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Chirurgia (Bucharest, Romania : 1990) 2018Jejunal diverticulitis is a rare entity with a higher prevalence among patients between 60 and 70 years. Jejunal diverticula are most often considered an incidental... (Review)
Review
Jejunal diverticulitis is a rare entity with a higher prevalence among patients between 60 and 70 years. Jejunal diverticula are most often considered an incidental finding, but, they can have complications such as diverticulitis, perforation, abscess, generalized peritonitis, fistula, obstruction and bleeding.Setting the diagnosis still remains challenging. Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis. A small amount of free air adjacent to the small bowel can be confusing and easily misdiagnosed as small bowel perforation, but, it can actually be found as a result of the inflammation itself without macroperforation or complications.This fact can change the therapeutic strategy to less aggressive, conservative treatments. We present a case of a patient coming to the emergency department with acute abdominal pain, signs of peritonitis, a small amount of extraluminal air, and jejunal diverticulitis without perforation was diagnosed on laparotomy, and a review of the current literature.
Topics: Diagnosis, Differential; Diverticulitis; Humans; Intestinal Perforation; Intestine, Small; Jejunal Diseases; Laparotomy
PubMed: 30183590
DOI: 10.21614/chirurgia.113.4.576 -
Transplantation and Cellular Therapy May 2024Inborn errors of immunity (IEI) are often associated with inflammatory bowel disease (IBD). IEI can be corrected by allogeneic hematopoietic stem cell transplantation...
Inborn errors of immunity (IEI) are often associated with inflammatory bowel disease (IBD). IEI can be corrected by allogeneic hematopoietic stem cell transplantation (HSCT); however, peritransplantation intestinal inflammation may increase the risk of gut graft-versus-host disease (GVHD). Vedolizumab inhibits the homing of lymphocytes to the intestine and may attenuate gut GVHD, yet its role in preventing GVHD in pediatric patients with IEI-associated IBD has not been studied. Here we describe a cohort of pediatric patients with IEI-associated IBD treated with vedolizumab before and during allogeneic HSCT. The study involved a retrospective chart review of pediatric patients with IEI-associated IBD treated with vedolizumab at 6 weeks, 4 weeks, and 1 week before undergoing HSCT. The conditioning regimen consisted of treosulfan, fludarabine, and cyclophosphamide with rabbit antithymocyte globulin, and GVHD prophylaxis included tacrolimus and steroids. Eleven patients (6 females) with a median age of 5 years (range, 0.4 to 14 years) with diverse IEI were included. IBD symptoms were characterized by abdominal pain, loose stools, and blood in stools. Four patients had developed a perianal fistula, and 1 patient had a rectal prolapse. One patient had both a gastrostomy tube and a jejunal tube in situ. Treatment of IBD before HSCT included steroids in 11 patients, anakinra in 2, infliximab in 4, sulfasalazine in 2, mesalazine in 2, and vedolizumab. IBD symptoms were considered controlled in the absence of abdominal pain, loose stools, or blood in stools. Graft sources for HSCT were unrelated donor cord in 5 patients (2 with a 5/8 HLA match, 2 with a 7/8 match, and 1 with a 6/8 match), peripheral blood stem cells in 5 patients (2 haploidentical, 1 with a 9/10 HLA match, and 2 with a 10/10 match), and bone marrow in 1 patient (10/10 matched sibling donor). The median number of vedolizumab infusions was 4 (range, 3 to 12) before HSCT and 1 (range, 1 to 3) after HSCT, and all were reported to be uneventful. All patients had engrafted. Acute GVHD occurred in 4 patients and was limited to grade I skin GVHD only. Chronic GVHD occurred in 1 patient and again was limited to the skin. There was no gut GVHD. Three patients experienced cytomegalovirus viremia, and 2 patients had Epstein-Barr virus viremia. At the time of this report, all patients were alive with no evidence of IBD at a median follow-up of 15 months (range, 3 to 39 months). Administration of vedolizumab pre- and post-HSCT in pediatric patients with IEI-associated IBD is well tolerated and associated with a low rate of gut GVHD. These findings provide a platform for the prospective study and use of vedolizumab for GVHD prophylaxis in pediatric patients with known intestinal inflammation as a pre-HSCT comorbidity.
Topics: Humans; Antibodies, Monoclonal, Humanized; Hematopoietic Stem Cell Transplantation; Female; Child; Male; Adolescent; Child, Preschool; Inflammatory Bowel Diseases; Retrospective Studies; Graft vs Host Disease; Infant; Transplantation, Homologous; Immunomodulation; Transplantation Conditioning
PubMed: 38458476
DOI: 10.1016/j.jtct.2024.03.006 -
International Journal of Surgery Case... 2019Gallstone ileus (GSİ) is a rare complication of cholelithiasis (gallbladderstone), which may lead to obstruction of the small intestine. Particularly, computerized...
INTRODUCTION
Gallstone ileus (GSİ) is a rare complication of cholelithiasis (gallbladderstone), which may lead to obstruction of the small intestine. Particularly, computerized tomographic (CT) imaging method and special findings in these images help diagnosing of gallstone ileus. Treatment of this disease is surgery, surgery involves cholecystectomy + fistula repair + enterolitotomy, but it is controversial to perform cholecystectomy with enterolitotomy and fistula repair in the same session.
PRESENTATION OF CASE
A 75-year-old male patient consulted to the emergency department with the complaints of nausea and vomiting. In the examinations of the patient, bilienteric fistula and gallstones that impacted in the jejunum leading to obstruction were observed in abdominal CT images of the patient who has ileus. The patient was evaluated as gallstone ileus. In addition, on tomographic images significant Forchet sign and Rigler's triad images were viewed which were pathognomonic for gallstone ileus and did not have images as clear as in our case in the literature search. Laparotomy was performed on the patient due to the fact that he was elderly and the duration of anesthesia was wanted to be kept short and stone was extracted by enterolitotomy. Cholecystectomy and fistula repair were left for another session because of gallbladder and surrounding tissues were edematous. The patient was discharged with full recovery on the 6th post-operative day.
DISCUSSION-CONCLUSION
As well as this disease is a rare cause of mechanical bowel obstruction, it is mostly seen in elderly patients. The most sensitive and specific imaging method in diagnosis is contrast-enhanced abdominal computerized tomography. In the tomographic images, especially the Rigler's triad, Forchet sign and Petren sign are pathognomonic for gallstone ileus.
PubMed: 31382234
DOI: 10.1016/j.ijscr.2019.06.063 -
Annals of Plastic Surgery Jun 2019The literature reports a wide variety of reconstructive methods for pharyngolaryngoesophageal (PLO) defects, the most widely used being anterolateral thigh (ALT), radial... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The literature reports a wide variety of reconstructive methods for pharyngolaryngoesophageal (PLO) defects, the most widely used being anterolateral thigh (ALT), radial forearm (RFF), and jejunal free flaps (JFF). However, there is a lack of uniform agreement among head and neck surgeons as to which technique offers the best results. With an increasing number of salvage PLO extirpations, determining the role of radiotherapy in influencing postoperative complication rates is becoming ever more important. Hence, this study aims to provide an up-to-date comparison of surgical and functional outcomes of the fasciocutaneous ALT and RFF versus the intestinal JFF for circumferential and partial PLO defects and determine whether radiotherapy, both preoperative and postoperative, influences the postoperative fistula and stricture rates in circumferential defects.
METHODS
A systematic review and meta-analysis were performed using PubMed for reports published in the most recent 10 years between 2007 and 2017.
RESULTS
A total of 33 articles comprising 1213 patients were reviewed. For circumferential defects, fistula and stricture rates were significantly lower in JFF than ALT and RFF. Of note, there was no statistical difference in tracheoesophageal speech and oral alimentation rates between JFF and the FC flaps. For near-circumferential and partial defects, ALT has a significantly lower fistula rate than RFF. There was no statistical difference in stricture and oral alimentation rates between ALT and RFF [corrected]. Fistula rates were significantly higher in patients who had preoperative radiotherapy than those without. However, there was no significant difference in fistula and stricture rates for postoperative radiotherapy.
CONCLUSIONS
Jejunal free flaps still remain an excellent first choice for PLO reconstruction of circumferential defects. For near-circumferential and partial defects, ALT seems to have a better performance than RFF. Preoperative radiotherapy was associated with an increased risk of fistula formation in circumferential PLO defects but not postoperative radiotherapy.
Topics: Aged; Esophageal Neoplasms; Female; Follow-Up Studies; Forearm; Free Tissue Flaps; Head and Neck Neoplasms; Humans; Jejunum; Laryngeal Neoplasms; Laryngectomy; Male; Middle Aged; Myocutaneous Flap; Pharyngeal Neoplasms; Pharyngectomy; Postoperative Complications; Plastic Surgery Procedures; Risk Assessment; Thigh; Treatment Outcome
PubMed: 30633018
DOI: 10.1097/SAP.0000000000001776 -
Acta Oto-laryngologica 2023Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of...
BACKGROUND
Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of postoperative complications.
AIMS/OBJECTIVES
We report the usefulness of reconstruction using a free jejunal patch flap in treating recurrence or residual head and neck carcinoma after radiotherapy. Furthermore, we investigated the factors for the occurrence of postoperative complications in patients who underwent salvage surgery using a free flap transfer.
MATERIAL AND METHODS
This study included 41 patients with head and neck carcinoma who underwent salvage surgery using a free flap transfer, including 11 patients who underwent reconstruction using a free jejunal patch flap. Prognostic analysis was performed for the development of complications.
RESULTS
Ten jejunal patch flaps survived without microvascular problems. One patient underwent revision reconstructive surgery because of flap failure. However, no patient had a pharyngocutaneous fistula. Oral intake could be resumed in all patients at a median 14 days postoperatively. Multivariate logistic regression analysis indicated that the use of cutaneous flaps was significantly associated with the development of complications.
CONCLUSIONS AND SIGNIFICANCE
Free jejunal patch flaps can be considered useful for head and neck reconstruction after radiotherapy for early intake resumption and complication prevention.
Topics: Humans; Free Tissue Flaps; Plastic Surgery Procedures; Head and Neck Neoplasms; Postoperative Complications; Carcinoma; Retrospective Studies; Salvage Therapy
PubMed: 38189417
DOI: 10.1080/00016489.2023.2298472 -
Cancers Aug 2021Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures...
BACKGROUND
Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients.
PATIENTS AND METHODS
18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major ( = 2), sternocleidomastoid muscle ( = 2), latissimus dorsi ( = 1) or intercostal muscle (ICM, = 7) flaps. Free flaps were anterolateral thigh (ALT, = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, = 1), jejunum ( = 3) or combined ALT-jejunum flaps ( = 2).
RESULTS
Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% ( = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF.
CONCLUSION
TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.
PubMed: 34503134
DOI: 10.3390/cancers13174329 -
Surgical Endoscopy Jul 2022To present a new pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy (LPD) and to evaluate its safety and reliability.
BACKGROUND
To present a new pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy (LPD) and to evaluate its safety and reliability.
METHODS
The data of 120 patients who underwent LPD at a single centre from October 2017 to October 2019 were retrospectively analysed. Of these patients, 71 received continuous suture pancreaticojejunostomy, and 49 received "8-character" suture pancreaticojejunostomy for LPD. We compared and analysed the operation time, anastomosis time, and incidence of postoperative complications between the patients in the two groups.
RESULTS
All operations were successfully performed, with no transfer to open surgery. The operation time and anastomosis time in the continuous suture group were lower than those in the "8-character" suture group (305.8 ± 60.7 min vs. 354.3 ± 69.1 min; 28.6 ± 6.3 min vs. 39.4 ± 11.9 min P < 0.001), and the postoperative hospital stay was also shorter (12.9 ± 3.8 days vs. 15.4 ± 5.8 days P < 0.05) in the continuous suture group. There was no significant difference in the pancreatic duct diameter or intraoperative blood loss between the two groups. There was also no significant difference in the incidence of a pancreatic fistula between the continuous suture group and the "8-character" suture group. The data of patients in the continuous suture group with pancreatic duct diameters < 3 mm and ≥ 3 mm were statistically analysed. There was no significant difference in the operation time, pancreaticojejunostomy time, postoperative hospital stay, or incidence of pancreatic fistula in the different pancreatic duct diameter groups.
CONCLUSIONS
Continuous suture of pancreaticojejunostomy in LPD is simple, safe, reliable, and rapid. This technique not only saves the anastomosis time but also suitable for pancreatic ducts < 3 mm.
Topics: Anastomosis, Surgical; Humans; Jejunum; Laparoscopy; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Reproducibility of Results; Retrospective Studies; Suture Techniques; Sutures
PubMed: 34988736
DOI: 10.1007/s00464-021-08920-1 -
BMC Surgery Nov 2021Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with...
Comparison between anterolateral thigh free flap and jejunal flap for tissue reconstruction in patients underwent resection of pharyngoesophageal squamous cell carcinoma after radiotherapy failure: a retrospective study.
BACKGROUND
Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with worsening tissue adhesion and necrosis after radiotherapy failure. However, the results of tissue reconstruction and postoperative complications of these two flaps are controversial. The purpose of this study was to compare outcomes between group ALT free flap and group JF in PESCC after radiotherapy failure.
METHODS
Intraoperative information and postoperative outcomes of patients with PESCC after radiotherapy failure who underwent ALT and JF reconstruction from January 2005 to December 2019 were compared and analyzed.
RESULTS
The defect size of ALT (Numbers, 34) and JF (Numbers, 31) was 36.19 ± 11.35 cm and 35.58 ± 14.32 cm (p = 0.884), respectively. ALT and JF showed no significant difference in operation time (p = 0.683) and blood loss (p = 0.198). For postoperative outcomes within 30 days both in recipient site and donor site including wound bleeding, wound dehiscence, wound infection, and pharyngocutaneous fistula, ALT free flap and JF showed similar results. Flap compromise (Numbers, 2 VS.3, p = 0.663), flap take backs (Numbers, 1 VS.1, p = 1.000), partial flap failures (Numbers, 4 VS.2, p = 0.674), and total flap failures (Numbers, 0 VS.0, p = 1.000) showed no difference between the two groups. In addition, no significance was found in hypoproteinemia between the two groups (Numbers, 4 VS.2, p = 0.674). ALT free flap was not statistically different from JF in the incidence of dysphagia at the postoperative 6 months (Numbers of liquid diet, 5VS.5; Numbers of partial tube feeding, 6VS.7; Numbers of total tube feeding, 3VS.1, p = 0.790) and 12 months (Numbers of liquid diet, 8VS.7; Numbers of partial tube feeding, 8VS.7; Numbers of total tube feeding, 5VS.5, p = 0.998). The cause of dysphagia not found to differ between the two groups both in postoperative 6 months (p = 0.814) and 12 months (p = 0.845).
CONCLUSION
Compared with JF, ALT free flap for PESCC patients after radiotherapy failure showed similar results in postoperative outcomes. ALT free flap may serve as a safe and feasible alternative for PESCC patients after radiotherapy failure.
Topics: Carcinoma, Squamous Cell; Free Tissue Flaps; Humans; Plastic Surgery Procedures; Retrospective Studies; Thigh; Treatment Outcome
PubMed: 34727910
DOI: 10.1186/s12893-021-01349-2 -
Asian Journal of Surgery Mar 2018Refractory external pancreatic fistula (REPF) is a rare but troublesome event. Fistulojejunostomy with direct suture of the fistula wall to jejunal wall has been...
BACKGROUND
Refractory external pancreatic fistula (REPF) is a rare but troublesome event. Fistulojejunostomy with direct suture of the fistula wall to jejunal wall has been demonstrated as a solution. However, it is sometimes technically difficult and some cases of failure were reported.
METHODS
An embedding fistulojejunostomy (EFJ) was designed. The fistula tract was detached from the abdominal wall and impactedly inserted into a Roux-en-Y jejunal lumen without direct suture of the fistula wall to the jejunal wall. Five patients with REPF for > 3 months underwent this procedure in the past 10 years. The preoperatively-placed drainage tubes temporarily exteriorized the pancreatic fluid for 30 days.
RESULTS
All fistulojejunostomy procedures were accomplished within 15 minutes. Four patients had uneventful recovery with a postoperative hospital stay ≤ 10 days. One patient had wound infection and needed hospitalization for 23 days. Except for one patient who required pancreatic enzyme supplements for 8 months, no other patient had pancreatic exocrine insufficiency. After follow up for 12-124 months, no patient required pancreatic enzyme supplements, and no patient had recurrent fistula or diabetes mellitus.
CONCLUSION
EFJ makes fistulojejunostomy easier and more secure with a satisfactory early and long-term outcome. It may be a desirable technique for REPF.
Topics: Adult; Aged; Anastomosis, Roux-en-Y; Cohort Studies; Cutaneous Fistula; Drainage; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pancreatic Diseases; Pancreatic Fistula; Pancreaticojejunostomy; Postoperative Complications; Recurrence; Retrospective Studies; Risk Assessment; Treatment Outcome
PubMed: 27816407
DOI: 10.1016/j.asjsur.2016.09.005 -
Ostomy/wound Management Jul 2016Enteroatmospheric fistulas (EAFs) represent a challenging problem in patients with an open abdomen (OA). A retrospective, descriptive study was conducted to evaluate the...
Enteroatmospheric fistulas (EAFs) represent a challenging problem in patients with an open abdomen (OA). A retrospective, descriptive study was conducted to evaluate the effects of enteral alimentation on wound status and management and nutrition. All patients with an EAF in an OA treated between October 2012 and December 2014 at a university hospital in Germany were included without criteria for exclusions. Demographic and morbidity-related data collected included age, gender, surgeries, OA grading, body mass index (BMI), serum albumin, and serum creatinin. Underlying diseases and time between the index operation and the formation of the OA and EAFs were analyzed in relation to the initiation of enteral nutrition (EN), which can aggravate and contaminate the OA due to intestinal secretions necessary for digestion. The OA was described in size and area of the fascia defect and classified according to the Björck Scale. The number and location of the fistulas and the duration of negative pressure wound therapy (NPWT) were documented. Outcome parameters included fistula volume, wound management (eg, dressing change frequency, need for wound revision), feeding tolerance, systemic impact of nutrition, nutrition status at discharge, and mortality. Data were analyzed using primary descriptive statistics. The Mann-Whitney test was used to evaluate changes in fistula volume and BMI; categorical data were compared using Fisher's exact test. A P value less than 0.05 was considered significant. Ten (10) patients (8 women, median age of participants 55.4 [range 44-71] years) were treated during the study time period. Seven (7) patients had the first fistula orifice in the upper jejunum (UJF); 8 had more than 1 fistula. EN was initiated with high caloric liquid nutrition and gradually increased to a 25 kcal/kg/day liquid or solid nutrition. All patients were provided NPWT at 75 mm Hg to 100 mm Hg. EN was not followed by a significant increase of median daily fistula volume (1880 mL versus 2520 mL, P = 0.25) or the need for more frequent changes of NPWT dressings (days between changes 2.6 versus 2.9, P = 0.19). In 9 patients, the severity of wound complications such as inflammation or skin erosion decreased both in frequency and magnitude (eg, affected area). All patients achieved a sufficient oral intake, but only 3 were discharged from the hospital without parenteral nutrition. In this study, EN did not cause additional problems in wound management but did not provide sufficient alimentation in patients with a UJF. Prospective studies are needed to clarify associations between EN, nutrition, and wound management.
Topics: Abdomen; Adult; Aged; Enteral Nutrition; Female; Humans; Intestinal Fistula; Male; Middle Aged; Negative-Pressure Wound Therapy; Prospective Studies; Retrospective Studies; Treatment Outcome; Wound Healing
PubMed: 27428564
DOI: No ID Found