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The Korean Journal of Thoracic and... Aug 2020Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and...
Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and esophageal-aorta fistulas. The diagnosis is confirmed with fluoroscopy using dilute barium oral contrast, followed by thin-section computed tomography, which defines the precise location and extent of the fistula. Flexible esophagoscopy and bronchoscopy are required for confirmation and anatomic assessment of the suspected fistula and provide additional information for treatment planning. Contamination is traditionally controlled by surgical exclusion, along with a jejunal feeding tube. Currently, fully covered self-expanding metal stents are the primary treatment option.
PubMed: 32793454
DOI: 10.5090/kjtcs.2020.53.4.211 -
International Journal of Surgery Case... May 2022Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. Although...
INTRODUCTION AND IMPORTANCE
Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. Although rare, this condition carries a high mortality rate and no current standardised guidelines for management.
CASE PRESENTATION
We present a case of a patient in their 60s with recurrent small bowel obstruction secondary to a cholecysto-duodenal fistula and large gallstone which became impacted in the fourth part of the duodenum. The patient had a P-POSSUM Score of 14% mortality and 60% morbidity risk, had multiple co-morbidities, was bedbound, BMI 59 and had been deemed high risk for general anaesthetic at oncology centre for a 10 × 10 cm likely gynaecological malignancy a month prior to this admission.
CLINICAL DISCUSSION
In contrast to existing literature, endoscopic lithotripsy was considered but not attempted due to unavailability of this service locally. Surgical intervention was decided based on radiological features of impending duodenal perforation on CT imaging and multiple disciplinary team discussion. The patient was managed with open enterolithotomy at the duodeno-jejunal (DJ) flexure and discharged 3 weeks post-operatively at her pre-operative baseline.
CONCLUSION
This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. In cases where anatomical location of impaction precludes retrieval via simple gastrostomy, we suggest using high pressure flush to mobilise the stone to more favourable location distally. We emphasise that stone size should be considered when planning surgical management.
PubMed: 35658279
DOI: 10.1016/j.ijscr.2022.107084 -
Journal of Plastic, Reconstructive &... May 2022Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances...
Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ H&N 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.
Topics: Esophagectomy; Free Tissue Flaps; Humans; Hypopharyngeal Neoplasms; Larynx; Pharynx; Plastic Surgery Procedures; Retrospective Studies
PubMed: 34955400
DOI: 10.1016/j.bjps.2021.11.083 -
Global Health & Medicine Aug 2022Pancreatic juice can leak not only from the main pancreatic duct but also from unclosed ductal branches appearing on the pancreatic stump. We have developed a suture...
Pancreatic juice can leak not only from the main pancreatic duct but also from unclosed ductal branches appearing on the pancreatic stump. We have developed a suture device consisting of three loops of suture attached to four small-curvature needles with the aim to maximize the area of pancreatic parenchyma to be ligated and reduce the number of punctures made on the pancreas during pancreatic closure or anastomosis. In pancreatojejunostomy, the dorsal wall of the jejunum and then the pancreatic parenchyma are sutured using the four needles. Following duct-to-mucosa anastomosis, the ventral jejunal wall is sutured, and the three threads are finally tied sequentially to complete the reconstruction following the Blumgart method. In distal pancreatectomy, the pancreatic stump is sutured from the dorsal aspect sequentially using the four needles, before or after the pancreatic transection. The three threads are then respectively tied on the ventral surface of the pancreas. This device was used in six pancreatoduodenectomies (including two minimally invasive procedures) and five distal pancreatectomies. A postoperative pancreatic fistula requiring additional drainage or repositioning of abdominal drains developed in two patients. No adverse events associated with this device were encountered. The four-needle three-loop suture device can be an alternative to conventional staplers or sutures for closure and anastomosis of the pancreatic stump.
PubMed: 36119788
DOI: 10.35772/ghm.2022.01044 -
World Journal of Clinical Cases Sep 2022A post-bulbar duodenal ulcer (PBDU) is an ulcer in the duodenum that is distal to the duodenal bulb. PBDU may coexist with a synchronous posterior ulcer in rare...
BACKGROUND
A post-bulbar duodenal ulcer (PBDU) is an ulcer in the duodenum that is distal to the duodenal bulb. PBDU may coexist with a synchronous posterior ulcer in rare occurrences, resulting in a kissing ulcer (KU). Duodenocaval fistula (DCF) is another uncommon but potentially fatal complication related to PBDU. There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously.
CASE SUMMARY
A 22-year-old man was admitted to the emergency department with abdominal pain, stiffness, and vomiting. The X-ray showed pneumoperitoneum, suggesting a perforated viscus. Laparotomy revealed a KU with anterior perforation and a DCF. After Kocherization, venorrahphy was used to control caval bleeding. Due to the critical condition of the patient, only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy. However, later, the patient developed obstructive jaundice and leakage, and two additional jejunal perforations were detected. Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer, neither primary repair nor pancreatic-free duodenectomy and ampulloplasty/ampullary reimplantation were considered viable; therefore, an emergency pancreaticoduodenectomy was performed, along with resection and anastomosis of the two jejunal perforations. The patient had a smooth recovery after surgery and was discharged after 27 d.
CONCLUSION
The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients, even in the most complex cases.
PubMed: 36157647
DOI: 10.12998/wjcc.v10.i25.9071 -
Zhonghua Wai Ke Za Zhi [Chinese Journal... Jun 2023To explore the development of the pancreatic surgeon technique in a high-volume center. A total of 284 cases receiving pancreatic surgery by a single surgeon from June...
To explore the development of the pancreatic surgeon technique in a high-volume center. A total of 284 cases receiving pancreatic surgery by a single surgeon from June 2015 to December 2020 were retrospectively included in this study. The clinical characteristics and perioperative medical history were extracted from the medical record system of Zhongshan Hospital,Fudan University. Among these patients,there were 140 males and 144 females with an age ( (IQR)) of 61.0 (16.8) years(range: 15 to 85 years). The "back-to-back" pancreatic- jejunal anastomosis procedure was used to anastomose the end of the pancreas stump and the jejunal wall. Thirty days after discharge,the patients were followed by outpatient follow-up or telephone interviews. The difference between categorical variables was analyzed by the Chi-square test or the CMH chi-square test. The statistical differences for the quantitative data were analyzed using one-way analysis of variance or Kruskal-Wallis test and further analyzed using the LSD test or the Nemenyi test,respectively. Intraoperative blood loss in pancreaticoduodenectomy between 2015 and 2020 were 300,100(100),100(100),100(0),100(200) and 150 (200) ml,respectively. Intraoperative blood loss in distal pancreatectomy was 250 (375),100 (50),50 (65), 50 (80),50 (50),and 50 (100) ml,respectively. Intraoperative blood loss did not show statistical differences in the same operative procedure between each year. The operative time for pancreaticoduodenectomy was respectively 4.5,5.0(2.0),5.5(0.8),5.0(1.3),5.0(3.3) and 5.0(1.0) hours in each year from 2015 to 2020,no statistical differences were found between each group. The operating time of the distal pancreatectomy was 3.8 (0.9),3.0 (1.5),3.0 (1.8),2.0 (1.1),2.0 (1.5) and 3.0(2.0) hours in each year,the operating time was obviously shorter in 2018 compared to 2015 (=0.026) and 2020 (=0.041). The median hospital stay in 2020 for distal pancreatectomy was 3 days shorter than that in 2019. The overall incidence of postoperative pancreatic fistula gradually decreased,with a incident rate of 50.0%,36.8%,31.0%,25.9%,21.1% and 14.8% in each year. During this period,in a total of 3,6,4,2,0 and 20 cases received laparoscopic operations in each year. The incidence of clinically relevant pancreatic fistula (grade B and C) gradually decreased,the incident rates were 0,4.8%,7.1%,3.4%,4.3% and 1.4%,respectively. Two cases had postoperative abdominal bleeding and received unscheduled reoperation. The overall rate of unscheduled reoperation was 0.7%. A patient died within 30 days after the operation and the overall perioperative mortality was 0.4%. The surgical training of a high-volume center can ensure a high starting point in the initial stage and steady progress of pancreatic surgeons,to ensure the safety of pancreatic surgery.
Topics: Male; Female; Humans; Pancreatic Fistula; Retrospective Studies; Blood Loss, Surgical; Pancreatectomy; Pancreaticoduodenectomy; Postoperative Complications; Surgeons; Postoperative Hemorrhage; Pancreatic Neoplasms
PubMed: 37088485
DOI: 10.3760/cma.j.cn112139-20221027-00462 -
Annali Italiani Di Chirurgia Sep 2023Pancreaticoduodenectomy is a major surgical procedure associated with various and important complications, often difficult to be managed. Pancreatic fistula is due to...
Pancreaticoduodenectomy is a major surgical procedure associated with various and important complications, often difficult to be managed. Pancreatic fistula is due to leakage of pancreatic juice in the abdominal cavity and is the main and most frequent complication after pancreatic surgery. The treatment of pancreatic fistula may change according to degree. Interventional radiology (IR) can offer powerful minimally invasive alternatives in managing pancreatic fistulas. We report the case of a patient affected by ampullar adenocarcinoma who underwent pancreaticoduodenectomy. Surgery was complicated by high-flow pancreatic fistula treated conservatively with CT guided percutaneous transhepatic drainage. Due to persistent leak of pancreatic fluid the abdominal effusion was drained percutaneously in the jejunal loop by Interventional radiology. KEY WORDS: Pancreatic fistula, Jejunal loop internal drainage, Radiological treatment.
Topics: Humans; Pancreatic Fistula; Radiology, Interventional; Drainage; Radiography; Pancreaticoduodenectomy
PubMed: 37737663
DOI: No ID Found -
Current Medical Imaging Apr 2024
Background: Congenital enterocolic fistula, an abnormal connection between the small intestine and the colon, is a rare condition with the potential for significant...
Background: Congenital enterocolic fistula, an abnormal connection between the small intestine and the colon, is a rare condition with the potential for significant complications affecting the patient's quality of life. Case Report: A 2 year and 7 months old girl presented with abdominal pain and diarrhea lasting more than 10 days. The formation of the intestinal fistula was first detected by ultrasound, and the blood flow in the intestinal wall was preliminally analyzed. Surgical exploration revealed a colonic fistula formed by the attachment of the jejunum to the descending colon. Postoperatively, symptoms improved; no secondary infection occurred and the fistula healed well. Conclusion: Congenital colon fistula is rarely reported, and ultrasound is becoming more and more important in its diagnosis. Here, we report a case of congenital colonic fistula diagnosed by ultrasound. Ultrasound can dynamically and in real-time observe the intestinal condition, which is conducive to the early diagnosis and staging of congenital intestinal diseases and the determination of diagnosis and treatment schemes.
.PubMed: 38676486
DOI: 10.2174/0115734056286242240222092226 -
Langenbeck's Archives of Surgery May 2021Patients with fistula risk score (FRS) ≥7 are at the highest risk of developing clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement... (Observational Study)
Observational Study
PURPOSE
Patients with fistula risk score (FRS) ≥7 are at the highest risk of developing clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement on the management of this subpopulation. The primary outcome of the study was the definition of the role of intraoperative completion pancreatectomy (ICP) in patients at high risk for CR-POPF, as an alternative to high-risk pancreaticoduodenectomy (PD).
METHODS
This is an observational study set in a single tertiary referral center. Patients scheduled for PD in our center between 2010 and 2019 with FRS ≥7 were included in the study. Data were prospectively collected.
RESULTS
A total of 738 patients were scheduled for between 2010 and 2019, and 62 had FRS ≥7. Thirty-five patients were managed with PD and pancreatico-jejunal anastomosis (group A), and 27 with ICP (group B). Overall complication rate was significantly higher in group A than group B (95 versus 59%; p=0.005) and there was a not significantly higher rate of major complications (Clavien-Dindo ≥3) (43 versus 26%; p=0.192). In group A, 49% of patients had a CR-POPF. Median post-operative length of stay was 15 days in group A and 12 in group B (p=0.043). Readmission was observed only in group A (26%). In multivariate analysis, PD was an independent predictive factor of major post-operative morbidity (RR 9.27; CI 1.74-49.31). No patients in either group suffered major adverse events related to endocrine and exocrine insufficiency.
CONCLUSION
In high-FRS patients, ICP has good short-term outcomes relative to PD without major long-term events related to endocrine and exocrine insufficiency. ICP could be considered as a feasible alternative in selected cases.
Topics: Anastomosis, Surgical; Humans; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Assessment; Risk Factors
PubMed: 33783612
DOI: 10.1007/s00423-021-02157-1 -
Medicine Jan 2024Our objective was to assess the safety and efficacy of 3 tubes with or without covered esophageal stent placement for the management of gastro-mediastinal or...
Our objective was to assess the safety and efficacy of 3 tubes with or without covered esophageal stent placement for the management of gastro-mediastinal or gastro-pleural fistula. We retrospectively assessed the clinical data of 31 consecutive patients with gastro-mediastinal or gastro-pleural fistula treated by using a noninvasive treatment from February 2013 to July 2022. Patients received 3 tubes (jejunal feeding tube, gastrointestinal drainage tube and abscess drainage tube) with or without esophageal-covered stent placement. All patients received continue abscess drainage and nutritional support after procedure. The tubes and/or esophageal-covered stents were removed after fistula healing. All patients received 3 tubes placement and 11 patients with luminal narrowing received esophageal covered stent placement. Technically success was found in all patients, with no procedure-related death, esophageal rupture or massive hemorrhage. Abscess cavity disappeared in 22 patients, with a clinical success rate of 71.0%. All patients received esophageal stent placement were cured and stents were removed, for a median duration of 1.6 months (interquartile ranges [IQR] 1.4, 3.7). Three patients showed clinical improved, with markedly decreased abscess cavity and markedly shrunk fistula. The median survival was 30.8 months. The 1-, 3-, 5-year survival rates were 71.1%, 46.1% and 39.5%, respectively. A noninvasive treatment of 3 tubes with or without covered esophageal stent placement is safe and effective for gastro-mediastinal or gastro-pleural fistula after esophagogastrectomy.
Topics: Humans; Abscess; Retrospective Studies; Treatment Outcome; Stomach; Gastric Fistula; Pleural Diseases; Stents; Esophageal Fistula
PubMed: 38277539
DOI: 10.1097/MD.0000000000037075