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Surgical Endoscopy Apr 2021Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of...
BACKGROUND AND AIM
Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions.
METHODS
It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted.
RESULTS
We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2-10). During the follow-up interval, no leak recurrences were observed.
CONCLUSIONS
Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.
Topics: Aged; Anastomotic Leak; Endoscopy; Female; Humans; Male; Middle Aged; Pancreas; Pancreaticoduodenectomy; Retrospective Studies; Stents; Treatment Outcome
PubMed: 33403464
DOI: 10.1007/s00464-020-08199-8 -
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 -
Transplantation Proceedings Nov 2022Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice in patients with type 1 diabetes and end-stage renal disease, because it improves survival...
BACKGROUND
Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice in patients with type 1 diabetes and end-stage renal disease, because it improves survival and quality of life. Currently, enteric exocrine drainage is the most commonly used method. Intestinal complications continue to be a major cause of posttransplant morbidity despite improvements in surgical technique. This study analyzed early and late intestinal complications related to SPK transplantation.
MATERIALS AND METHODS
We performed a retrospective analysis of 100 adult patients undergoing SPK transplantation between January 2009 and December 2019. We performed systemic venous drainage and exocrine enteric drainage with duodenojejunostomy. Statistical analysis was performed using SPSS v2. This study was performed in accordance with the Declaration of Istanbul and the 1964 Declaration of Helsinki. Informed consent was obtained from all participants involved in the study.
RESULTS
Intestinal complications were reported in 18 patients. Ten patients (10%) had the following early intestinal complications including: ileus (n = 4), intestinal obstruction (n = 2), graft volvulus (n = 1), duodenal graft fistula (n = 1), and jejunal fistula after pancreas transplantation (n = 1). Two cases required relaparotomy: graft repositioning with Roux-en-Y conversion (n = 1) and Y-roux conversion (n = 1). Eight patients had repeated episodes of intestinal obstruction (8%), of whom 2 required surgery for resolution with 100% postoperative mortality.
CONCLUSIONS
SPK transplantation with enteric drainage via duodenojejunostomy has a low rate of short- and long-term postoperative intestinal complications. Surgery in patients with recurrent intestinal obstruction has a high mortality risk and should be performed in reference transplant centers.
Topics: Adult; Humans; Pancreas Transplantation; Kidney Transplantation; Retrospective Studies; Quality of Life; Graft Survival; Pancreas; Drainage; Postoperative Complications; Diabetes Mellitus, Type 1; Kidney; Intestinal Obstruction; Fistula
PubMed: 36328814
DOI: 10.1016/j.transproceed.2022.09.014 -
Frontiers in Surgery 2021Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic...
Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic pancreaticoduodenectomy. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. We modified Blumgart pancreaticojejunostomy and applied the modified procedure during laparoscopic pancreaticoduodenectomy. The modified procedure entailed a longitudinal U-shaped suture through the pancreas for anastomosis of the pancreatic duct and the jejunal mucosa. We prospectively collected and retrospectively analyzed the data of 120 patients who underwent laparoscopic pancreaticoduodenectomy from January 2016. The total operative time, time for complete pancreaticojejunostomy, postoperative pancreatic fistula rate, postoperative delayed gastric emptying, postoperative bleeding, postoperative length of hospital stays, and mortality within 90 days after surgery were analyzed. An analysis of laparoscopic pancreaticojejunostomy compared with open pancreaticojejunostomy is also reported. In the laparoscopic pancreaticojejunostomy group, the average total operative time, the average time for complete pancreaticojejunostomy, and the average intraoperative blood loss were 271 min, 35.3 min, and 184 ml, respectively. The total postoperative clinically relevant pancreatic fistula rate was 9.2% (Grade B and C fistulas). The incidence rates of postoperative delayed gastric emptying and postoperative biliary fistula were ~2.5 and 1.7%, respectively. The postoperative bleeding rate was 0.83%, and the average postoperative indwelling time of the abdominal drainage tube was 7.3 days. The postoperative length of hospital stay was 10.8 days, and the mortality rate within 90 days after surgery was 0.83%. The rates of clinically relevant postoperative clinically relevant pancreatic fistula are comparable between laparoscopic and open surgery, there were no other severe postoperative complications in either group. The mean postoperative length of hospital stay was significantly shorter in the laparoscopic pancreaticojejunostomy group. The modified laparoscopic-adapted Blumgart anastomosis simplifies and facilitates the creation of the pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. The rates of clinically relevant postoperative pancreatic fistula are comparable with those obtained by open surgery, and length of stay are shoter.
PubMed: 33777996
DOI: 10.3389/fsurg.2021.583671 -
BMC Surgery Jul 2022Pancreatic fistula remains the biggest problem in pancreatic surgery. We have previously reported a new pancreatojejunostomy method using an inter-anastomosis drainage... (Observational Study)
Observational Study
BACKGROUND
Pancreatic fistula remains the biggest problem in pancreatic surgery. We have previously reported a new pancreatojejunostomy method using an inter-anastomosis drainage (IAD) suction tube with Blumgart anastomosis for drainage of the pancreatic juice leaking from the branched pancreatic ducts. This study aimed to evaluate the postoperative outcomes of our novel method, in pancreatojejunostomy and investigate the nature of the inter-anastomosis space between jejunal wall and pancreas parenchyma.
METHODS
This retrospectively study consist of 282 pancreatoduodenectomy cases, including 86 reconstructions via the Blumgart method plus IAD (B + IAD group) and 196 cases reconstructed using the Blumgart method alone (B group). Postoperative outcomes and the amylase value and the volume of the drainage fluids were compared between the two groups. The IAD tube was placed to collect amylase-rich fluid from the inter-anastomosis space during operative procedure between the jejunal wall and pancreatic stump.
RESULTS
The daily IAD drainage volume and the amylase level was significantly higher in patients with a soft pancreas (vs hard pancreas; 16.5 vs. 10.0 mL/day, p = 0.012; 90,900 vs. 1634 IU/L, p < 0.001, respectively). The mean amylase value of IAD collection in 86 cases of B + IAD group was 63,100 IU/L. The incidence of clinically relevant pancreatic fistula grade B and C (23.2% vs. 23.0%, p = 0.55) and the hospital stay was similar between the groups (median 17 vs. 18 days, p = 0.55). In 176 patients with soft pancreas, the incidence of pancreatic fistula grade B and C (33.3% vs. 35.3%, p = 0.67) and the hospital stay was also similar between the groups (median 22.5 vs. 21 days, p = 0.81).
CONCLUSIONS
Positive effect of the IAD method observed in the pilot cases was not reproduced in the current study. IAD tube objectively demonstrated the existence of amylase-rich discharge at the anastomosis site, and countermeasures to eliminate this liquid are highly desired for preventing pancreatic fistula, especially in patients with soft pancreatic texture. Trial registration Retrospectively registered.
Topics: Amylases; Anastomosis, Surgical; Drainage; Humans; Pancreatic Fistula; Pancreatic Juice; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 35836157
DOI: 10.1186/s12893-022-01669-x -
Maedica Dec 2022The aim of this study was to compare the perioperative outcomes and complications between pancreaticoduodenectomy (PD) candidates with and without jejunostomy tube...
The aim of this study was to compare the perioperative outcomes and complications between pancreaticoduodenectomy (PD) candidates with and without jejunostomy tube (J-tube) feeding. This retrospective cohort study was performed on 48 patient candidates for PD, with or without J-tube placement during surgery, in Shahid Modarres Hospital, Tehran, Iran, between 2013 and 2021. Two groups were matched for age, gender, history of heart, endocrine, hypertension and kidney diseases, and drug use. A 12 French jejunal feeding tube was placed at 20-30 cm distal to gastrojejunostomy anastomosis. Outcomes, including biliary leak, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), surgical site infection (SSI), intra-abdominal infection, duration of nasogastric tube (NGT) stay, postoperative (PO) tolerance length, need for total parenteral nutrition (TPN), hospitalization length, and mortality rate, were assessed. There were eight cases with leak (37.5% J-tube group, of which six (75%) were pancreatic type and two (25%) biliary type. There were 11 (22.9%) patients with DGE (54.5% in J-tube group). There was no significant inter-group difference in SSI (P=0.340), intra-abdominal infection managed non-invasively (P=0.369), intra-abdominal abscess managed by percutaneous drainage (P=0.158), patients requiring TPN (P=0.447), NGT placement duration (P=0.088), PO tolerance time (P=0.327), hospital stay (P=0.760) and mortality rate (P=0.851). J-tube placement after PD for pancreatic cancer may be associated with increased postoperative complications. The conclusion of the present study is that there is no difference between performing and not performing the J-tube placement method in terms of complications and consequences.
PubMed: 36818256
DOI: 10.26574/maedica.2022.17.4.840 -
World Journal of Clinical Cases Jun 2023Gallstone ileus is a rare complication of gallstone disease in which a stone enters the enteric lumen and causes mechanical obstruction usually by bilioenteric fistula....
BACKGROUND
Gallstone ileus is a rare complication of gallstone disease in which a stone enters the enteric lumen and causes mechanical obstruction usually by bilioenteric fistula. Gallstone ileus accounts for 25% of all bowel obstructions among the population > 65 years of age. Despite medical advances over the last decades, gallstone ileus is still associated with high rates of morbidity and mortality.
CASE SUMMARY
An 89-year-old man with a history of gallstones was admitted to the Gastroenterology Department of our hospital, complaining of vomiting and cessation of bowel movements and flatus. Abdominal computed tomography showed cholecystoduodenal fistula and upper jejunum obstruction due to gallstones, pneumatosis in the gallbladder, and pneumobilia indicating Rigler's triad. Considering the high risk of surgical management, we performed propulsive enteroscopy and laser lithotripsy twice to relieve the bowel occlusion. However, the intestinal obstruction was not relieved by the less invasive procedure. Then, the patient was transferred to the Department of Biliary-pancreatic Surgery. The patient underwent the one-stage procedure including laparoscopic duodenoplasty (fistula closure), cholecystectomy, enterolithotomy, and repair. After surgery, the patient presented with complications of acute renal failure, postoperative leak, acute diffuse peritonitis, septicopyemia, septic shock, and multiple organ failure, and finally died.
CONCLUSION
Early surgical intervention is the mainstay of treatment for gallstone ileus. For elderly patients with significant comorbidities, enterolithotomy alone is advised.
PubMed: 37388782
DOI: 10.12998/wjcc.v11.i17.4159 -
Intractable & Rare Diseases Research Feb 2023Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to... (Review)
Review
Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to misdiagnosis and occasionally catastrophic outcomes. The lifestyles of those who are afflicted are mostly responsible for the underlying conditions that result in the hemorrhagic cases. The development of a novel approach targeted at raising public awareness of the issue and educating the public about it could significantly contribute to the elimination of gastrointestinal bleeding with no associated risks and to a nearly zero mortality rate. There are reports of UGB related to Sarcina ventriculi, gastric amyloidosis, jejunal lipoma, gastric schwannoma, hemobilia, esophageal varices, esophageal necrosis, aortoenteric fistula, homosuccus pancreaticus, and gastric trichbezoar in the literature. The common feature of these rare causes of UGB is that the diagnosis is difficult to establish before surgery. Fortunately, UGB with a clear lesion in the stomach itself is a clear sign for surgical intervention, and the diagnosis can only be verified by pathological examination with the help of immunohistochemical detection of a particular antigen for a specific condition. The clinical traits, diagnostic techniques, and the therapeutic, or surgical options of unusual causes of UGB reported in the literature are compiled in this review.
PubMed: 36873674
DOI: 10.5582/irdr.2022.01128 -
Head & Neck Dec 2023Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral...
BACKGROUND
Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral thigh (ALT) free flap.
METHODS
We reviewed the medical records of 92 patients with ALT free flaps and 140 who underwent FJ transfer between 2009 and 2022, and compared their surgical outcomes.
RESULTS
Total flap loss occurred in two (2%) and five (4%) patients in the ALT free flap and FJ transfer groups, respectively. Fistula rates were 5% in both groups. Stricture rates were 21% and 5% in the ALT free flap and FJ transfer groups, respectively (p < 0.01). At the 5-year follow-up evaluation, intelligible speech was achieved by 83% and 28% of patients (p < 0.01) in the ALT free flap and FJ transfer groups, respectively.
CONCLUSIONS
Each reconstructive method can be further optimized by proficient surgeons with expertise in the available methods and by considering patient-specific factors and available evidence.
Topics: Humans; Free Tissue Flaps; Pharyngectomy; Plastic Surgery Procedures; Thigh; Treatment Outcome
PubMed: 37755124
DOI: 10.1002/hed.27526 -
Plastic and Reconstructive Surgery.... Feb 2020The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of...
Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer.
BACKGROUND
The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer.
METHODS
We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46-88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation.
RESULTS
One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed.
CONCLUSION
Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.
PubMed: 32309103
DOI: 10.1097/GOX.0000000000002663