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BMC Surgery May 2023Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently,...
BACKGROUND
Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently, there exists no flawless pancreaticojejunal anastomosis approach. We presents a new approach called Chen's penetrating-suture technique for pancreaticojejunostomy (PPJ), which involves end-to-side pancreaticojejunostomy by suture penetrating the full-thickness of the pancreas and jejunum, and evaluates its safety and efficacy.
METHODS
To assess this new approach, between May 2006 and July 2018, 193 consecutive patients who accepted the new Chen's Penetrating-Suture technique after a PD were enrolled in this study. Postoperative morbidity and mortality were evaluated.
RESULTS
All cases recovered well after PD. The median operative time was 256 (range 208-352) min, with a median time of 12 (range 8-25) min for performing pancreaticojejunostomy. Postoperative morbidity was 19.7% (38/193) and mortality was zero. The POPF rate was 4.7% (9/193) for Grade A, 1.0% (2/193) for Grade B, and no Grade C cases and one urinary tract infection.
CONCLUSION
PPJ is a simple, safe, and reliable technique with ideal postoperative clinical results.
Topics: Humans; Pancreaticojejunostomy; Pancreaticoduodenectomy; Anastomosis, Surgical; Pancreas; Pancreatic Fistula; Postoperative Complications; Suture Techniques
PubMed: 37248522
DOI: 10.1186/s12893-023-02054-y -
Journal of Personalized Medicine May 2023(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ)...
(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates ( values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.
PubMed: 37241028
DOI: 10.3390/jpm13050858 -
Otolaryngologic Clinics of North America Aug 2023Pharyngoesophageal reconstruction is one of the most challenging reconstructive dilemmas that demands extensive planning, meticulous surgical execution, and timely... (Review)
Review
Pharyngoesophageal reconstruction is one of the most challenging reconstructive dilemmas that demands extensive planning, meticulous surgical execution, and timely management of postoperative complications. The main goals of reconstruction are to protect critical blood vessels of the neck, to provide alimentary continuity, and to restore functions such as speech and swallowing. With the evolution of techniques, fasciocutaneous flaps have become the gold standard for most defects in this region. Major complications include anastomotic strictures and fistulae, but most patients can tolerate an oral diet and achieve fluent speech after rehabilitation with a tracheoesophageal puncture.
Topics: Humans; Plastic Surgery Procedures; Laryngectomy; Treatment Outcome; Surgical Flaps; Postoperative Complications; Retrospective Studies
PubMed: 37221117
DOI: 10.1016/j.otc.2023.04.005 -
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 -
Surgical Case Reports May 2023The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound...
BACKGROUND
The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF.
CASE PRESENTATION
A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up.
CONCLUSIONS
The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.
PubMed: 37212955
DOI: 10.1186/s40792-023-01659-y -
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 -
Khirurgiia 2023Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common...
[One-stage reconstructive jejunogastroplasty after previous multiple abdominal surgeries for left-sided diaphragm rupture complicated by gastric incarceration and necrosis].
Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common complication of gastrectomy with reconstruction is failure of esophagojejunostomy and duodenal stump. In case of severe esophagojejunostomy failure, appropriate surgical approach and timing of reconstructive stage should be analyzed. We report one-stage reconstructive surgery in a patient with multiple fistulas after previous gastrectomy. Surgery included reconstructive jejunogastroplasty with jejunal graft interposition. The patient underwent previous several unsuccessful reconstructive procedures complicated by failure of esophagojejunostomy and duodenal stump with external intestinal, duodenal and esophageal fistulas. Nutritional insufficiency, water and electrolyte disorders due to significant loss of proteins and intestinal juice through the drain tubes deteriorated clinical status. Surgical procedures finished reconstruction, provided closure of multiple fistulas and stomas and restored physiological duodenal passage.
Topics: Humans; Diaphragm; Stomach Neoplasms; Gastrectomy; Necrosis
PubMed: 37186656
DOI: 10.17116/hirurgia202305192 -
Clinical Journal of Gastroenterology Oct 2023A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was... (Review)
Review
A case of hepaticojejunal anastomotic obstruction after a living-donor liver transplantation and recanalization using a high-frequency knife under the rendezvous technique.
A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was diagnosed with obstructive cholangitis due to stricture during a hepaticojejunostomy following impaired liver function. Endoscopic balloon dilation of anastomosis and placement of a plastic stent resulted in improved liver function. However, at 72 years, the patient experienced a flare-up of liver damage. The plastic stent had fallen out, and although endoscopic stenotic dilation was attempted, the anastomotic site was obstructed completely. Therefore, recanalization of the hepaticojejunostomy was attempted using a rendezvous technique. A percutaneous transhepatic biliary drainage tube was inserted through the B3 bile duct, and the complete obstructed anastomosis was confirmed by percutaneous transhepatic and transjejunal approaches. The anastomosis was reopened by excising the scarred tissues from the jejunal side using a 1.5-mm high-frequency knife. A 14-Fr. catheter for the internal fistula tube was percutaneously placed at the opened anastomosis to achieve anastomotic site recanalization. The patient's liver damage improved after the re-internalization, and no symptom recurrence such as obstructive cholangitis developed for 1 year. There are few reports of recanalization of the hepaticojejunostomy with a high-frequency knife. Herein, we report the case with a literature review.
Topics: Female; Humans; Aged; Liver Transplantation; Living Donors; Liver; Anastomosis, Surgical; Cholangitis; Postoperative Complications; Stents
PubMed: 37170062
DOI: 10.1007/s12328-023-01812-y -
Zhonghua Wai Ke Za Zhi [Chinese Journal... Jun 2023To explore the development of the pancreatic surgeon technique in a high-volume center. A total of 284 cases receiving pancreatic surgery by a single surgeon from June...
To explore the development of the pancreatic surgeon technique in a high-volume center. A total of 284 cases receiving pancreatic surgery by a single surgeon from June 2015 to December 2020 were retrospectively included in this study. The clinical characteristics and perioperative medical history were extracted from the medical record system of Zhongshan Hospital,Fudan University. Among these patients,there were 140 males and 144 females with an age ( (IQR)) of 61.0 (16.8) years(range: 15 to 85 years). The "back-to-back" pancreatic- jejunal anastomosis procedure was used to anastomose the end of the pancreas stump and the jejunal wall. Thirty days after discharge,the patients were followed by outpatient follow-up or telephone interviews. The difference between categorical variables was analyzed by the Chi-square test or the CMH chi-square test. The statistical differences for the quantitative data were analyzed using one-way analysis of variance or Kruskal-Wallis test and further analyzed using the LSD test or the Nemenyi test,respectively. Intraoperative blood loss in pancreaticoduodenectomy between 2015 and 2020 were 300,100(100),100(100),100(0),100(200) and 150 (200) ml,respectively. Intraoperative blood loss in distal pancreatectomy was 250 (375),100 (50),50 (65), 50 (80),50 (50),and 50 (100) ml,respectively. Intraoperative blood loss did not show statistical differences in the same operative procedure between each year. The operative time for pancreaticoduodenectomy was respectively 4.5,5.0(2.0),5.5(0.8),5.0(1.3),5.0(3.3) and 5.0(1.0) hours in each year from 2015 to 2020,no statistical differences were found between each group. The operating time of the distal pancreatectomy was 3.8 (0.9),3.0 (1.5),3.0 (1.8),2.0 (1.1),2.0 (1.5) and 3.0(2.0) hours in each year,the operating time was obviously shorter in 2018 compared to 2015 (=0.026) and 2020 (=0.041). The median hospital stay in 2020 for distal pancreatectomy was 3 days shorter than that in 2019. The overall incidence of postoperative pancreatic fistula gradually decreased,with a incident rate of 50.0%,36.8%,31.0%,25.9%,21.1% and 14.8% in each year. During this period,in a total of 3,6,4,2,0 and 20 cases received laparoscopic operations in each year. The incidence of clinically relevant pancreatic fistula (grade B and C) gradually decreased,the incident rates were 0,4.8%,7.1%,3.4%,4.3% and 1.4%,respectively. Two cases had postoperative abdominal bleeding and received unscheduled reoperation. The overall rate of unscheduled reoperation was 0.7%. A patient died within 30 days after the operation and the overall perioperative mortality was 0.4%. The surgical training of a high-volume center can ensure a high starting point in the initial stage and steady progress of pancreatic surgeons,to ensure the safety of pancreatic surgery.
Topics: Male; Female; Humans; Pancreatic Fistula; Retrospective Studies; Blood Loss, Surgical; Pancreatectomy; Pancreaticoduodenectomy; Postoperative Complications; Surgeons; Postoperative Hemorrhage; Pancreatic Neoplasms
PubMed: 37088485
DOI: 10.3760/cma.j.cn112139-20221027-00462 -
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