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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 -
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 -
Annals of Hepato-biliary-pancreatic... Aug 2023Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the...
BACKGROUNDS/AIMS
Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the most common specific complications following PD. DGE can lead to significant morbidity, resulting in prolonged hospital stay and increased cost. Various factors might influence the occurrence of DGE. We hypothesized that kinking of jejunal limb could be a cause of DGE post PD.
METHODS
Antecolic (AC) and retrocolic (RC) side-to-side gastrojejunostomy (GJ) groups in classical PD were compared for the occurrence of DGE in a prospective study. All patients who underwent PD between April 2019 and September 2020 in a tertiary care center in south India were included in this study.
RESULTS
After classic PD, RC GJ was found to be superior to AC in terms of DGE rate (26.7% vs. 71.9%) and hospital stay (9 days vs. 11 days).
CONCLUSIONS
Route of reconstruction of GJ can influence the occurrence of DGE as RC anastomosis in classical PD provides the most straight route for gastric emptying.
PubMed: 37066756
DOI: 10.14701/ahbps.22-123 -
ACG Case Reports Journal Apr 2023Enterocolic fistulae lead to abnormal diversion of gastrointestinal contents from the small intestine to the colon, causing diarrhea and protein energy malnutrition. We...
Enterocolic fistulae lead to abnormal diversion of gastrointestinal contents from the small intestine to the colon, causing diarrhea and protein energy malnutrition. We describe a rare case of a 40-year-old patient presenting with chronic diarrhea, unintentional weight loss, sitophobia, and severe abdominal pain in the setting of extensive thrombosis due to JAK2 V617F mutant disorder and associated tobacco use. Computed tomography enterography demonstrated an enterocolic fistula (jejunum to cecum), and a colonoscopy confirmed a 4 mm fistula in the cecum. The patient was nutritionally optimized with plans for a surgical fistula takedown in the future.
PubMed: 37057193
DOI: 10.14309/crj.0000000000001021 -
Journal of the Korean Society of... Mar 2023Transanastomotic pancreatic duct stent placement during reconstruction following pancreaticoduodenectomy is widely performed to prevent postoperative pancreatic fistulas...
Transanastomotic pancreatic duct stent placement during reconstruction following pancreaticoduodenectomy is widely performed to prevent postoperative pancreatic fistulas and duct stenosis. However, stent-related complications, such as stent occlusion and migration, may occur. Here, we report a rare case of a migrated pancreatic duct plastic stent. After pylorus-preserving pancreaticoduodenectomy, the stent migrated to the jejunum and served as a nidus of the stent-stone complex, which developed jejunal obstruction. The stent-stone complex was removed by explorative laparotomy.
PubMed: 37051393
DOI: 10.3348/jksr.2022.0102 -
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 Surgical Case Reports Mar 2023Multiply high-output enterocutaneous fistulas (ECF) is a tragic postoperative complication. This report describes complex treatment of patient with multiple...
Multiply high-output enterocutaneous fistulas (ECF) is a tragic postoperative complication. This report describes complex treatment of patient with multiple enterocutaneous fistulas after bariatric surgery, including a comprehensive preoperative preparation for 3 months (sepsis control, nutritional support and wound care) and reconstructive surgery (laparotomy, distal gastrectomy, resection of the small bowel with fistulas, Roux-gastrojejunostomy, transversostomy).
PubMed: 36896159
DOI: 10.1093/jscr/rjad096 -
Intractable & Rare Diseases Research Feb 2023Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to... (Review)
Review
Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to misdiagnosis and occasionally catastrophic outcomes. The lifestyles of those who are afflicted are mostly responsible for the underlying conditions that result in the hemorrhagic cases. The development of a novel approach targeted at raising public awareness of the issue and educating the public about it could significantly contribute to the elimination of gastrointestinal bleeding with no associated risks and to a nearly zero mortality rate. There are reports of UGB related to Sarcina ventriculi, gastric amyloidosis, jejunal lipoma, gastric schwannoma, hemobilia, esophageal varices, esophageal necrosis, aortoenteric fistula, homosuccus pancreaticus, and gastric trichbezoar in the literature. The common feature of these rare causes of UGB is that the diagnosis is difficult to establish before surgery. Fortunately, UGB with a clear lesion in the stomach itself is a clear sign for surgical intervention, and the diagnosis can only be verified by pathological examination with the help of immunohistochemical detection of a particular antigen for a specific condition. The clinical traits, diagnostic techniques, and the therapeutic, or surgical options of unusual causes of UGB reported in the literature are compiled in this review.
PubMed: 36873674
DOI: 10.5582/irdr.2022.01128