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Arquivos Brasileiros de Cirurgia... 2023New therapies have revolutionized the treatment of Crohn's disease (CD), but in some countries, the surgery rate has not changed, the frequency of emergency surgery is...
BACKGROUND
New therapies have revolutionized the treatment of Crohn's disease (CD), but in some countries, the surgery rate has not changed, the frequency of emergency surgery is underestimated, and surgical risk is poorly studied.
AIMS
The aim of this study was to identify risk factors and clinical indications for primary surgery in CD patients at the tertiary hospital.
METHODS
This was a retrospective cohort of a prospectively collected database of 107 patients with CD from 2015 to 2021. The main outcomes were the incidence of surgery treatment, types of procedures performed, surgical recurrence, surgery free time, and risk factors for surgery.
RESULTS
Surgical intervention was performed in 54.2% of the patients, and most of the procedures were emergency surgeries (68.9%). The elective procedures (31.1%) were performed over 11 years after diagnosis. The main indications for surgery were ileal stricture (34.5%) and anorectal fistulas (20.7%). The most frequent procedure was enterectomy (24.1%). Recurrence surgery was most common in emergency procedures (OR 2.1; 95%CI 1.6-6.6). Montreal phenotype L1 stricture behavior (RR 1.3; 95%CI 1.0-1.8, p=0.04) and perianal disease (RR 1.43; 95%CI 1.2-1.7) increased the risk of emergency surgeries. The multiple linear regression showed age at diagnosis as a risk factor for surgery (p=0.004). The study of surgery free time showed no difference in the Kaplan-Meier curve for Montreal classification (p=0.73).
CONCLUSIONS
The risk factors for operative intervention were strictures in ileal and jejunal diseases, age at diagnosis, perianal disease, and emergency indications.
Topics: Humans; Crohn Disease; Constriction, Pathologic; Retrospective Studies; Risk Factors; Hospitals
PubMed: 37194862
DOI: 10.1590/0102-672020230002e1730 -
Frontiers in Pharmacology 2022In the Montreal classification, L4 Crohn's disease (CD) is defined as an ileal disease, including L4-esophagogastric duodenum (EGD), L4-jejunum, and L4-proximal ileal...
In the Montreal classification, L4 Crohn's disease (CD) is defined as an ileal disease, including L4-esophagogastric duodenum (EGD), L4-jejunum, and L4-proximal ileal involvement. According to the previous studies, the prognosis of L4 disease was worse than that of non-L4 disease. Among L4 diseases, the phenotypes of L4-jejunum and L4-proximal ileum indicated that the risk of abdominal surgery was higher. However, the prognosis of L4-esophagogastroduodenal remains largely elusive. Therefore, we aim to investigate whether the prognosis differs between CD patients with and without esophagogastroduodenal involvement. In this study, patients with L4-EGD phenotype ( = 74) who underwent gastroscopy, ileocolonoscopy, biopsies, and CTE from 2018 to 2020 were compared with L4 non-EGD controls ( = 148) who were randomly selected at a ratio of 1:2 in the same period. Demographic information inclusive of disease conduct and location, important points of the surgery, and hospitalization have been collected. The distinction between L4-EGD patients and non-L4-EGD patients was identified by way of multivariable logistic regression analysis. The Kaplan-Meier technique was used to consider the possibility of abdominal surgical operation and complications, observed by means of Cox percentage hazard fashions to decide if L4 EGD independently estimated the endpoints inclusive of the abdominal surgery and the occurrences of complications. L4-EGD group ( = 74) had a lower proportion of intestinal fistula than the control group ( = 148) (17.6% 34.5%; = 0.009), and the probabilities of requiring abdominal surgery and multiple abdominal surgeries were also lower (21.6% 36.5%; = 0.025), (6.8% 18.9%; = 0.016), respectively. The frequency of hospitalization was lower in the L4-EGD group than in the control group (3-7 4-9; = 0.013). L4-EGD phenotype was found to be an independent protective factor for abdominal surgery and intestinal fistula in the Cox regression model, with HRs of 0.536 (95%CI: 0.305-0.940; = 0.030) and 0.478 (95%CI: 0.259-0.881; = 0.018), respectively. Our data suggest that the L4-EGD phenotype may have a better prognosis compared to the Non-L4-EGD phenotype. Our data may advocate a revision of the Montreal classification including separate designations for L4-EGD disease.
PubMed: 36386193
DOI: 10.3389/fphar.2022.963892 -
Annals of Surgery Open : Perspectives... Jun 2022To assess whether prophylactic irrigation and passive drainage of pancreatico-jejunal anastomosis could reduce leak and mortality rates after high-risk...
OBJECTIVE
To assess whether prophylactic irrigation and passive drainage of pancreatico-jejunal anastomosis could reduce leak and mortality rates after high-risk pancreaticoduodenectomies.
BACKGROUND
Postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreaticoduodenectomy. Several risk factors have been proposed likewise potential mitigation strategies. Regarding the latter, surgical drain policy remains a "hot topic." We propose an innovative approach to mitigate POPF and POPF-related mortality following high-risk pancreaticoduodenectomies.
METHODS
One hundred fifty-seven patients undergoing pancreaticoduodenectomy between January 2012 and November 2021 were included in the study. Subjects with main pancreatic duct ≤ 3 mm and soft parenchyma were classified as high-risk for POPF development. Since August 2015, high-risk patients received prophylactic irrigation and drainage of the perianastomotic area. These patients were compared with risk-matched historical controls.
RESULTS
We identified 73 high-risk patients. Of these, the 47 subjects receiving prophylactic perianastomotic irrigation showed significantly lower POPF rates (12.7% vs 69.2%, < 0.001). Multivariate regression analysis confirmed the significant association between irrigation drainages and POPF (odds ratio 0.014, = 0.01). Although not significant, mortality was lower in the irrigation group (4.2% vs 13.0%, = 0.340). However, none of the fatalities in the irrigation-drainage group were POPF-related. No significant difference in length of hospital stay was observed between the 2 groups (18.0 vs 21.0 days, = 0.091).
CONCLUSIONS
Irrigation and drainage of the perianastomotic area represents a powerful approach to reduce POPF and, potentially, mortality after high-risk pancreaticoduodenectomies.
PubMed: 37601610
DOI: 10.1097/AS9.0000000000000154 -
World Journal of Surgical Oncology Oct 2023This is a letter to the editor on a study by Ding et al. on the role of the three-tube method via precise interventional placement for esophagojejunal anastomotic...
This is a letter to the editor on a study by Ding et al. on the role of the three-tube method via precise interventional placement for esophagojejunal anastomotic fistula after gastrectomy. They suggest using transnasal insertion of abscess drainage catheter, jejunal decompression tube, and jejunal nutrition tube under fluoroscopy as a simple, minimally invasive, effective, and safe method for treating esophagojejunal anastomotic fistula. Compared to Ding et al.'s method, we presented a new procedure for the esophagojejunal anastomotic fistula. In this procedure, we precisely place a homemade triple-cavity drainage tube by guide wire exchange method near the esophagojejunal anastomotic fistula for continuous irrigation and negative pressure suction, which can provide adequate drainage and result in fistula's self-healing. This procedure can also be performed at bedside without any anesthesia; therefore, it is a more simple, minimally invasive, effective, and safe treatment for esophagojejunal anastomotic fistula.
Topics: Humans; Drainage; Fistula; Anastomosis, Surgical; Gastrectomy; Abscess; Anastomotic Leak; Retrospective Studies
PubMed: 37891613
DOI: 10.1186/s12957-023-03224-1 -
Case Reports in Surgery 2022Intestinal malrotation is a rare congenital disease caused by abnormal intestinal rotation and fixation of the intestinal tract in the early embryonic state. Adult cases...
Intestinal malrotation is a rare congenital disease caused by abnormal intestinal rotation and fixation of the intestinal tract in the early embryonic state. Adult cases are rare. A laparoscopic Ladd procedure for adult intestinal malrotation is increasingly reported, but owing to the rarity, some important aspects of the disease and its treatment may be overlooked. Three adult cases of intestinal malrotation that underwent surgery at our hospital between January 2019 and October 2020 were retrospectively examined about patient backgrounds, short-term results, and complications. All patients were male, median age was 54.6 years, and the complaints were abdominal pain and/or distention. No midgut volvulus was observed. The laparoscopic Ladd procedure was performed for all cases. One patient underwent reoperation (duodenoduodenostomy) because of impaired passage of the duodenal descending section due to postoperative pancreatic fistula. The postoperative courses of the other two patients were good. No recurrence of symptoms was observed in any of the cases. The reason for reoperation in one of the cases is considered to be pancreatic injury when the severe curve from the duodenum to the upper jejunum near the pancreatic head was straightened. Correction of the curve is important to improve passage disorder of the duodenum, but special care is required to avoid organ damage, especially during a laparoscopic procedure with forceps. The laparoscopic Ladd procedure for adult intestinal malrotation is recommended if there is no midgut volvulus; it is minimally invasive and a comparatively simple technique, but surgeons should take special care to avoid organ damage.
PubMed: 36304201
DOI: 10.1155/2022/6874885 -
Proceedings (Baylor University. Medical... 2022Small bowel diverticulum, though rare, can result in complications including diverticulitis, hemorrhage, intussusception, fistula, perforation, or bacterial overgrowth....
Small bowel diverticulum, though rare, can result in complications including diverticulitis, hemorrhage, intussusception, fistula, perforation, or bacterial overgrowth. Here, we present a case of gastrointestinal bleeding as a complication of jejunal diverticulum, resulting in hemorrhagic shock. The patient had a negative endoscopy and colonoscopy, prompting computed tomography angiogram, which identified one jejunal diverticulum with active contrast extravasation into the lumen of the small bowel. She underwent successful coil embolization, resulting in cessation of bleeding. This case demonstrates the difficult but successful identification of nonsteroidal antiinflammatory drug-induced jejunal diverticular bleeding in the acute emergent setting.
PubMed: 36304625
DOI: 10.1080/08998280.2022.2097573 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... May 2024Magnet ingestion in children can lead to serious complications, both acutely and chronically. This case report discusses the treatment approach for a case involving... (Review)
Review
Magnet ingestion in children can lead to serious complications, both acutely and chronically. This case report discusses the treatment approach for a case involving multiple magnet ingestions, which resulted in a jejuno-colonic fistula, segmental intestinal volvulus, hepa-tosteatosis, and renal calculus detected at a late stage. Additionally, we conducted a literature review to explore the characteristics of intestinal fistulas caused by magnet ingestion. A six-year-old girl was admitted to the Pediatric Gastroenterology Department pre-senting with intermittent abdominal pain, vomiting, and diarrhea persisting for two years. Initial differential diagnoses included celiac disease, cystic fibrosis, inflammatory bowel disease, and tuberculosis, yet the etiology remained elusive. The Pediatric Surgery team was consulted after a jejuno-colonic fistula was suspected based on magnetic resonance imaging findings. The physical examination revealed no signs of acute abdomen but showed mild abdominal distension. Subsequent upper gastrointestinal series and contrast enema graphy confirmed a jejuno-colonic fistula and segmental volvulus. The family later reported that the child had swallowed a magnet two years prior, and medical follow-up had stopped after the spontaneous expulsion of the magnets within one to two weeks. Surgical intervention was necessary to correct the volvulus and repair the large jejuno-colonic fistula. To identify relevant studies, we conducted a detailed literature search on magnet ingestion and gastrointestinal fistulas according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified 44 articles encompassing 55 cases where symptoms did not manifest in the acute phase and acute abdomen was not observed. In 29 cases, the time of magnet ingestion was unknown. Among the 26 cases with a known ingestion time, the average duration until fistula detection was 22.8 days (range: 1-90 days). Fistula repairs were performed via laparotomy in 47 cases.
Topics: Humans; Female; Intestinal Fistula; Child; Foreign Bodies; Magnets; Malabsorption Syndromes; Jejunal Diseases; Intestinal Volvulus; Colonic Diseases
PubMed: 38738679
DOI: 10.14744/tjtes.2024.50845 -
Journal of Cardiothoracic Surgery Dec 2022Acute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence...
BACKGROUND
Acute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence about their management is poor and surgical treatment is mostly based on tailored approaches, so each new experience could be useful to improve knowledge about this peculiar condition. We report a unique case of an esophago-colonic resection and re-anastomosis without sternal approximation after recurrent anastomosis failure and strictures.
CASE PRESENTATION
A 69-year-old woman was referred to our hospital for worsening dysphagia. The patient had undergone esophago-gastrectomy with right colon interposition 12 years prior due to caustic ingestion. The esophago-colonic anastomosis was initially complicated by an enterocutaneous fistula, which was treated with anastomosis resection and left colon transposition. This was then further complicated by dehiscence and sternal infection treated with resection of the distal portion of the sternum and a new colo-jejunal anastomosis. Finally, a chronic anastomotic stricture occurred, refractory to endoscopic dilatation and prothesis positioning. We planned a new colonic-esophageal resection and re-anastomosis. The main technical challenges were addressing the adhesions resulting from previous surgery and mobilizing an adequate length of the intestinal tract to allow conduit continuity restoration. Blood supply was assessed through Indocyanine Green Fluorescence. To avoid compression of the digestive conduit sternal margins were not re-approximated, and the transposed tube was covered and protected using both pectoralis major muscles flap. We decided to avoid the use of any prosthetic material to reduce the risk of infection. The patient was able to resume oral food intake on the 12th day postoperatively after a barium swallowing test showed an adequate conduit caliber.
CONCLUSION
Esophago-colonic anastomosis complications represent a life-threatening condition. Therefore, reports and sharing of knowledge are important to improve expertise in management of these conditions.
Topics: Female; Humans; Aged; Anastomosis, Surgical; Esophagus; Gastrectomy; Colon; Dilatation; Postoperative Complications
PubMed: 36527148
DOI: 10.1186/s13019-022-02085-1 -
International Journal of Surgery Case... May 2023Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual....
INTRODUCTION AND IMPORTANCE
Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual. We report a rare case of GI with a successful surgical treatment for a 65 year-old-female.
CASE PRESENTATION
A 65 year-old-woman, presented with biliary colic pain and vomiting for three days. On examination, she had a distended tympanic abdomen. A computed tomography scan revealed signs of small bowel obstruction due to a jejunal gallstone. She had pneumobilia due to a cholecysto-duodenal fistula. We performed a midline laparotomy. We found a dilated and ischemic jejunum with false membranes regarding the migrated gallstone. We performed a jejunal resection with primary anastomosis. We performed cholecystectomy and closed the cholecysto-duodenal fistula at the same operative time. The postoperative course was uneventful.
CLINICAL DISCUSSION
We reported successful surgical treatment for GI. It was a one-step procedure. GI is a rare situation. Due to their restricted lumen, the terminal ileum and the ileocaecal valve are where GI occurs most commonly. GI appears usually in elderly patients with comorbidities. The clinical presentation is not specific. CT scan evokes the diagnosis with high specificity. The surgical management of GI is not consensual. In our case, we performed bowel resection due to the presence of an ischemic intestine.
CONCLUSION
GI is a rare situation. It appears usually in elderly patients with comorbidities. The clinical presentation is not specific. The surgical management of GI is not consensual.
PubMed: 37075501
DOI: 10.1016/j.ijscr.2023.108221 -
BMJ Case Reports Mar 2022Jejunocolic fistula, a late complication of intestinal lymphoma, is a rare entity with only five reported cases in the literature. We report a young male presenting with...
Jejunocolic fistula, a late complication of intestinal lymphoma, is a rare entity with only five reported cases in the literature. We report a young male presenting with a left lateral neck mass 5 years ago which then progressed to superior vena cava syndrome. Despite receiving radiotherapy and two cycles of chemotherapy, there was still tumour progression. He presented with a 2-week history of diarrhoea, haematochezia and weight loss for which antibiotics provided no relief. Esophagogastroduodenoscopy and colonoscopy showed a jejunocolic fistula. After discussion with the multidisciplinary team, nutritional upbuilding was initiated followed by exploratory laparotomy with segmental resection and anastomosis. On histopathology, diffuse large B-cell lymphoma involving the jejunum and colon was noted. Despite receiving palliative chemotherapy, he still succumbed to disease progression. This case highlights the importance of early recognition of jejunocolic fistulas among patients with intestinal lymphomas to facilitate early multidisciplinary intervention.
Topics: Colonic Diseases; Diarrhea; Humans; Intestinal Fistula; Lymphoma, Large B-Cell, Diffuse; Male; Superior Vena Cava Syndrome
PubMed: 35241445
DOI: 10.1136/bcr-2021-245495