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International Journal of Surgery Case... Aug 2023Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation,...
INTRODUCTION
Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation, can account for 1.8-7% of cases. In an infant with non-specific abdominal complaints and a vaguely palpable upper abdominal mass, a perforated CC may be overlooked, leading to a delayed or misdiagnosis and a detrimental outcome.
CASE PRESENTATION
We describe a 10-month-old girl who presented to the office with upper abdominal pain and associated fullness for two weeks. An abdominal ultrasonogram revealed perihepatic collections and an evident dilatation of the common bile duct. The bile aspirated from the collections prompted pigtail drainage as an emergency. Magnetic resonance cholangiopancreatography later revealed a spontaneously perforated CC with residual bilioma. Elective resection after six weeks, followed by bilio-enteric reconstruction, resulted in an uneventful recovery.
CLINICAL DISCUSSION
Biliary peritonitis and localized biliomas are rare forms among the wide range of findings that can accompany CC. Satisfactory outcomes can be achieved with a two-stage procedure that entails biliary drainage with sepsis control, followed by resection of the CC and bilio-enteric reconstruction a few weeks later.
CONCLUSION
It is important to be aware of the spectrum of findings that CC may present. We discussed our experience successfully treating a perforated type IVa CC.
PubMed: 37490811
DOI: 10.1016/j.ijscr.2023.108555 -
Cureus Jun 2023Duodenal trauma resulting in perforation is rare and management can be challenging due to injuries in other organs and vascular structures. Primary repair is the...
Duodenal trauma resulting in perforation is rare and management can be challenging due to injuries in other organs and vascular structures. Primary repair is the preferred option and is technically feasible even in cases with large defects. In more complex injuries with pancreaticobiliary tract involvement, damage control techniques and staged procedures may be required. Triple tube drainage with tube gastrostomy, tube duodenostomy, and feeding jejunostomy can benefit the adequate decompression of the duodenum and protect the primary repair suture line. We report the case of a 35-year-old male patient with perforation in the second part of the duodenum following a gunshot injury, who was managed with primary repair and triple tube drainage.
PubMed: 37416037
DOI: 10.7759/cureus.39995 -
Pediatric Surgery International May 2023Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically...
INTRODUCTION
Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management.
AIM
To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details.
MATERIALS AND METHOD
All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied.
RESULTS
The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively.
CONCLUSION
3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery.
LEVEL OF EVIDENCE
Treatment study level IV.
Topics: Child; Humans; Female; Child, Preschool; Choledochal Cyst; Duodenostomy; Retrospective Studies; Treatment Outcome; Laparoscopy; Anastomosis, Roux-en-Y
PubMed: 37133562
DOI: 10.1007/s00383-023-05472-4 -
Gastroenterology Aug 2023Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of... (Randomized Controlled Trial)
Randomized Controlled Trial
EUS-Guided Choledocho-duodenostomy Using Lumen Apposing Stent Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Trial (DRA-MBO Trial).
BACKGROUND & AIMS
Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of metal stents in unresectable malignant distal biliary obstruction (MDBO) and the results were conflicting. The aim of the current study was to compare the outcomes of the procedures in a large-scale study.
METHODS
This was a multicenter international randomized controlled study. Consecutive patients admitted for obstructive jaundice due to unresectable MDBO were recruited. Patients were randomly allocated to receive EUS-guided choledocho-duodenostomy (ECDS) or ERCP for drainage. The primary outcome was the 1-year stent patency rate. Other outcomes included technical success, clinical success, adverse events, time to stent dysfunction, reintervention rates, and overall survival.
RESULTS
Between January 2017 and February 2021, 155 patients were recruited (ECDS 79, ERCP 76). There were no significant differences in 1-year stent patency rates (ECDS 91.1% vs ERCP 88.1%, P = .52). The ECDS group had significantly higher technical success (ECDS 96.2% vs ERCP 76.3%, P < .001), whereas clinical success was similar (ECDS 93.7% vs ERCP 90.8%, P = .559). The median (interquartile range) procedural time was significantly shorter in the ECDS group (ECDS 10 [5.75-18] vs ERCP 25 [14-40] minutes, P < .001). The rate of 30-day adverse events (P = 1) and 30-day mortality (P = .53) were similar.
CONCLUSION
Both procedures could be options for primary biliary drainage in unresectable MDBO. ECDS was associated with higher technical success and shorter procedural time then ERCP. Primary ECDS may be preferred when difficult ERCPs are anticipated. This study was registered to Clinicaltrials.gov NCT03000855.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cholestasis; Duodenostomy; Common Bile Duct; Neoplasms; Endosonography; Stents; Drainage; Ultrasonography, Interventional
PubMed: 37121331
DOI: 10.1053/j.gastro.2023.04.016 -
Cureus Mar 2023One of the main causes of proximal bowel obstruction in neonates is congenital duodenal obstruction. It can be grouped by intrinsic and extrinsic factors and the...
One of the main causes of proximal bowel obstruction in neonates is congenital duodenal obstruction. It can be grouped by intrinsic and extrinsic factors and the presentation may differ depending on whether the obstruction is complete or partial. The intrinsic factors include duodenal atresia, duodenal stenosis, or duodenal web. The extrinsic factors include malrotation with Ladd's band, annular pancreas, anterior portal vein, and duodenal duplication. Malrotation may present with or without midgut volvulus. We are sharing a rare presentation of congenital duodenal obstruction with combined intrinsic and extrinsic causes, namely, duodenal stenosis with gastrointestinal malrotation in a neonate. The patient underwent successful exploratory laparotomy, corrective Kimura's procedure (duodenostomy), Ladd's procedure, and appendicectomy. Early recognition of signs and symptoms, prompt corrective surgery, and adequate optimization of metabolic components post-operatively are important to determine the decreased morbidity and mortality of neonates.
PubMed: 37065346
DOI: 10.7759/cureus.36137 -
Mymensingh Medical Journal : MMJ Apr 2023Of all varieties, Type I Choledochal cyst causing saccular or fusiform dilatation of the extra-hepatic biliary ductal system is the commonest (90.0 - 95.0%). Its...
Of all varieties, Type I Choledochal cyst causing saccular or fusiform dilatation of the extra-hepatic biliary ductal system is the commonest (90.0 - 95.0%). Its presentations vary. To restore the continuity of the extra-hepatic biliary tract after excision of type I Choledochal cyst, surgeons have few alternatives to use, with their advantages and disadvantages. Roux en-Y Hepatico-jejunostomy (RYHJ) has been very popular and long studied standard surgical treatment for type I Choledochal cyst. But now Hepatico-duodenostomy (HD) is also being practiced and studied in different centers all over the world for the treatment of the same disease. For the last five years, we, at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, have been using Hepatico-duodenostomy as preferred anastomotic option in treating type I Choledochal cyst. Here, we are presenting our experience at BSMMU Hospital, regarding operative events and time requirement of Hepaticoduodenostomy for the treatment of type I Choledochal cyst and, to show whether this procedure can be safely practiced, producing acceptable results. It is a retrospective document study, from January 2013 to December 2017, at BSMMU Hospital, on forty two, MRCP confirmed type I Choledochal cyst patients of pediatric age. Patients' particulars, history, physical examination, investigations (including MRCP confirmation), assessment, surgical plan were collected from relevant medical records and documented in duly coded individual data collection sheet maintaining standard privacy protocol. Information regarding presentations, operative findings and procedural events including per-operative mortality, injury to the vital structures during operation, conversion to RYHJ, operative time (minutes), blood loss and transfusion requirements (ml) of Heaticoduodenostomy for type I Choledochal cyst, were specially searched for. There was no operative mortality. None of these patients required per-operative blood transfusion. Nor there was any inadvertent injury to the adjacent structures. The mean operative time required for Hepaticoduodenostomy was 88 minutes with a range of 75 to 125 minutes. Through this study, at BSMMU Hospital, operative events and time requirement of Hepatico-duodenostomy for treating type I Choledochal cyst, was found to be yielding acceptable results, for safe practice.
Topics: Child; Humans; Choledochal Cyst; Retrospective Studies; Treatment Outcome; Duodenostomy; Laparoscopy; Bangladesh; Hospitals
PubMed: 37002757
DOI: No ID Found -
Endoscopic Ultrasound 2023EUS-guided choledoco-duodenostomy using electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) is becoming the gold standard in case of endoscopic retrograde...
BACKGROUND
EUS-guided choledoco-duodenostomy using electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) is becoming the gold standard in case of endoscopic retrograde cholangio-pancreatography failure for distal malignant obstruction. Long-term data in larger samples are lacking.
METHODS
This was a prospective monocentric study including all patients who underwent EUS-guided choledochoduodenostomy (CDS) between September 2016 and December 2021. The primary endpoint was the rate of biliary obstruction during follow-up. Secondary endpoints were technical and clinical success rates, adverse event rates, and identification of risk factors for biliary obstruction.
RESULTS
One hundred and twenty-three EUS-guided CDS using ECE-LAMS were performed at Limoges University Hospital were performed during the study period and included in the study. The main cause of obstruction was pancreatic adenocarcinoma in 91 (74.5%) cases. The technical and clinical success rates were 97.5% and 91%, respectively. Twenty patients (16.3%) suffered from biliary obstructions during a mean follow-up of 242 days. The clinical success rate for endoscopic desobstruction was 80% (16/20). In uni- and multivariate analyses, only the presence of a duodenal stent (odds ratio [OR]: 3.6, 95% confidence interval [CI] 95%: 1.2-10.2; P = 0.018) and a bile duct thinner than 15 mm (OR: 3.9, CI 95%: 1.3-11.7; P = 0.015) were the significant risk factors for biliary obstruction during the follow-up.
CONCLUSION
Obstruction of LAMS occurred in 16.3% of cases during follow-up and endoscopic desobstruction is efficacious in 80% of cases. The presence of duodenal stent and a bile duct thinner than 15 mm are the risk factors of obstruction. Except in these situation, EUS-CDS with ECE-LAMS could be proposed in the first intent in case of distal malignant obstruction.
PubMed: 36891940
DOI: 10.4103/EUS-D-22-00120 -
Acta Gastro-enterologica Belgica 2023Malignant biliary obstruction (MBO) is often diagnosed at late stages with mostly unresectable lesions. Recently, EUS-guided biliary drainage (EUS-BD) has gained wide...
BACKGROUND/AIM
Malignant biliary obstruction (MBO) is often diagnosed at late stages with mostly unresectable lesions. Recently, EUS-guided biliary drainage (EUS-BD) has gained wide acceptance and appears to be a feasible and safe backup option after ERCP failure in such patients. Herein, we aimed to represent a 3-year multi-center Egyptian experience in the application of this challenging procedure for distal MBO as a salvage technique after failed ERCP.
PATIENTS AND METHODS
This was a prospective multi-center study of patients underwent EUS-BD for distal MBO in the duration between December 2018 and December 2021, after ERCP failure.
RESULTS
Ninety-one patients (59 males, median age: 61 years) were included in the study. EUS-guided extrahepatic approach including choledocho-duodenostomy (CDS) was done for 48 patients (52.8%), followed by choledecho-antrostomy (CAS) in 4 patients (4.4%). The intrahepatic approach included hepaticogastrostomy (HGS) for 35 patients (38.5%) and antegrade stenting (AG) stenting in 2 patients (2.2%), while Rendezvous (RV) approach was performed in 2 patients (2.2%). Technical and Clinical success were achieved in the majority of cases; 93.4% and 94.1% respectively. Adverse events occurred in 13.2% of patients which were mostly mild (8.2%) to moderate (2.4%). Only one patient died within 48h after the procedure with progression of preceding sepsis and organ failure.
CONCLUSION
EUS-BD is a feasible option, even in developing countries, after a failed ERCP, and it is a relatively safe option in patients with MBO once experienced team and resources were present. Majority of cases in our study have achieved technical and clinical success with relatively low incidence of adverse events.
Topics: Male; Humans; Middle Aged; Prospective Studies; Egypt; Cholangiopancreatography, Endoscopic Retrograde; Neoplasms; Endosonography; Cholestasis; Stents; Drainage; Ultrasonography, Interventional
PubMed: 36842173
DOI: 10.51821/86.1.10828 -
Annali Italiani Di Chirurgia 2023To describe our Spoke Center experience in Damage Control Surgery (DCS) in a non traumatic patient and the possibility of delayed abdominal wall reconstruction (AWR)....
AIM
To describe our Spoke Center experience in Damage Control Surgery (DCS) in a non traumatic patient and the possibility of delayed abdominal wall reconstruction (AWR). Material of Study The case of a 73 years old Caucasian male treated with DCS for a septic shock due to a duodenal perforation and his clinical course till the abdominal wall reconstruction.
RESULTS
We made DCS with abbreviated laparotomy, suture of the ulcer and duodenostomy with a foley placed in right hypochondrium. Patiens was discharged with a low-flow fistula and with TPN. After 18 months we made an open cholecystectomy and a complete abdominal wall reconstruction with Fasciotens Hernia System® adding a biological mesh.
DISCUSSION AND COMMENTS
Periodic training in emergency settings and in complex abdominal wall procedures is the right way to manage critic clinical case. Like Niebuhr's abbreviated laparotomy experience also in our case this procedure allows primary closure of complex hernias and is potentially less prone to complications than component separation methods. Unlike Fung's experience we didn' t use negative pressure wound therapy system (NPWT) equally achieving good results.
CONCLUSIONS
Elective repair of abdominal wall disaster is possible even in elderly patients who have been treated by abbreviated laparotomy and DCS surgery. In order to obtain good results is fundamental to have a trained staff.
KEY WORDS
Damage Control Surgery (DCS), Giant incisional Hernia, Abdominal Wall Repair.
Topics: Aged; Humans; Male; Abdominal Muscles; Abdominal Wall; Hernia, Ventral; Incisional Hernia; Laparotomy; Surgical Mesh
PubMed: 36810304
DOI: No ID Found -
Clinical Endoscopy Mar 2023Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may... (Review)
Review
Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.
PubMed: 36796854
DOI: 10.5946/ce.2022.198