jaundice. There was a necrotic patch with feculent discharge from left lumbar region with underlying lump that was 5 Χ 4 cm, firm, non-tender and immobile. Following complete evaluation including abdomino-pelvic ultrasound that revealed an ill-defined mass arising from sigmoid colon, a diagnosis of colocutaneous fistula secondary to colonic malignancy was made. After resuscitation, the patient had exploration and Hartmann's procedure. Histopathology confirmed growth as adenocarcinoma and patient was placed on chemotherapy. We present this case to illustrate the challenges of diagnosis and management of such patients.

Left-Sided Sigmoid Diverticulitis Presenting as Right-Sided Thigh Abscess

Acquired diverticular disease of the colon is very common in the North American population. Atypical presentations are usually due to complications and rarely the predominant complaint may be related to an associated fistula. Thigh abscesses due to colocutaneous fistula represent an uncommon complication of sigmoid diverticulitis. In rare cases, a thigh abscess may be the only symptom, but gas in the thigh should raise the index of suspicion for bowel pathology. We report the second known case of a left-sided sigmoid diverticulitis leading to an isolated right thigh abscess with no gastrointestinal symptoms.

Endoscopic Management for Colocutaneous Fistula as a Complication of Percutaneous Endoscopic Gastrostomy

Endoscopic Management for Colocutaneous Fistula as a Complication of Percutaneous Endoscopic Gastrostomy

Spontaneous Colo-Umbilical Fistula Complicating Diverticulitis of the Sigmoid Colon

Colocutaneous fistula caused by diverticulitis is relatively uncommon with colo-umbilical fistulas being even rarer. We herein report a rare case of a spontaneous colo-umbilical fistula due to diverticulitis of the sigmoid colon. The fistula developed from a diverticulum of the sigmoid colon that discharged through the umbilicus after two episodes of acute diverticulitis. The condition was successfully treated by resectional surgery.

Pentadecapeptide BPC 157 and the esophagocutaneous fistula healing therapy

Esophagocutaneous fistulas are a failure of the NO-system, due to NO-synthase blockage by the NOS-blocker L-NAME consequently counteracted by l-arginine and gastric pentadecapeptide BPC 157 (l-arginine <BPC 157), precipitating a therapeutic benefit. Previously, there was an established BPC 157—NO-system interaction. BPC 157 GEPPPGKPADDAGLV, MW 1419 (LD1 not achieved), is a safe and stable anti-ulcer peptide, successful in inflammatory bowel disease trials, counteracting esophagitis, sphincter failure, gastrointestinal and skin ulcers, gastrocutaneous or colocutaneous fistulas. We treated rats with established cervical esophagocutaneous fistulas throughout four days (both open skin and esophageal defects, with significant leakage) with BPC 157 (parenterally and perorally) and L-NAME (blocking NO genesis) and l-arginine (NO-substrate) alone or in combination. RT-PCR investigated eNOS, iNOS, COX-2 mRNA levels in the fistulas. We evidenced a closely inter-related process of unhealed skin, esophageal defects, unhealed fistulas (up regulated eNOS, iNOS and COX2 mRNA levels), usually lethal, particularly NO-system related and therapy dependent. Generally, the course of fistula healing was accelerated either to a greater extent (with BPC 157 (in particular, less eNOS gene expression) completely counteracting L-NAME effects, in L-NAME+BPC 157 and L-NAME+l-arginine+BPC 157 groups), or to a lesser extent (with l-arginine). Conversely, the process was aggravated, rapidly and prominently (with L-NAME). In particular, BPC 157 was effective either given per-orally/intraperitoneally, in μg- and ng-regimens. Shortly, defects started to heal, with less fistula leakage and no mortality at day 4. Failure of pyloric and lower esophageal sphincter pressure was restored, with practically no esophagitis.