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Arquivos Brasileiros de Cirurgia... 2017Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described.
BACKGROUND
Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described.
AIM
To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results.
METHOD
The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o'clock, 4 o'clock, 6 o'clock, 8 o'clock, 10 o'clock, and 12 o'clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied.
RESULTS
Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed.
CONCLUSION
Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 29340550
DOI: 10.1590/0102-6720201700040008 -
BMC Surgery May 2023Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently,...
BACKGROUND
Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently, there exists no flawless pancreaticojejunal anastomosis approach. We presents a new approach called Chen's penetrating-suture technique for pancreaticojejunostomy (PPJ), which involves end-to-side pancreaticojejunostomy by suture penetrating the full-thickness of the pancreas and jejunum, and evaluates its safety and efficacy.
METHODS
To assess this new approach, between May 2006 and July 2018, 193 consecutive patients who accepted the new Chen's Penetrating-Suture technique after a PD were enrolled in this study. Postoperative morbidity and mortality were evaluated.
RESULTS
All cases recovered well after PD. The median operative time was 256 (range 208-352) min, with a median time of 12 (range 8-25) min for performing pancreaticojejunostomy. Postoperative morbidity was 19.7% (38/193) and mortality was zero. The POPF rate was 4.7% (9/193) for Grade A, 1.0% (2/193) for Grade B, and no Grade C cases and one urinary tract infection.
CONCLUSION
PPJ is a simple, safe, and reliable technique with ideal postoperative clinical results.
Topics: Humans; Pancreaticojejunostomy; Pancreaticoduodenectomy; Anastomosis, Surgical; Pancreas; Pancreatic Fistula; Postoperative Complications; Suture Techniques
PubMed: 37248522
DOI: 10.1186/s12893-023-02054-y -
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 -
Plastic and Reconstructive Surgery.... Aug 2018Although there have been many reports on the success of free jejunal flap transfer for pharyngoesophageal reconstruction, reports on salvage procedures for failed...
BACKGROUND
Although there have been many reports on the success of free jejunal flap transfer for pharyngoesophageal reconstruction, reports on salvage procedures for failed transfers remain sparse. In this report, we retrospectively reviewed our salvage procedures for failed jejunal transfers and previous articles describing salvage treatment in failed jejunal flap cases.
METHODS
This report includes 6 cases of failed jejunal flap transfer, leading to necessary salvage surgery. We reviewed all cases to examine salvage procedures and early postoperative complications such as fistula formation. We also assessed postoperative late complications and swallowing function during long-term follow-up. A review of the literature was performed via PubMed.
RESULTS
Rejejunal transfer was performed successfully in 3 of 6 cases. Gastric pull-up reconstruction was adopted in 2 cases. In 1 case, an external stoma was created because of the patient's poor medical condition. All 3 cases of rejejunal transfer and 1 gastric pull-up case recovered to resuming a normal diet. However, 1 gastric pull-up case required supplemental feeding with a jejunostomy tube. We reviewed 6 articles describing salvage treatment in failed jejunal flap cases.
CONCLUSION
When free jejunal transfer fails, rejejunal transfer is optimal. However, in cases that lack suitable recipient vessels or have infection, a second jejunal transfer should not be considered. In such cases, gastric pull-up or colon interposition may be an alternative because they do not require vascular anastomosis. Pedicled pectoralis major flap is also an alternative, although the risk of salivary fistulas is very high.
PubMed: 30324068
DOI: 10.1097/GOX.0000000000001889 -
Therapeutic Advances in Gastroenterology Jan 2017Mitochondrial disorders (MIDs) due to respiratory-chain defects or nonrespiratory chain defects are usually multisystem conditions [mitochondrial multiorgan disorder... (Review)
Review
Mitochondrial disorders (MIDs) due to respiratory-chain defects or nonrespiratory chain defects are usually multisystem conditions [mitochondrial multiorgan disorder syndrome (MIMODS)] affecting the central nervous system (CNS), peripheral nervous system, eyes, ears, endocrine organs, heart, kidneys, bone marrow, lungs, arteries, and also the intestinal tract. Frequent gastrointestinal (GI) manifestations of MIDs include poor appetite, gastroesophageal sphincter dysfunction, constipation, dysphagia, vomiting, gastroparesis, GI pseudo-obstruction, diarrhea, or pancreatitis and hepatopathy. Rare GI manifestations of MIDs include dry mouth, paradontosis, tracheoesophageal fistula, stenosis of the duodeno-jejunal junction, atresia or imperforate anus, liver cysts, pancreas lipomatosis, pancreatic cysts, congenital stenosis or obstruction of the GI tract, recurrent bowel perforations with intra-abdominal abscesses, postprandial abdominal pain, diverticulosis, or pneumatosis coli. Diagnosing GI involvement in MIDs is not at variance from diagnosing GI disorders due to other causes. Treatment of mitochondrial GI disease includes noninvasive or invasive measures. Therapy is usually symptomatic. Only for myo-neuro-gastro-intestinal encephalopathy is a causal therapy with autologous stem-cell transplantation available. It is concluded that GI manifestations of MIDs are more widespread than so far anticipated and that they must be recognized as early as possible to initiate appropriate diagnostic work-up and avoid any mitochondrion-toxic treatment.
PubMed: 28286566
DOI: 10.1177/1756283X16666806 -
International Journal of Surgery Case... Jan 2022Gallstone ileus is an uncommon complication of long-term cholelithiasis. Emergent operations for gallstone ileus are associated with high postoperative morbidity. When...
INTRODUCTION
Gallstone ileus is an uncommon complication of long-term cholelithiasis. Emergent operations for gallstone ileus are associated with high postoperative morbidity. When feasible, the minimally invasive approach might help to improve the postoperative outcomes.
PRESENTATION OF CASE
A 63-year-old female was admitted for abdominal pain and vomiting. Computed tomography (CT) scan showed a cholecystoduodenal fistula and a 5 × 3 cm gallstone in the jejunum causing obstruction. An emergent laparoscopy was performed, and a gallstone was found inside the jejunum 40 cm distal to the ligament of Treitz. The 5 cm gallstone was extracted through an antimesenteric enterotomy. The jejunum was then closed transversally using interrupted sutures. The postoperative course was uneventful, and the patient was discharged on postoperative day 3.
DISCUSSION
Surgery is the mainstream treatment for gallstone ileus. Multiple operations and surgical approaches have been described: enterolithotomy (EL), one-stage surgery (EL, cholecystectomy, and fistula closure), bowel resection, and two-stage surgery (EL and delayed cholecystectomy with fistula closure). The choice of the procedure depends on the patient's characteristics, comorbidities, and experience of the surgical team.
CONCLUSION
In the emergency setting, a simple enterolithotomy with primary closure seems to be the optimal approach to solve the intestinal obstruction with low postoperative morbidity. The laparoscopic approach to gallstone ileus results in additional benefits for patients' recovery.
PubMed: 34915442
DOI: 10.1016/j.ijscr.2021.106682 -
Annals of Translational Medicine May 2021Long-gap esophageal defects, whether congenital or acquired, are very difficult to manage. Any significant surgical peri-esophageal dissection that is performed to allow... (Review)
Review
Long-gap esophageal defects, whether congenital or acquired, are very difficult to manage. Any significant surgical peri-esophageal dissection that is performed to allow for potential stretching of two ends of a defect interrupts the esophageal blood supply and leads to complications such as leak and stricture, even in the youngest, healthiest patients. The term "congenital" applied to these defects refers mainly to long-gap esophageal atresia (LGA). Causes of acquired long-segment esophageal disruption include recurrent leaks and fistulae after primary repair, refractory GERD, caustic ingestions, cancer, and strictures. 5,000-10,000 patients per year in the US require esophageal replacement. Gastric, colonic, and jejunal pull-up surgeries are fraught with high rates of both short and long term complications thus creating a space for a better option. Since the 1970's many groups around the world have been unsuccessfully attempting esophageal replacement with tissue-engineered grafts in various animal models. But, recent advances in these models are now combining novel technologic advances in materials bioscience, stem-cell therapies, and transplantation and are showing increasing promise to human translational application. Transplantation has been heretofore unsuccessful, but given modern improvements in transplant microsurgery and immunosuppressive medications, pioneering trials in animal models are being undertaken now. These rapidly evolving medical innovations will be reviewed here.
PubMed: 34164544
DOI: 10.21037/atm-20-3906 -
Chirurgia (Bucharest, Romania : 1990) Aug 2021Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous...
Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous fistula which increases morbidity and mortality. Treatment of duodeno-jejunal flexure transection has been traditionally done by pyloric exclusion with gastrojejunostomy, but more recent evidence suggests that end-to-end anastomosis or primary closure may be equally effective in which duodeno-jejunal anastomosis is protected via an external tube duodenostomy. The objective of the study is to provide a modification to the technique of management of duodeno-jejunal flexure injury, avoiding external tube duodenostomy. Material and Patients admitted from July 1, 2015 to June 1, 2018 were identified and examined for duodeno-jejunal flexure transection. Non-accidental injury cases were excluded. In the study period, a total of 10 patients were admitted with duodeno-jejunal flexure transection. All cases were admitted 24 hours after the injury and presented with shock. After fluid resuscitation and investigations, they were taken for urgent laparotomy. The whole of duodenum was mobilised, the transected ends were debrided and end-to-end duodenojejunal anastomosis was performed in two-layer fashion. An 18-French Nasojejunal (NJ) tube was placed beyond the anastomosis, and an 18-French nasogastric (NG) tube was placed in the stomach for gastric decompression. A feeding jejunostomy was performed in all cases. Both NG and NJ tubes were removed after bowel movements started and FJ was removed on first follow up. There was no incidence of duodenum related complications, and all were doing well on follow up. Placing the nasojejunal and nasogastric tube eliminates the need for duodenostomy and gastrostomy, respectively. This method protects the duodeno-jejunal anastomosis and decreases the incidence of duodenum-related complications.
Topics: Duodenostomy; Duodenum; Gastric Bypass; Humans; Treatment Outcome; Wounds, Nonpenetrating
PubMed: 34463243
DOI: 10.21614/chirurgia.116.eC.2282 -
Journal of Medical Case Reports Apr 2021Thromboangiitis obliterans or Buerger's disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2%...
BACKGROUND
Thromboangiitis obliterans or Buerger's disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2% of the cases, when they may present as acute abdomen due to mesenteric ischemia. The uncommonness of the condition makes it a less suspected differential diagnosis, leading to a delay in appropriate management, thereby increasing chances of morbidity or mortality. Cessation of smoking is known to stall the disease progression including visceral involvement, but may not always be the case as happened in the case being presented.
CASE PRESENTATION
Our Indian Hindu male patient, a known smoker, presented with diffuse abdominal pain along with bouts of vomiting and loose motions. He had a prior history of amputation of the right foot, 4 years before. At presentation he had abdominal distension with diffuse tenderness and guarding. An omental band attached to the tip of the appendix was discovered at the initial exploration along with dilated proximal bowel loops, for which a release of the omental band along with appendectomy was done. He developed an enterocutaneous fistula on the 6th postoperative day for which he had to be reexplored, and multiple jejunal perforations were found. Segmental jejunal resection and a Roux-en-Y gastrojejunostomy with distal ileostomy were done along with a feeding jejunostomy. The patient however again had feculent discharge from the wound for which a third exploration was done. The gastrojejunostomy and feeding jejunostomy sites were leaky, both of which were repaired primarily. The patient developed septicemia which progressed to refractory septic shock, and he ultimately succumbed to his illness on the 23rd postoperative day of the index surgery.
CONCLUSION
Acute abdomen in a young man who is a chronic smoker and having an antecedent history of amputation of some part of an extremity for a nontraumatic cause should raise the suspicion of Buerger's disease of the intestine. Although it is a progressive disease and the situation has already progressed by the time intestinal symptoms manifest, early detection may give some scope of salvage and decrease the morbidity and mortality.
Topics: Abdomen, Acute; Humans; Intestinal Perforation; Intestines; Male; Mesenteric Ischemia; Thromboangiitis Obliterans
PubMed: 33892806
DOI: 10.1186/s13256-021-02719-3