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Surgical Endoscopy Dec 2023Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The...
INTRODUCTION
Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks.
METHODS
A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed.
RESULTS
The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery.
CONCLUSIONS
Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.
Topics: Male; Humans; Female; Adult; Follow-Up Studies; Obesity, Morbid; Laparoscopy; Gastrectomy; Stomach; Retrospective Studies; Treatment Outcome; Anastomotic Leak
PubMed: 37640954
DOI: 10.1007/s00464-023-10386-2 -
International Journal of Surgery Case... Sep 2023By 2030 it is predicted that 1 in 5 women and 1 in 7 men will be living with obesity. The only long-term effective strategy for achieving significant weight loss over...
INTRODUCTION AND IMPORTANCE
By 2030 it is predicted that 1 in 5 women and 1 in 7 men will be living with obesity. The only long-term effective strategy for achieving significant weight loss over time is surgical treatment. One Anastomosis Gastric Bypass (OAGB) has been proposed as an effective therapeutic option. Stenosis of Gastro-Jejunal Anastomosis (GJA) is one of the most common long-term complications and its cause recognized as multifactorial.
CASE PRESENTATION
We present the case of a patient with a history of progressive postoperative oral intolerance after OAGB with 60 kg weight loss (BMI 20.7 kg/m). Severe stenosis of the GJA and massive dilation of the gastric remnant was documented, treated multiple times with endoscopic balloon dilation. He was referred to our unit due to persistent symptoms. Revision surgery to a Gastric Bypass was programmed, ultimately performed via an open approach with resection of 80 % of the gastric remnant.
CLINICAL DISCUSSION
Endoscopic dilatation and surgical revision are the two primary treatment options for GJA stricture. In refractory cases to pneumatic dilation, laparoscopic revision surgery is indicated, however an open approach is frequently required, as surgeries are technically demanding due to distorted anatomy in this population.
CONCLUSION
Operations to correct chronic complications are tailored to the patient's anatomy as well as the symptoms or pathologies they are intended to correct. Whilst revision surgeries are associated with an increased risk of conversion, complications and longer hospital stay, they can be performed safely in experienced centers.
PubMed: 37633198
DOI: 10.1016/j.ijscr.2023.108557 -
Heliyon Jul 2023A systematic review of international case reports of patients with Heyde syndrome (HS) treated by transcatheter aortic valve implantation (TAVI) was conducted to explore... (Review)
Review
OBJECTIVE
A systematic review of international case reports of patients with Heyde syndrome (HS) treated by transcatheter aortic valve implantation (TAVI) was conducted to explore the clinical characteristics of this group of patients and sirgical success. Methods: Electronic databases, including PubMed, Embase and CNKI, were searched with combinations of the search terms, Heyde syndrome, gastrointestinal bleeding, aortic stenosis, angiodysplasia and transcatheter aortic valve replacement. All case reports were screened according to inclusion criteria, and HS patient data was summarized.
RESULTS
A total of 31 case reports concerned patients with a history of aortic stenosis and repeated gastrointestinal bleeding. Ultrasonic cardiograms (UCG) were recorded for 27 cases, including those with critical aortic stenosis (n = 26). Gastrointestinal sequelae were reported in 22 cases with duodenal and jejunal being the most common (n = 9). High-molecular-weight multimers of von Willebrand Factor (vWF-HMWM) were measured in 17 cases with the majority being lower (n = 15) and the minority normal (n = 2). All patients experienced recurrent bleeding after medication and endoscopic therapy and symptoms improved after TAVI (31/31). vWF was at normal levels in 11/12 cases post-TAVI. Twenty-five patients were followed up and 22 had no recurrence of symptoms giving an efficacy rate of 88% for TAVI in HS patients.
CONCLUSIONS
HS is characterized by angiodysplasia, aortic stenosis and von Willebrand disease with frequent recurrence of bleeding after drug and endoscopic treatment. TAVI is an effective therapy with an 88% resolution rate.
PubMed: 37539190
DOI: 10.1016/j.heliyon.2023.e17952 -
Surgical Laparoscopy, Endoscopy &... Oct 2023The treatment of hepaticojejunal anastomotic strictures in patients with surgically altered anastomosis is challenging. Endoscopic ultrasound (EUS)-guided biliary... (Review)
Review
The Use of Oblique-viewing Endoscopic Ultrasound for Accessing the Afferent Limb for Endoscopic Ultrasound-guided Biliary Drainage in Patients with Severe Stenotic Hepaticojejunal Anastomosis: One Case and Literature Review.
BACKGROUND
The treatment of hepaticojejunal anastomotic strictures in patients with surgically altered anastomosis is challenging. Endoscopic ultrasound (EUS)-guided biliary drainage is being established as a feasible biliary drainage procedure. How can oblique-viewing endoscopic ultrasound (OV-EUS) safely reach the treatment area in the afferent limb for EUS-guided hepaticojejunostomy? This is a key, meaningful, and challenging question.
METHODS
A unique case of an OV-EUS-guided hepaticojejunostomy performed in a patient with severe stenotic hepaticojejunal anastomosis was reported, and the relevant literatures were reviewed.
RESULTS
There are only 3 previous case reports of EUS-guided transanastomotic drainage using OV-EUS. The above 3 cases reported did not elaborate on the key treatment details of the procedure. Especially how can the OV-EUS safely reach the treatment area in the afferent limb?
CONCLUSIONS
For patients with severe anastomotic stricture, when the retrograde or antegrade guide wire cannot pass through the stenosis to establish biliary drainage, OV-EUS can safely reach the treatment area in the afferent limb under the guidance of a fluoroscopic view and a guide wire. Thus, an OV-EUS-guided hepaticojejunostomy can be achieved.
Topics: Humans; Male; Anastomosis, Surgical; Cholestasis; Constriction, Pathologic; Drainage; Endosonography; Jejunum; Ultrasonography, Interventional; Middle Aged
PubMed: 37523516
DOI: 10.1097/SLE.0000000000001199 -
Journal of Gastroenterology Oct 2023Evidence of small-bowel capsule endoscopy (SBCE) for evaluating lesions in Crohn's disease (CD) is lacking. We aimed to clarify the effectiveness and safety of SBCE in a...
BACKGROUND
Evidence of small-bowel capsule endoscopy (SBCE) for evaluating lesions in Crohn's disease (CD) is lacking. We aimed to clarify the effectiveness and safety of SBCE in a large sample of patients with CD.
METHODS
This multicenter prospective registration study recorded the clinical information and SBCE results of patients with definitive CD (d-CD) or suspected CD (s-CD). The primary outcomes were the rates of successful assessment of disease activity using SBCE, definitive diagnosis of CD, and adverse events. Secondary outcomes were the assessment of SBCE findings in patients with d-CD and s-CD and factors affecting SBCE incompletion and retention; and tertiary outcomes included the association between clinical disease activity or blood examination, endoscopic disease activity, ileal CD, and the questionnaire assessment of patient acceptance of SBCE.
RESULTS
Of 544 patients analyzed, 541 underwent SBCE with 7 (1.3%) retention cases. Of 468 patients with d-CD, 97.6% could be evaluated for endoscopic activity. Of 76 patients with s-CD, 15.8% were diagnosed with 'confirmed CD'. CD lesions were more frequently observed in the ileum and were only seen in the jejunum in 3.4% of the patients. Male sex and stenosis were risk factors for incomplete SBCE, and high C-reactive protein levels and stenosis were risk factors for capsule retention. In L1 (Montreal classification) patients, clinical remission was associated with endoscopic remission but showed low specificity and accuracy. The answers to the acceptability questionnaire showed the minimal invasiveness and tolerability of SBCE.
CONCLUSION
SBCE is practical and safe in patients with CD.
Topics: Humans; Male; Crohn Disease; Constriction, Pathologic; Japan; Capsule Endoscopy; Prospective Studies
PubMed: 37479808
DOI: 10.1007/s00535-023-02017-3 -
Radiographics : a Review Publication of... Aug 2023Radiologic evaluation of neonatal bowel obstruction is challenging owing to the overlapping clinical features and imaging appearances of the most common differential...
Radiologic evaluation of neonatal bowel obstruction is challenging owing to the overlapping clinical features and imaging appearances of the most common differential diagnoses. The key to providing an appropriate differential diagnosis comes from a combination of the patient's gestational age, clinical features, and imaging findings. While assessment of radiographs can confirm bowel obstruction and indicate whether it is likely proximal or distal, additional findings at upper or lower gastrointestinal contrast study together with use of US are important in providing an appropriate differential diagnosis. The authors provide an in-depth assessment of the appearances of the most common differential diagnoses of proximal and distal neonatal bowel obstruction at abdominal radiography and upper and lower gastrointestinal contrast studies. These are divided into imaging patterns and their associated differential diagnoses on the basis of abdominal radiographic findings. These findings include esophageal atresia variants including the "single bubble," "double bubble," and "triple bubble" and distal bowel obstruction involving the small and large bowel. Entities discussed include esophageal atresia, hypertrophic pyloric stenosis, pyloric atresia, duodenal atresia, duodenal web, malrotation with midgut volvulus, jejunal atresia, ileal atresia, meconium ileus, segmental volvulus, internal hernia, colonic atresia, Hirschsprung disease, and functional immaturity of the large bowel. The authors include the advantages of abdominal US in this algorithm, particularly for hypertrophic pyloric stenosis, duodenal web, malrotation with midgut volvulus, and segmental volvulus. RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
Topics: Infant, Newborn; Humans; Intestinal Volvulus; Esophageal Atresia; Pyloric Stenosis, Hypertrophic; Intestinal Obstruction; Duodenal Obstruction; Digestive System Abnormalities; Radiography, Abdominal; Duodenal Diseases
PubMed: 37471246
DOI: 10.1148/rg.230035 -
Langenbeck's Archives of Surgery Jul 2023Biliary reconstruction remains a technically demanding and complicated procedure in minimally invasive hepatopancreatobiliary surgeries. No optimal hepaticojejunostomy...
PURPOSE
Biliary reconstruction remains a technically demanding and complicated procedure in minimally invasive hepatopancreatobiliary surgeries. No optimal hepaticojejunostomy (HJ) technique has been demonstrated to be superior for preventing biliary complications. This study aimed to investigate the feasibility of our unique technique of posterior double-layer interrupted sutures in robotic HJ.
METHODS
We performed a retrospective analysis of a prospectively collected database. Forty-two patients who underwent robotic pancreatoduodenectomy using this technique between September 2020 and November 2022 at our center were reviewed. In the posterior double-layer interrupted technique, sutures were placed to bite the bile duct, posterior seromuscular layer of the jejunum, and full thickness of the jejunum.
RESULTS
The median operative time was 410 (interquartile range [IQR], 388-478) min, and the median HJ time was 30 (IQR, 28-39) min. The median bile duct diameter was 7 (IQR, 6-10) mm. Of the 42 patients, one patient (2.4%) had grade B bile leakage. During the median follow-up of 12.6 months, one patient (2.4%) with bile leakage developed anastomotic stenosis. Perioperative mortality was not observed. A surgical video showing the posterior double-layer interrupted sutures in the robotic HJ is included.
CONCLUSIONS
Posterior double-layer interrupted sutures in robotic HJ provided a simple and feasible method for biliary reconstruction with a low risk of biliary complications.
Topics: Humans; Anastomosis, Surgical; Bile Ducts; Biliary Tract Diseases; Liver; Retrospective Studies; Robotic Surgical Procedures; Suture Techniques; Sutures
PubMed: 37468703
DOI: 10.1007/s00423-023-03020-1 -
Journal of Medical Case Reports Jul 2023Sclerosing encapsulating peritonitis is a rare condition with a typical macroscopic appearance, with fibrocollagenous membrane enclosing loops of the small intestine,...
BACKGROUND
Sclerosing encapsulating peritonitis is a rare condition with a typical macroscopic appearance, with fibrocollagenous membrane enclosing loops of the small intestine, causing intestinal obstruction. Unexplained recurrent abdominal pain, obstruction, and a large array of other possible clinical signs and symptoms make sclerosing encapsulating peritonitis a diagnostic challenge.
CASE PRESENTATION
A 48-year-old man of Persian ethnicity was admitted multiple times to the emergency surgery department due to recurrent sudden abdominal pain and chronic obstruction without significant findings in medical history or clinical evaluation. Computed tomography was positive for proximal jejunal dilatation and duodenojejunal flexure stenosis due to internal mesenteric hernia. Exploratory laparoscopy, followed by laparotomy, confirmed thick membrane-like fibrous tissue with complete small intestinal loop envelopment. Extensive membrane excision and adhesiolysis was performed, but no mesenteric herniation was found. Early postoperative paralytic ileus with introduction of low-dose steroid therapy, based on histopathological and immunological results, confirming type III sclerosing encapsulating peritonitis, was completely resolved.
CONCLUSION
Sclerosing encapsulating peritonitis is a rare and difficult-to-diagnose condition, further divided into primary and secondary sclerosing encapsulating peritonitis, on the basis of underlying etiology, dictating treatment modality and prognosis. Intraoperative diagnosis and surgical treatment are mandatory, besides a wide variety of abdominal computed tomography scans, inconclusive results, and clinical presentations. There are so far no known specific markers for the diagnosis of sclerosing encapsulating peritonitis.
Topics: Humans; Middle Aged; Peritonitis; Intestinal Obstruction; Prognosis; Laparotomy; Abdominal Pain
PubMed: 37443141
DOI: 10.1186/s13256-023-04020-x -
Journal of Minimal Access Surgery Apr 2024We, herein, report a surgical technique for laparoscopy-assisted jejunostomy tube placement in an infant using a loop needle device to fix the jejunum and abdominal...
We, herein, report a surgical technique for laparoscopy-assisted jejunostomy tube placement in an infant using a loop needle device to fix the jejunum and abdominal wall. A 3-year-old boy with Down's syndrome underwent nutritional management by gastrostomy due to oral feeding difficulty after radical surgery for congenital duodenal stenosis and following bile duct stenosis. However, intractable gastrostomy site leakage emerged; hence, laparoscopy-assisted gastrostomy takedown and simultaneous laparoscopy-assisted jejunostomy tube placement were planned. After laparoscopy-assisted gastrostomy closure was performed, the jejunum was extracted through the umbilical trocar wound. A jejunostomy tube kit was inserted at the left side of the umbilicus. After tube insertion into the jejunum, the jejunostomy tube was wrapped with four interrupted sutures using the Witzel technique. Suture threads were extracted by percutaneous insertion of a loop needle device, and then, the jejunum was fixed to the abdominal wall. The post-operative course was uneventful. Percutaneous insertion of a loop needle device is useful for fixing a jejunostomy tube to the abdominal wall using the Witzel technique. Our technique is safe, secure and expected to reduce the risk of dislodgement of tube and peritonitis associated with jejunostomy tube placement.
PubMed: 37357488
DOI: 10.4103/jmas.jmas_10_23 -
Updates in Surgery Jan 2024Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This...
Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed. Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.
Topics: Humans; Constriction, Pathologic; Retrospective Studies; Venous Thrombosis; Obesity, Morbid; Laparoscopy; Disease Progression; Mesenteric Ischemia; Gastrectomy
PubMed: 37278935
DOI: 10.1007/s13304-023-01545-0