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Biomedical Reports Sep 2023Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive...
Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.
PubMed: 37614988
DOI: 10.3892/br.2023.1643 -
Journal of Gastrointestinal Surgery :... Dec 2021Gastro- or duodenojejunostomy leaks after pancreatoduodenectomy is rare. This study aims to analyze the incidence, management, and outcome of gastro- or... (Review)
Review
BACKGROUND AND METHODS
Gastro- or duodenojejunostomy leaks after pancreatoduodenectomy is rare. This study aims to analyze the incidence, management, and outcome of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy based on a single center experience from 2004 to 2020 with a narrative literature review.
RESULTS
Of a total of 1494 pancreatoduodenectomies, eight patients with gastrojejunostomy (n=1) or duodenojejunostomy (n=7) leak were identified from the institutional pancreatic database. All leaks were treated operatively. In two patients dismantling of the duodenojejunostomy, distal gastrectomy, and closure of the pyloric and jejunal side, a percutaneous endoscopic gastrostomy and a feeding jejunostomy ultimately had to be performed after an unsuccessful attempt of gastrojejunostomy and suture of the duodenojejunostomy, respectively. The literature search revealed three more studies specifically addressing this complication after pancreatoduodenectomy (36 patients of a total of 4739 pancreatoduodenectomies). Based on an analysis of the current study and the literature review, the overall incidence of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy was 0.71 % (44/6233 pancreatoduodenectomies). The occurrence of a gastro- or duodenojejunostomy leak was associated with a concomitant postoperative pancreatic fistula in 50 % of the cases, an increased length of hospital stay, and a mortality rate of 15.9 %. Surgical treatment was performed in 84 % of the cases.
CONCLUSION
Gastro- or duodenojejunostomy leak is a rare complication after pancreatoduodenectomy. Prompt diagnosis and early repair is important. In most cases, a surgical intervention is necessary for a good outcome. Under salvage conditions, a bailout strategy may be to temporarily dismantle the gastro- or duodenojejunal anastomosis.
Topics: Anastomotic Leak; Gastric Bypass; Gastroenterostomy; Humans; Pancreatic Fistula; Pancreaticoduodenectomy; Stomach; Treatment Outcome
PubMed: 34131862
DOI: 10.1007/s11605-021-05058-2 -
Diseases of the Esophagus : Official... Mar 2022The role of surgery in treatment of locally advanced cervical esophageal cancer (CEC) remains debated. In the European and American treatment guidelines, definitive...
Oncological results and morbidity following intended curative resection and free jejunal graft reconstruction of cervical esophageal cancer: a retrospective Danish consecutive cohort study.
BACKGROUND
The role of surgery in treatment of locally advanced cervical esophageal cancer (CEC) remains debated. In the European and American treatment guidelines, definitive chemoradiotherapy (dCRT) is preferred over surgery, while in the Danish guidelines, the two treatment modalities are equally recommended. Surgical treatment of CEC is centralized at our center in Denmark. We present our outcomes following neoadjuvant chemoradiotherapy (nCRT) when possible and resection as first-line therapy for CEC and compare with recent published dCRT results.
METHOD
We retrospectively reviewed the medical charts of patients treated for cervical esophageal cancer at Aarhus University Hospital from 2001-2018 with nCRT when possible and pharyngolaryngectomy followed by reconstruction with a free jejunal graft.
RESULTS
Forty consecutive patients were included. About, 45% received nCRT. The median survival was 21 months. The overall, disease-specific and disease-free 5-year survival was 43.6%, 53.2%, and 47.4%, respectively. The rate of microscopically radical resection was 85%. The recurrence rate was 47% and 81% of recurrences were locoregional. The in-hospital and 30-day mortality rate was 0%. Major complications occurred in 27.9%. Anastomotic leakage, graft failure, fistulas and strictures occurred in 10%, 7.5%, 30%, and 30%, respectively.
CONCLUSION
Our treatment offers equal oncological results compared to the best internationally published results for dCRT for CEC. Results vary considerably between dCRT studies. Morbidity appears more pronounced following surgery. Future studies are warranted to investigate the Danish national outcomes following dCRT as first-line treatment for curable locally advanced CEC.
Topics: Chemoradiotherapy; Cohort Studies; Denmark; Esophageal Neoplasms; Humans; Morbidity; Retrospective Studies
PubMed: 34286828
DOI: 10.1093/dote/doab048 -
Head & Neck Jun 2024It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal...
BACKGROUND
It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects.
METHODS
All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications.
RESULTS
In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007).
CONCLUSIONS
The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.
Topics: Humans; Male; Free Tissue Flaps; Female; Jejunum; Middle Aged; Plastic Surgery Procedures; Aged; Hypopharyngeal Neoplasms; Postoperative Complications; Cohort Studies; Retrospective Studies; Hypopharynx; Adult; Fascia; Treatment Outcome
PubMed: 38294120
DOI: 10.1002/hed.27667 -
Head & Neck Oct 2018In pharyngoesophageal reconstruction, we transferred a long jejunum flap containing multiple pedicles to achieve a 100% flap survival rate, and used the redundant...
BACKGROUND
In pharyngoesophageal reconstruction, we transferred a long jejunum flap containing multiple pedicles to achieve a 100% flap survival rate, and used the redundant mesentery to cover important tissues and fill in the dead space to reduce common postoperative complications, such as surgical site infections and fistula formation.
METHODS
A total of 243 jejunal flap transfers with multiple vascular anastomoses were reviewed to examine flap survival and rates of early postoperative complications, such as surgical site infections and fistula formation, perioperative mortality, and donor site morbidity.
RESULTS
All 243 jejunal flaps survived without any partial necrosis. The surgical site infections occurred in 15 cases (6.2%) and fistula formation in 9 cases (3.7%). The perioperative mortality rate was 0.4%. There were 7 cases (2.9%) with donor site morbidity.
CONCLUSION
Although our procedure requires extra operating time for additional vessel anastomoses, it could be performed safely and reliably with a high success rate.
Topics: Adult; Aged; Aged, 80 and over; Cutaneous Fistula; Esophageal Neoplasms; Esophagectomy; Female; Free Tissue Flaps; Graft Survival; Humans; Jejunum; Male; Middle Aged; Pharyngeal Neoplasms; Pharyngectomy; Postoperative Complications; Retrospective Studies; Surgical Wound Infection
PubMed: 29756364
DOI: 10.1002/hed.25313 -
Microsurgery Jul 2015The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral... (Comparative Study)
Comparative Study
An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction.
BACKGROUND
The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral thigh (ALT) flap, and the jejunum flap. This study was to objectively compare three different flaps for pharyngeal reconstruction during the past 10 years. Stricture and fistula were assessed using esophagogram and esophagoscopy.
METHODS
Forty-five patients with pharyngeal reconstructions had esophagram and esophagoscopy done postoperatively to assess for strictures and fistulas. These patients were divided into three groups based on pharyngeal reconstruction by ALT, RFF, and jejunal flaps. From the results of the esophagogram and esophagoscope, the presence of a fistula or stricture was compared and analyzed.
RESULTS
There was only one ALT flap failure. The rate of fistula was 33%, 50%, and 30% in the ALT, RFF, and jejunal flap group respectively. The fistula rate revealed no significant difference between ALT, RFF, jejunal flap groups (P = 0.63). The rate of stricture was 38.1%, 57.1%, and 0% in the ALT, RFA, jejunal flap groups respectively. The stricture rate in jejunal flap group revealed significant decrease (P = 0.0093).
CONCLUSION
Jejunal flap has a significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps.
Topics: Adult; Aged; Esophageal Fistula; Esophageal Stenosis; Esophagus; Female; Forearm; Free Tissue Flaps; Humans; Jejunum; Laryngectomy; Male; Middle Aged; Pharyngectomy; Pharynx; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies; Thigh
PubMed: 25430852
DOI: 10.1002/micr.22359 -
Obesity Surgery May 2018Proximal gastric leak is one of the most common complications after laparoscopic sleeve gastrectomy (LSG). Endoscopy is the gold standard treatment for acute staple-line...
INTRODUCTION
Proximal gastric leak is one of the most common complications after laparoscopic sleeve gastrectomy (LSG). Endoscopy is the gold standard treatment for acute staple-line leaks. Surgery is the most effective treatment modality in case of chronic fistula.
MATERIAL AND METHODS
A 55-year- old man presented an acute leak after LSG. The leak was treated with metal stent deployment with temporary closure. After 6 months, he presented leak recurrence with general sepsis, perigastric-infected collection, and gastro-jejunal fistula.
RESULTS
Endoscopic internal drainage (EID) was performed; however, due to fistula persistence, a surgical procedure was proposed. The patient refused revisional surgery; therefore, endoscopic salvage procedure was decided. A fully covered metal stent was deployed in order to bypass the perigastric collection creating an endoscopic gastro-jejunal anastomosis.
CONCLUSION
Revisional surgery is the gold standard treatment for chronic fistula after SG. Endoscopic treatment with SEMS deployment may be a sound option in selected cases especially after failure of other endoscopic techniques or refusal of revisional surgery.
Topics: Anastomotic Leak; Chronic Disease; Drainage; Endoscopy; Gastrectomy; Gastric Fistula; Gastroenterostomy; Humans; Intestinal Fistula; Jejunum; Male; Middle Aged; Obesity, Morbid; Stents; Stomach; Surgical Stapling; Treatment Outcome
PubMed: 29524185
DOI: 10.1007/s11695-018-3193-0 -
European Archives of... Nov 2020Large pharyngocutaneous fistulas or pharyngostomes are difficult complications to solve, which generate high morbidity and mortality, a poor quality of life and an... (Review)
Review
PURPOSE
Large pharyngocutaneous fistulas or pharyngostomes are difficult complications to solve, which generate high morbidity and mortality, a poor quality of life and an increase in health costs. Its management must be comprehensive according to general, local and regional factors. We review our experience in treating these pharyngostomes with free flaps.
METHODS
Retrospective study analyzing the results of the reconstruction of 50 patients using free flaps during the period 1991-2019. We exclude patients who required free-flap reconstruction due to primary tumor or those who resolved in other ways. The different types of reconstruction were classified into three types.
RESULTS
The 86% (43) were men, and the mean age was 57 years (25-76). In 48% (24/50) the flaps performed were anterolateral thigh (ALT), in 24% (12/50) forearm, in 22% (11/50) parascapular, in 4% (2/50) jejunum and in 2% (1/50) ulnar. A salivary by-pass was placed in 74% (37/50) of the cases. Four cases (8%) presented flap necrosis and two patients died due to treatment. In 86% (43/50) there was some type of complication and 34% (17/50) required surgical revision. 94% (45/48) were able to reintroduce oral feeding.
CONCLUSION
According to our experience, we proposed a regardless size classification: type 1 when only a mucous closure (pharynx) are required (6%), type 2 exclusively skin for cutaneous coverage (10%) and mixed type 3 (mucous and skin) (84%). The treatment of large pharyngostomes with free flaps, despite its complexity, is in our experience the best option for its management.
Topics: Female; Free Tissue Flaps; Head and Neck Neoplasms; Humans; Male; Middle Aged; Quality of Life; Plastic Surgery Procedures; Retrospective Studies; Thigh; Treatment Outcome
PubMed: 32377856
DOI: 10.1007/s00405-020-06010-x -
Diseases of the Esophagus : Official... Sep 2017Aortoesophageal fistula is a critical and life-threatening disease. The cardiovascular strategy for graft replacement has been widely discussed. However, the surgical...
Aortoesophageal fistula is a critical and life-threatening disease. The cardiovascular strategy for graft replacement has been widely discussed. However, the surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula has rarely been discussed. The objective of this study is to establish a surgical strategy and procedure of esophageal resection and reconstruction for aortoesophageal fistula. Eleven patients with aortoesophageal fistula who underwent aortic graft replacement and esophagectomy between 2008 and 2015 at Kobe University Hospital were enrolled in this study. Patient characteristics, operative methods, and clinical outcomes were obtained by retrospective chart review. All 11 patients underwent graft replacement, esophagectomy, and omental wrapping. Ten esophagectomies were simultaneously accomplished in the same operative field as aortic graft replacement. Seven patients underwent subtotal esophagectomy from a left thoracotomy, and three patients underwent upper hemiesophagectomy from a median sternotomy. The other patient underwent staged esophagectomy from a right thoracotomy. Seven of 11 patients (63.6%) successfully underwent staged esophageal reconstruction. Pedicled jejunal transfer with supercharge and superdrainage were performed in six patients, and ileocecal reconstruction was performed in one patient. Median survival time in the patients with esophageal reconstruction was 21 months while that in the patients without esophageal reconstruction was 10 months. Six of 7 patients (85.7%) who underwent esophageal reconstructions were alive. Our surgical strategy for aortoesophageal fistula, which includes simultaneous graft replacement and esophagectomy in the same operative field and staged reconstruction by pedicled jejunal transfer to ensure omental wrapping, is feasible and promising.
Topics: Adult; Aged; Aged, 80 and over; Aortic Diseases; Cecum; Esophageal Fistula; Esophagectomy; Female; Humans; Ileum; Jejunum; Male; Middle Aged; Omentum; Plastic Surgery Procedures; Retrospective Studies; Sternotomy; Survival Rate; Thoracotomy; Vascular Fistula; Vascular Grafting; Vascular Surgical Procedures
PubMed: 28859368
DOI: 10.1093/dote/dox077 -
GE Portuguese Journal of... Jul 2019Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and...
BACKGROUND AND AIMS
Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas.
METHODS
This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence.
RESULTS
The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4-145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1-10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15-72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50-205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence.
CONCLUSIONS
A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically.
KEY MESSAGES
Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.
PubMed: 31328138
DOI: 10.1159/000492637