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Annals of Vascular Surgery Apr 2023Pharyngo-esophageal reconstruction using free jejunal grafts has been widely used for the treatment of locally advanced carcinomas of the hypopharynx and cervical...
BACKGROUND
Pharyngo-esophageal reconstruction using free jejunal grafts has been widely used for the treatment of locally advanced carcinomas of the hypopharynx and cervical esophagus. However, the procedure is technically demanding and requires complex recontractions. The aim of this study was to evaluate our institutional outcomes of reconstruction using a free jejunal graft with vascular reconstruction in patients undergoing pharyngo laryngo esophagectomy with a multidisciplinary surgical team.
METHODS
There were 90 consecutive patients between October 2006 and February 2021. The mean age was 64.6 ± 10.3 years, and there were 76 male patients. Of 90 patients, 49 underwent preoperative chemotherapy and/or radiotherapy. Jejunal vessels were commonly anastomosed to the common carotid artery and the internal jugular vein (77.8% and 92.2%, respectively). Continuous intravenous infusion of heparin was used postoperatively.
RESULTS
Necrosis of the graft was observed in 5 patients. An isolated revision of vein was necessary in 1 patient. In all cases of graft failure, heparin was not used postoperatively. On the other hand, among the patients without graft failure, heparin was used for about two-thirds of the patients and was significantly different (0% vs. 66%, P = 0.01).
CONCLUSIONS
Free jejunal graft with vessel reconstruction is a safe and effective method for patients undergoing pharyngo laryngo esophagectomy. The position for the prevention of kinking as well anastomosis maneuver of vein is especially important. Moreover, early postoperative anticoagulation is essential.
Topics: Humans; Male; Middle Aged; Aged; Esophagectomy; Esophageal Neoplasms; Treatment Outcome; Anastomosis, Surgical
PubMed: 36521762
DOI: 10.1016/j.avsg.2022.11.012 -
International Journal of Surgery Case... May 2023A small bowel gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal tract. The manifestation of bleeding is a diagnostic challenge and could...
INTRODUCTION
A small bowel gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal tract. The manifestation of bleeding is a diagnostic challenge and could present as a life-threatening situation that needs urgent intervention.
PRESENTATION OF CASE
64-year-old woman consulted for episodes of melena and anemia. The upper and lower endoscopies were not diagnostic. Capsule endoscopy (CE) revealed a probable jejunal hemangioma, however double-balloon enteroscopy and magnetic resonance imaging (MRI) did not show any intestinal nodule but MRI show a pelvic mass apparently related to the uterus confirmed by a gynecologist. Even so, the patient returned with melena, and a contrast-enhanced computed tomography (CT) scan again identified a pelvic mass, highlighting that its vascularization drained into the superior mesenteric territory and seemed to invade the jejunum, with active bleeding, suspicious for jejunal GIST. A laparotomy was performed to remove the jejunal mass. Histopathology and immunohistochemical studies confirmed the diagnosis.
DISCUSSION
Bleeding is a common symptom in small bowel GISTs but its diagnoses could be difficult because its location. In most cases, gastroscopy and colonoscopy are not useful and CE or imaging studies are necessary to find the cause of bleeding. Moreover, it has recently proved that bleeding is a prognostic risk factor because it is related to tumor rupture and tumor invasion of blood vessels.
CONCLUSION
In this case, bleeding caused by small bowel GIST was misdiagnosed in endoscopic procedures and the clinical management was delayed. CT angiography was the most effective investigation to detect the source of bleeding.
PubMed: 37137174
DOI: 10.1016/j.ijscr.2023.108257 -
Medicine Sep 2022A jejunal gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal (GI) tract. Massive bleeding due to a jejunal GIST is a diagnostic and...
BACKGROUND
A jejunal gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal (GI) tract. Massive bleeding due to a jejunal GIST is a diagnostic and therapeutic challenge. It may be a life-threatening GIST complication that requires urgent intervention. Acute GI bleeding, which requires urgent surgical intervention, is a very rare clinical manifestation of GIST. A jejunal GIST with massive hemorrhage with coronavirus disease 2019 in a male patient in older age with many comorbidities has been not reported in the worldwide literature.
METHODS
In this case report, we present an 80-year-old man who was admitted to surgery due to abdominal pain, melena, and hematochezia for several hours. An upper endoscopy and colonoscopy were inconclusive. A multidetector contrast-enhanced computed tomography (CT) of the abdominal and pelvic cavity showed concentric irregular thickening in the distal jejunum.The histopathological finding showed a GIST measuring 6 cm with a mitotic index 2/50 high power fields. The patient's hemodynamic condition deteriorated despite initial conservative treatment including a blood transfusion. Therefore, patient underwent the emergency surgery 24 hours after admission: partial jejunal resection with the tumor followed by primary end-to-end anastomosis.
RESULTS
The mass was removed completely. There were no surgical complications in the postoperative course. On the first postoperative day, a severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was performed due to a persistent dry cough, which yielded a positive result. After 14 days, the patient died due to pneumonia and circulatory failure.
CONCLUSIONS
This case indicates that jejunal GIST can present as massive lower gastrointestinal bleeding and urgent surgery can successfully stop bleeding and save the patient's life. The CT scan was the most effective investigation to find the source of GI bleeding in this case. Therefore, we suggest performing CT in patients with acute massive lower gastrointestinal bleeding when the source of bleeding is not visible on endoscopy, and urgent surgical jejunal resection to stop life-threatening bleeding caused by a jejunal GIST.
Topics: Aged, 80 and over; COVID-19; Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Gastrointestinal Stromal Tumors; Humans; Jejunum; Male
PubMed: 36107510
DOI: 10.1097/MD.0000000000030098 -
Surgical Oncology Mar 2022Postoperative Pancreatic Fistula (POPF) development remains a challenge after pancreaticoduodenectomy, occurring in 3-45% of cases [1]. The placement of a...
BACKGROUND
Postoperative Pancreatic Fistula (POPF) development remains a challenge after pancreaticoduodenectomy, occurring in 3-45% of cases [1]. The placement of a trans-anastomotic Wirsung stent is usually done in high-risk patients to decrease incidence and severity of POPF.
METHODS
Herein, we present a fully robotic pancreaticoduodenectomy with a biodegradable ductal stent interposition in a 47 y.o. female with a main duct IPMN of the pancreatic head and a fistula risk score of 6 (Moderate-risk).
VIDEO
After gastrocolic ligament division and hepatic flexure and duodenum mobilization, the loco-regional lymphadenectomy was performed. Following gastric transection with endo-GIA, the bile duct and gastroduodenal artery have been divided, and the cholecystectomy performed. The neck of the pancreas has been transected, the jejunum divided with endo-GIA and mobilized from the Treitz ligament, and the uncinate process dissected from the mesenteric vessels. A Blumgart anastomosis has been performed between the soft-texture pancreatic stump and the jejunal loop with the interposition of a 6 Fr/60 mm long, medium degrading stent (20 days) in the 2 mm duct (Archimedes BPS®, AMG Int., Winsen-Germany). The hepatico-jejunostomy and gastro-jejunostomy have been performed distally on the same loop. Three abdominal drains have been positioned.
RESULTS
Surgery lasted 480 min, with 175 mls blood loss. The patient postoperatively developed a biochemical leak and was discharged home by day 12. She was readmitted a month later for an amylase-negative intra-abdominal abscess that was successfully treated with percutaneous drainage.
CONCLUSION
Biodegradable pancreatic stent positioning could be an effective strategy in reducing POPF occurrence in high-risk patients.
Topics: Absorbable Implants; Female; Humans; Middle Aged; Pancreatic Intraductal Neoplasms; Pancreaticoduodenectomy; Robotic Surgical Procedures; Stents
PubMed: 35030411
DOI: 10.1016/j.suronc.2021.101706 -
The American Journal of Surgical... Jul 2021The tumor microenvironment (TME) has become an important area of investigation with respect to improving prognosis in malignancies. Here we evaluated TME prognostic risk...
The tumor microenvironment (TME) has become an important area of investigation with respect to improving prognosis in malignancies. Here we evaluated TME prognostic risk in small intestinal adenocarcinomas based on histologic assessment of tumor budding at the peritumoral-invasive front (pTB) and stromal tumor-infiltrating lymphocytes (sTILs). pTB and sTILs were analyzed in 230 surgically resected small intestinal adenocarcinomas, as recommended by the International Tumor Budding Consensus Conference (ITBCC) and the International TILs Working Group (ITWG). On the basis of high levels of pTB count (≥10) and sTIL density (≥20%), we combined pTB and sTIL to produce a collective TME-based prognostic risk index: low-risk (pTBLow/sTILHigh; n=39, 17.0%), intermediate-risk (pTBLow/sTILLow or pTBHigh/sTILHigh; n=99, 43.0%), and high-risk groups (pTBHigh/sTILLow; n=92, 40.0%). TME risk index provided better prognostic stratification than the individual pTB and sTIL (14.9 vs. 6.7 vs. 10.3). Tumors with higher TME prognostic risk were associated with an infiltrative growth pattern and nonintestinal immunophenotype (both P=0.001), pancreatic invasion (P=0.010), lymphovascular (P<0.001) or perineural invasion (P=0.006), higher T-category (P<0.001), N-category (P=0.004), and stage grouping (P=0.002), and KRAS mutation (P=0.008). In multivariate analysis, higher TME prognostic risk index (P<0.001), distal tumor location and nonintestinal immunophenotype (both P=0.001), higher N-category (P<0.001), and microsatellite stable (P=0.015) were worse-independent prognosticators. TME prognostic risk index consistently stratified patient survival regardless of tumor location (P<0.001 in proximal; P=0.002 in distal), stages (P<0.001 in lower stages I to II; P=0.028 in stage III), and DNA mismatch repair gene status (P<0.001 in microsatellite stable; P=0.001 in microsatellite instability). TME risk index is a powerful prognostic predictor for risk stratification of patients with small intestinal adenocarcinoma.
Topics: Adenocarcinoma; Aged; Cell Movement; Decision Support Techniques; Digestive System Surgical Procedures; Duodenal Neoplasms; Female; Humans; Ileal Neoplasms; Intestinal Neoplasms; Jejunal Neoplasms; Lymphocytes, Tumor-Infiltrating; Male; Middle Aged; Neoplasm Grading; Neoplasm Staging; Predictive Value of Tests; Retrospective Studies; Risk Assessment; Risk Factors; Stromal Cells; Time Factors; Treatment Outcome; Tumor Microenvironment
PubMed: 33443865
DOI: 10.1097/PAS.0000000000001668 -
Journal of Gastrointestinal Cancer Mar 2024One anastomosis gastric bypass (OAGB) is mainly criticized for the supposed carcinogenic effect of bile reflux on the gastric pouch mucosa.
INTRODUCTION
One anastomosis gastric bypass (OAGB) is mainly criticized for the supposed carcinogenic effect of bile reflux on the gastric pouch mucosa.
CASE PRESENTATION
A 56-year-old male patient presented 12 years after OAGB with a 10-month history of gradual dysphagia and vomiting. He was diagnosed with a tumor of the gastro-jejunal anastomosis, and underwent total gastrectomy with D2 lymphadenectomy. Specimen examination showed a diffuse isolated cell-type adenocarcinoma. To our knowledge, we report the first case in literature of adenocarcinoma of the gastro-jejunal anastomosis post-OAGB, and the second reported case if we include the Mason loop gastric bypass, which was the earlier version of OAGB with a different conceptual and physiological aspect.
CONCLUSION
The carcinogenic effect of bile reflux in OAGB will remain hypothetical until a detailed controlled study may prove the causality between bile reflux and gastric pouch malignancies in patients with a history of OAGB.
Topics: Humans; Male; Gastric Bypass; Middle Aged; Adenocarcinoma; Stomach Neoplasms; Anastomosis, Surgical; Gastrectomy; Jejunum; Bile Reflux
PubMed: 37690067
DOI: 10.1007/s12029-023-00968-7 -
PloS One 2021The current understanding of clinicopathological features and genomic variants of small-bowel cancer is limited, in part due to the rarity of the disease. However,...
The current understanding of clinicopathological features and genomic variants of small-bowel cancer is limited, in part due to the rarity of the disease. However, understanding of these factors is necessary for the development of novel therapeutic agents for small-bowel cancer. Thus, we aimed to identify the clinicopathological features and genomic variants associated with its prognosis and recurrence. We retrospectively examined 24 consecutive patients with primary small-bowel cancer surgically treated between May 2005 and August 2018 and collected 29 tumor specimens. The 29 lesions were subjected to mismatch repair status evaluation, using immunohistochemistry (IHC), and targeted genomic sequencing, after which they were analyzed using a panel of 90 cancer-related genes. IHC revealed that 45% (13/29) of the lesions exhibited deficient mismatch repair. The most common genomic variants in small-bowel cancers were in TP53 (48%, 13/27), followed by KRAS (44%, 12/27), ARID1A (33%, 9/27), PIK3CA (26%, 7/27), APC (26%, 7/27), and SMAD4, NOTCH3, CREBBP, PTCH1, and EP300 (22%, 6/27 each). Overall survival and disease-specific survival of patients with tumor mutational burden (TMB) ≥10 mutations/Mb (n = 17) were significantly better than those of patients with TMB <10 mutations/Mb (n = 6). Additionally, patients with a mutant SMAD4 had poorer recurrence-free survival than those with wild-type SMAD4. Our results suggested that TMB and SMAD4 mutations were associated with the prognosis of small-bowel cancer patients. Thus, cancer genomic analysis could be useful in the search for biomarkers of prognosis prediction in small-bowel cancers.
Topics: Adult; Aged; Biomarkers, Tumor; CREB-Binding Protein; DNA-Binding Proteins; Female; Humans; Ileal Neoplasms; Jejunal Neoplasms; Male; Middle Aged; Mutation; Receptors, Notch; Smad Proteins; Survival Analysis; Transcription Factors; Tumor Suppressor Protein p53; ras Proteins
PubMed: 34014970
DOI: 10.1371/journal.pone.0241454 -
Journal of Gastrointestinal Surgery :... Jun 2022The incidence of adenocarcinoma of the esophagogastric junction (AEG) has rapidly increased in recent years. Popular surgical approaches for AEG are proximal gastrectomy... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The incidence of adenocarcinoma of the esophagogastric junction (AEG) has rapidly increased in recent years. Popular surgical approaches for AEG are proximal gastrectomy (PG) and total gastrectomy (TG), but it is controversial as to which approach is superior. Therefore, we conducted a systematic review and meta-analysis to evaluate the short- and long-term clinical outcomes of PG and TG for AEG.
METHODS
PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to 1 June 2021. The Newcastle-Ottawa scale was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.
RESULTS
In all, 1,734 patients with Siewert II/III AEG in 12 studies were included in the meta-analysis. PG was associated with less number of harvested lymph nodes (WMD = - 9.00, 95% CI - 12.61 to - 5.39, P < 0.00001), smaller tumor size (WMD = - 1.02, 95% CI - 1.71 to - 0.33, P = 0.004), shorter hospital length of stay (WMD = - 3.99, 95% CI - 7.27 to - 0.71, P = 0.02), and better long-term nutritional status compared with TG. Overall complications, other complications, and overall survival were not significantly different between the two groups. Moreover, subgroup analysis revealed that the occurrence of anastomotic strictures and reflux esophagitis was associated with the use of novel gastrointestinal tract (GI) anastomoses (double-tract reconstruction, jejunal interposition, and semi-embedded valve anastomosis) after PG.
CONCLUSIONS
Based on the available evidence, we recommend that surgeons accept PG combined with multiple novel anastomoses as an optimal surgical approach in patients diagnosed with resectable Siewert type II/III AEG.
Topics: Adenocarcinoma; Esophageal Neoplasms; Esophagogastric Junction; Gastrectomy; Humans; Retrospective Studies; Stomach Neoplasms
PubMed: 35355172
DOI: 10.1007/s11605-022-05304-1 -
Clinical Journal of Gastroenterology Feb 2022The typical macroscopic appearance of gastrointestinal follicular lymphoma (FL) are multiple white granules or small white polyps, called multiple lymphomatous polyposis...
The typical macroscopic appearance of gastrointestinal follicular lymphoma (FL) are multiple white granules or small white polyps, called multiple lymphomatous polyposis type, and subsequent mass lesions with or without ulceration; however, an ulcer type with a stricture is extremely rare. We report a case of a 79-year-old male with severe jejunal stricture due to FL with an uncommon chromosomal translocation t(2;18)(p12;q21). The patient was treated with jejunectomy subsequent rituximab monotherapy with a favorable response. The presence of the stricture made its endoscopic diagnosis confusing; however, it was certainly accompanied by the distinctive white granules on the surface of the tumor as seen in typical FL. With the possibility of an FL with stricture in mind, it is important to collect subtle endoscopic findings of the surrounding mucosa carefully, in order to arrive at an accurate endoscopic diagnosis and eventually to the proper therapeutic option.
Topics: Aged; Constriction, Pathologic; Gastrointestinal Neoplasms; Humans; Lymphoma, Follicular; Male; Rituximab
PubMed: 34617259
DOI: 10.1007/s12328-021-01530-3 -
Minimally Invasive Therapy & Allied... Apr 2022The aim of this study was to compare the 1 year incidence of Petersen's hernia between individuals who were treated with the jejunal mesentery fixing (Mefix) method...
BACKGROUND
The aim of this study was to compare the 1 year incidence of Petersen's hernia between individuals who were treated with the jejunal mesentery fixing (Mefix) method and those with the closure of Petersen's space method.
MATERIAL AND METHODS
We retrospectively collected clinical data of patients who underwent gastrectomy for gastric cancers with the closure of Petersen's space defect ( = 49) and Mefix ( = 26). The Mefix method was performed by fixing the jejunal mesentery (jejunojejunostomy below 30 cm) to the transverse mesocolon using nonabsorbable barbed sutures.
RESULTS
The procedure time for mesentery fixing (3.7 ± 1.1 mins) was significantly shorter than that for Petersen's space closure (7.5 ± 1.5 mins) ( < .001) although the operation times were similar between the two groups. There was no incidence of Petersen's hernias postoperatively in both groups. One case of reoperation was reported in the closure group due to small bowel obstruction by kinking of the jejunojejunostomy.
CONCLUSION
We found no occurrence of Petersen's hernias postoperatively in either group. We also found that the Mefix method was faster and easier to perform than the closure method. The Mefix method is an excellent alternative method to prevent the occurrence of Petersen's hernia after B-II or Roux-en-Y reconstruction.
Topics: Gastric Bypass; Hernia, Abdominal; Humans; Laparoscopy; Mesentery; Obesity, Morbid; Retrospective Studies
PubMed: 33269633
DOI: 10.1080/13645706.2020.1848872