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Case Reports in Gastroenterology 2022Bouveret's syndrome is an unusual clinical presentation of gastric-outlet obstruction and is the most infrequent variant of gallstone ileus with just over 300 cases in...
Bouveret's syndrome is an unusual clinical presentation of gastric-outlet obstruction and is the most infrequent variant of gallstone ileus with just over 300 cases in the literature. A 73-year-old female presented with innocuous constitutional symptoms and was found to have Mirizzi type Vb, a cholecystoduodenal fistula with obstruction. Esophago-gastroduodenoscopy-attempted dislodgement was unsuccessful. A gastric-jejunal bypass was the only option due to friability of the tissue. On post-op day 5, the patient developed acute abdominal pain and was found to have gallstone ileus. This case emphasizes the importance of early surgical intervention in cases of acute on chronic cholecystitis.
PubMed: 35611125
DOI: 10.1159/000522251 -
Plastic and Reconstructive Surgery.... Aug 2020[This corrects the article DOI: 10.1097/GOX.0000000000002663.].
Erratum: Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunum Transfer: Erratum.
[This corrects the article DOI: 10.1097/GOX.0000000000002663.].
PubMed: 32983818
DOI: 10.1097/GOX.0000000000003094 -
Cureus Feb 2023Established consensus suggests that enteral nutrition is more beneficial in patients with a functioning gut than parenteral nutrition. It helps in early physical...
Established consensus suggests that enteral nutrition is more beneficial in patients with a functioning gut than parenteral nutrition. It helps in early physical rehabilitation from a disease or surgical stress and is associated with fewer complications compared to parenteral nutrition. Jejunal feeding is one of the routine modes of enteral nutrition in patients with gastric dysfunction, either due to surgery or critical illness. Various complications have been reported when using feeding tubes, grouped as mechanical, infectious, gastrointestinal, and metabolic. Here, we report an unusual case of a 47-year male with a history of prepyloric perforation repair leak who presented to us on postoperative day 14 with an enterocutaneous fistula and a feeding jejunostomy tube in situ. He was evaluated and managed conservatively and discharged on enteral feeds, both orally and via a jejunostomy tube. One month after discharge, he presented with features of intestinal obstruction with a missing jejunostomy tube. Radiological investigations suggested enteral migration of the jejunostomy tube, which was managed non-operatively, and the patient was discharged on day three post-admission after per rectal expulsion of the tube.
PubMed: 36923197
DOI: 10.7759/cureus.34861 -
Journal of Indian Association of... 2022Gastrointestinal (GI) malformations have varied short-term and long-term outcomes reported across various neonatal units in India.
BACKGROUND
Gastrointestinal (GI) malformations have varied short-term and long-term outcomes reported across various neonatal units in India.
METHODS
This descriptive study was done to study the clinical profile, outcomes and predictors of mortality in neonates operated for congenital GI malformations in a tertiary neonatal care unit in South India between years 2011 and 2020. Details were collected by retrospective review of the case sheets.
RESULTS
Total of 68 neonates were included with esophageal atresia (EA) in 10, infantile hypertrophic pyloric stenosis (IHPS) in 9, duodenal atresia (DA) in 10, ileal atresia in 8, jejunal atresia in 5, anorectal malformations (ARM) in 11, meconium ileus/peritonitis in 9, malrotation in 2, and Hirschsprung's disease (HD) in 4. Antenatal diagnosis was highest in DA (80%). Associated anomalies were maximum in EA (50%), the most common being vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal and radial abnormalities, and limb abnormalities association (VACTERL). Overall mortality was 15%. IHPS, DA, Malrotation, HD and ARM had 100 % survival while ileal atresia had the least survival (38%). Gestational age <32 weeks (odds ratio [OR] 12.77 [1.96, 82.89]) and outborn babies (OR 5.55 [1.01, 30.33]) were significant predictors of mortality in babies operated for small intestinal anomalies. None of the surviving infants were moderately or severely underweight at follow-up.
CONCLUSION
Overall survival of surgically correctable GI anomalies is good. Among the predictors for mortality, modifiable factors such as in-utero referral of antenatally diagnosed congenital anomalies need attention. One-fifth had associated anomalies highlighting the need to actively look for the same. Although these neonates are vulnerable for growth failure, they had optimal growth on follow-up possibly due to standardized total parenteral nutritional policy during neonatal intensive care unit stay.
PubMed: 35733590
DOI: 10.4103/jiaps.JIAPS_10_21 -
Nutrients May 2020Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous...
Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm ( = 232), and the length of distal small intestine was 117 ± 72 cm ( = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.
Topics: Aged; Bile Acids and Salts; Bodily Secretions; Digestion; Duodenum; Enterostomy; Female; Gastric Juice; Humans; Intestinal Absorption; Jejunum; Male; Middle Aged; Pancreatic Juice; Parenteral Nutrition; Parenteral Nutrition Solutions; Saliva; Short Bowel Syndrome; Treatment Outcome
PubMed: 32403450
DOI: 10.3390/nu12051376 -
Surgical Endoscopy Feb 2021The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging...
BACKGROUND
The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the "classical" Wirsung-jejunostomy.
METHODS
The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3-0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer.
RESULTS
A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks.
CONCLUSIONS
RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation.
Topics: Female; Humans; Jejunostomy; Male; Pancreaticojejunostomy; Robotic Surgical Procedures; Suture Techniques
PubMed: 33025248
DOI: 10.1007/s00464-020-07991-w -
Journal of Indian Association of... 2022Following esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, the standard leak rate reported in the literature is 5%-10%, and stricture rate is 40%-72%. There...
BACKGROUND
Following esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, the standard leak rate reported in the literature is 5%-10%, and stricture rate is 40%-72%. There is a global quest for surgical innovations to drive down these complication rates which can cause considerable morbidity.
METHODS
A prospectively maintained database of the senior author's patients who had esophageal atresia repair from 1995 to 2016 was reviewed. Two distinct innovations were implemented: (1) adequate or generous mobilization of the lower esophageal pouch and (2) a 2-5 mm slit in distal esophagus to widen its circumference.
RESULTS
Forty-three patients with EA/TEF were reviewed. Of those, 40 underwent primary repair. The median follow-up was 12.5 years (range 4-26 years). There were no anastomotic leaks and only 8 (20%) patients developed anastomotic strictures requiring dilations (1-5 dilations/patients). One patient (2.5%) had a recurrent fistula. One early mortality was recorded. At the latest follow-up, 35 (87.5%) patients had normal oral feeding, while 1 (2.5%) patient had occasional food sticking episodes. Four syndromic patients (10%) were on jejunal or gastrostomy feeding.
CONCLUSION
An adequate or generous mobilization of the distal esophageal pouch, together with a 2-5 mm slit in the distal esophagus, achieves a tension-free and wide anastomosis. All anastomoses eventually narrow, sometimes just a little, and starting on a higher scale with a small slit, helps. These seemingly minor innovations, when used together, contributed to a substantially lower complication rate sustained over a 22-year period - no leaks and only 20% stricture rate.
PubMed: 36714494
DOI: 10.4103/jiaps.jiaps_61_22 -
Head & Neck Aug 2021Pharyngocutaneous fistula is a potential life-threatening complication following head and neck surgery. There is only limited evidence about the efficacy of... (Review)
Review
BACKGROUND
Pharyngocutaneous fistula is a potential life-threatening complication following head and neck surgery. There is only limited evidence about the efficacy of vacuum-assisted closure (VAC) therapy and endoscopic vacuum-assisted closure (EndoVAC) therapy for the treatment of pharyngocutaneous fistulas.
METHODS
In this article, we report on a consecutive case series of six male patients with pharyngocutaneous fistula treated with a modified outside-in EndoVAC technique. We also present a review of the current related literature.
RESULTS
EndoVAC therapy alone was successful in five of the six patients (83.3%) with a median duration of EndoVAC therapy of 18.5 days (range: 7 to 32 days) and a median number of EndoVAC sponge changes of 4 (range: 1 to 9 changes). One patient needed additional reconstructive surgery after prior radiochemotherapy and jejunal transfer. No treatment-related complications were observed.
CONCLUSION
EndoVAC therapy is an easy-to-perform, safe procedure for the treatment of pharyngocutaneous fistulae.
Topics: Cutaneous Fistula; Endoscopy; Humans; Laryngectomy; Male; Negative-Pressure Wound Therapy; Pharyngeal Diseases; Postoperative Complications; Retrospective Studies
PubMed: 33830587
DOI: 10.1002/hed.26684 -
International Journal of Surgery Case... Jun 2023Aortoenteric fistulas (AEF) are infrequent malignant complications of abdominal aortic aneurysms (AAA). We present a unique case of a patient with recurring AAA...
INTRODUCTION
Aortoenteric fistulas (AEF) are infrequent malignant complications of abdominal aortic aneurysms (AAA). We present a unique case of a patient with recurring AAA fistulisations.
PRESENTATION OF CASE
During oncologic treatment, a 63-year-old male was incidentally diagnosed with infrarenal AAA and assigned follow-up but was hospitalised with anaemia and elevated inflammation markers 14 months later. A CT-angiography scan detected an AAA enlargement, but no extravasation (negative FOBT). Another CTA-scan displayed a pseudoaneurysm and ruptured AAA 10 days later. During a total laparotomy, an enlarged pulsating inflammatory conglomerate without active leakage was detected, with a 2 cm duodenal defect (PAEF). The AAA was resected and replaced by a linear silver-coated Dacron graft. 3,5 years after PAEF, the patient was hospitalised with abdominal pain and haematemesis. He underwent gastroscopies, coloscopies, CT- and CTA-scans - all without significant findings. Only after the capsule-endoscopy detected a jejunal ulcer, the PET-scan visualized active regions in the jejunum and the aortic graft. A total laparotomy was performed; previous stapler-lined jejuno-jejunal anastomosis had adhered to the silver-coated Dacron graft (SAEF). The Dacron graft was removed and replaced with a linear xenograft from bovine pericardium.
DISCUSSION
No evidence-based recommendations prefer endovascular aneurysm repair (EVAR) over open repair, leaving the strategy dependent on local preferences. Whether EVAR or initial xenograft usage would have shown surpassing results, is speculative, as no graft material/type has proved long-term pre-eminence.
CONCLUSIONS
This case displays AEF's complex treatment and challenging diagnosis. Multimodal diagnostic and strategic approaches should be considered for best patient outcome.
PubMed: 37220677
DOI: 10.1016/j.ijscr.2023.108344 -
Medicine Jan 2021Atrioesophageal fistula (AEF) is a rare but serious complication of atrial fibrillation (AF) catheter ablation with associated high mortality rates.
RATIONALE
Atrioesophageal fistula (AEF) is a rare but serious complication of atrial fibrillation (AF) catheter ablation with associated high mortality rates.
PATIENT CONCERNS
A 42-year-old male patient who underwent catheter ablation in local hospital 20 days ago because of persistent AF was admitted to our Emergency Room with unconsciousness and high axillary temperature and white blood cell count. Craniocerebral CT scan found multiple infarct lesions in both frontal and occipital lobes. Pneumatosis between the left atrium and the esophagus was observed in the chest CT.
DIAGNOSES
AEF.
INTERVENTIONS
We performed a salvage operation of the left atrium debridement, and left atrium patch repairing under extracorporeal circulation. We opened the mediastinum, and dissected the esophageal perforation. A special irrigating catheter with multiple side ports on the tip was placed from the esophagus to the posterior mediastinum through the esophageal orificium fistulae. We also inserted a gastrointestinal tube to the jejunum under gastroscopy. Three additional drainage tubes were inserted into the esophageal bed and the right thoracic cavity.
OUTCOMES
The procedure was successful. But 7 days later, the patient's family chose to forgo treatment due to multiple cerebral infarcts, respiratory and blood system infection, liver failure, and other complications.
LESSONS
AEF is a rare but fatal complication after catheter ablation. Heightened vigilance is required for early recognition of the AEF. Surgical treatment should be performed as early as possible, especially before the neurological complications occur.
Topics: Adult; Atrial Fibrillation; Catheter Ablation; Esophageal Fistula; Heart Atria; Heart Diseases; Humans; Male; Postoperative Complications; Vascular Fistula
PubMed: 33466203
DOI: 10.1097/MD.0000000000024226