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Canadian Journal of Surgery. Journal... Oct 2012Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The... (Review)
Review
Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.
Topics: Adult; Anastomotic Leak; Canada; Constriction, Pathologic; Evidence-Based Medicine; Female; Gastric Bypass; Gastrointestinal Hemorrhage; Humans; Intestinal Fistula; Intestinal Obstruction; Jejunum; Laparoscopy; Length of Stay; Male; Malnutrition; Middle Aged; Obesity, Morbid; Postoperative Complications; Surgical Stapling; Ulcer; Weight Gain
PubMed: 22854113
DOI: 10.1503/cjs.002011 -
The Surgical Clinics of North America Dec 1990Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to... (Review)
Review
Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to the bile duct during cholecystectomy. In addition, strictures can occur at the site of previous biliary anastomoses for reconstruction of the biliary tree. Most patients with benign bile duct strictures present soon after their initial operation; however, in some cases, presentation is delayed for years. Cholangiography is essential for defining the anatomy of the biliary tree prior to management. In many cases, nonoperative biliary drainage is useful to treat sepsis and biliary fistulas. A number of alternatives exist for elective repair of bile duct strictures. Experience would suggest, however, that a choledochojejunostomy or hepaticojejunostomy performed through a Roux-en-Y limb of jejunum is the preferable management in most cases. Postoperative biliary stenting may be valuable in optimizing the results. Nonoperative management by percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in a number of small series. Long-term results are limited, however. Comparative data suggest that surgical repair for benign postoperative strictures is associated with fewer long-term problems and with similar overall morbidity and costs.
Topics: Bile Ducts; Cholangiography; Cholecystectomy; Constriction, Pathologic; Humans; Intraoperative Complications; Postoperative Complications; Stents
PubMed: 2247820
DOI: 10.1016/s0039-6109(16)45289-8 -
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 -
PloS One 2022Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated...
Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan.
BACKGROUND/PURPOSE
Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE).
METHODS
Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE.
RESULTS
The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate.
CONCLUSION
VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.
Topics: Humans; Retrospective Studies; Taiwan; Constriction, Pathologic; Gastrointestinal Hemorrhage; Angiodysplasia; Risk Factors; Colonic Diseases; Autonomic Nervous System Diseases; Heart Valve Diseases
PubMed: 36449459
DOI: 10.1371/journal.pone.0277434 -
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 -
BMC Cancer Jan 2024The optimal reconstruction method after proximal gastrectomy remains unclear. This systematic review and meta-analysis aimed to compare the short-term outcomes and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The optimal reconstruction method after proximal gastrectomy remains unclear. This systematic review and meta-analysis aimed to compare the short-term outcomes and long-term quality of life of various reconstruction methods.
METHODS
PubMed, Embase, Web of Science and Cochrane Library were searched to identify comparative studies concerning the reconstruction methods after proximal gastrectomy. The reconstruction methods were classified into six groups: double tract reconstruction (DTR), esophagogastrostomy (EG), gastric tube reconstruction (GT), jejunal interposition (JI), jejunal pouch interposition (JPI) and double flap technique (DFT). Esophagogastric anastomosis group (EG group) included EG, GT and DFT, while esophagojejunal anastomosis group (EJ group) included DTR, JI and JPI.
RESULTS
A total of 27 studies with 2410 patients were included in this meta-analysis. The pooled results indicated that the incidences of reflux esophagitis of DTR, EG, GT, JI, JPI and DFT were 7.6%, 27.3%, 4.5%, 7.1%, 14.0%, and 9.1%, respectively. The EG group had more reflux esophagitis (OR = 3.68, 95%CI 2.44-5.57, P < 0.00001) and anastomotic stricture (OR = 1.58, 95%CI 1.02-2.45, P = 0.04) than the EJ group. But the EG group showed shorter operation time (MD=-56.34, 95%CI -76.75- -35.94, P < 0.00001), lesser intraoperative blood loss (MD=-126.52, 95%CI -187.91- -65.12, P < 0.0001) and shorter postoperative hospital stay (MD=-2.07, 95%CI -3.66- -0.48, P = 0.01). Meanwhile, the EG group had fewer postoperative complications (OR = 0.68, 95%CI 0.51-0.90, P = 0.006) and lesser weight loss (MD=-1.25, 95%CI -2.11- -0.39, P = 0.004). For specific reconstruction methods, there were lesser reflux esophagitis (OR = 0.10, 95%CI 0.06-0.18, P < 0.00001) and anastomotic stricture (OR = 0.14, 95%CI 0.06-0.33, P < 0.00001) in DTR than the esophagogastrostomy. DTR and esophagogastrostomy showed no significant difference in anastomotic leakage (OR = 1.01, 95%CI 0.34-3.01, P = 0.98).
CONCLUSION
Esophagojejunal anastomosis after proximal gastrectomy can reduce the incidences of reflux esophagitis and anastomotic stricture, while esophagogastric anastomosis has advantages in technical simplicity and long-term weight status. Double tract reconstruction is a safe technique with excellent anti-reflux effectiveness and favorable quality of life.
REGISTRATION
This meta-analysis was registered on the PROSPERO (CRD42022381357).
Topics: Humans; Quality of Life; Constriction, Pathologic; Esophagitis, Peptic; Gastrectomy; Anastomosis, Surgical
PubMed: 38200411
DOI: 10.1186/s12885-024-11827-4 -
Annals of Surgical Innovation and... 2016Bariatric surgery has been considered one of best treatments for obesity. As every surgical procedure-and any medical intervention, it is not exempt of complications,...
Bariatric surgery has been considered one of best treatments for obesity. As every surgical procedure-and any medical intervention, it is not exempt of complications, among which leaks, strictures, acute hemorrhages and fistulae highlight. Leaks are more common in the gastro-jejunal anastomosis (GJA) in the case of Roux-en-y Gastric Bypass (RYGB), while in Sleeve Gastrectomy (LSG) they locate in the stapler line. Stenosis can be seen in the gastro-jejunostomy in the RYGB and in the gastric tube in case of the LSG. For each of these complications, many innovative solutions have been developed, including new surgical devices. In spite of promising good results, evidence regarding utility and safeness of these technologies is still scarce. Self-expandable endoscopic stents have been used to treat leaks, with an overall success rate of 80-90 % and a migration rate of 15-35 %. The bear trap-like over-the-scope (Ovesco) clips have been used to treat GI hemorrhages, leaks and even fistulae, with a 70-80 % success rate, although more endoscopic sessions may be needed. Overstitch, an endosurgical suture devices, have been used to treat leaks, fistulae and perforations. Overall, technical success achievement approaches to 90 %, while clinical success ranges from 80 to 90 %, except for leaks closure, where a lower success rate has been observed. Despite of all of these advances, early diagnosis and treatment remains the main strategy to achieve success. In summary, novel therapies for complication management can be very useful, though further studies with larger series are still needed in order to confirm their efficacy and safeness.
PubMed: 26981148
DOI: 10.1186/s13022-015-0021-2 -
Medicine Jan 2018Small bowel adenocarcinoma (SBA) is an uncommon gastrointestinal cancer, thus limited data about treatment for advanced disease are available. The lack of specific... (Review)
Review
RATIONALE
Small bowel adenocarcinoma (SBA) is an uncommon gastrointestinal cancer, thus limited data about treatment for advanced disease are available. The lack of specific guidelines has justified the use of therapeutic protocols usually applied in advanced colorectal cancer. Few and preliminary data have suggested possible clinical benefit from the use of target therapy such as bevacizumab and cetuximab.
PATIENT CONCERNS
We present the case of a young woman who was admitted to the emergency department for acute abdominal pain, nausea, and vomiting related to a jejunal stenosis.
DIAGNOSES
An enteroscopy with jejunal biopsy showed poorly differentiated cancerous cells suggestive for primary intestinal cancer. There were no signs of metastatic disease at radiological evaluation. A jejunal resection was subsequently carried out and the diagnosis of mucinous adenocarcinoma of the jejunum was confirmed.
INTERVENTIONS
The computed tomography scan performed 1 month after surgery showed metastatic disease. Therefore, the patient received combined protocols of chemotherapy and either bevacizumab or the anti-epidermal growth factor receptor (EGFR) panitumumab.
OUTCOMES
A partial response (PR) was achieved with Folfox plus panitumumab and a maintenance therapy with panitumumab is being conducted with a mild toxicity and a progression free survival of 19 months since the beginning of panitumumab.
LESSONS
This is, to the best of our knowledge, the first report in the literature of a patient with SBA who has benefitted from panitumumab with an overall survival of 83 months.
Topics: Adenocarcinoma; Antibodies, Monoclonal; Antineoplastic Agents; ErbB Receptors; Female; Humans; Jejunal Neoplasms; Middle Aged; Panitumumab
PubMed: 29505011
DOI: 10.1097/MD.0000000000009672 -
World Journal of Gastroenterology Apr 2021Gastric pull-up (GPU) procedures may be complicated by leaks, fistulas, or stenoses. These complications are usually managed by endoscopy, but in extreme cases...
BACKGROUND
Gastric pull-up (GPU) procedures may be complicated by leaks, fistulas, or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperation may be necessary. Here, we report a combined endoscopic and surgical approach to manage a failed secondary GPU procedure.
CASE SUMMARY
A 70-year-old male with treatment-refractory cervical esophagocutaneous fistula with stenotic remnant esophagus after secondary GPU was transferred to our tertiary hospital. Local and systemic infection originating from the infected fistula was resolved by endoscopy. Hence, elective esophageal reconstruction with free-jejunal interposition was performed with no subsequent adverse events.
CONCLUSION
A multidisciplinary approach involving interventional endoscopists and surgeons successfully managed severe complications arising from a cervical esophagocutaneous fistula after GPU. Endoscopic treatment may have lowered the perioperative risk to promote primary wound healing after free-jejunal graft interposition.
Topics: Aged; Anastomosis, Surgical; Esophageal Fistula; Esophagoplasty; Humans; Jejunum; Male; Postoperative Complications
PubMed: 33967561
DOI: 10.3748/wjg.v27.i16.1841 -
Revista Espanola de Enfermedades... Jul 2009recent advances in endoscopy have enabled us to explore the small intestine more efficiently, both with capsule endoscopy and double-balloon enteroscopy. However, these...
BACKGROUND
recent advances in endoscopy have enabled us to explore the small intestine more efficiently, both with capsule endoscopy and double-balloon enteroscopy. However, these methods are not available in all hospitals. Therefore, when capsule endoscopy reveals proximal jejunal lesions, a possible alternative for treatment could involve push enteroscopy combined with colonoscopy. Lesions can thus be marked for subsequent monitoring.
OBJECTIVES
to describe the efficacy of pediatric colonoscopy for diagnosis, the marking of the area explored, and therapeutic options.
MATERIAL AND METHODS
between October 2007 and September 2008 a total of 21 enteroscopies were performed using a pediatric colonoscope. Nine of these were used to take jejunal biopsy samples due to suspected disease of the mucosa. In 10 of the remaining 12, capsule endoscopy revealed lesions (vascular malformations or jejunal bleeding), and in 2 intestinal transit time was analyzed due to suspected jejunal stenosis. We used a PENTAX EC-3470-LK pediatric colonoscope, whose 11.6-mm sectional diameter and 3.8-mm working channel make it possible to administer all the usual endoscopic treatments.
RESULTS
therapeutic endoscopy was performed on 7 men and 5 women (mean age 63.3 years). Jejunal lesions were observed in 10 cases (5 cases of angiodysplasia, 2 cases of jejunal stenosis, 1 case of nonmalignant thickened jejunal folds, 1 eroded submucosal tumor, and 1 case of duodenal and jejunal varices). The most distal area was marked with India ink (2), hemoclips (4), or both to help locate the lesions using simple abdominal radiography or capsule endoscopy.
CONCLUSIONS
jejunal enteroscopy enabled a firm diagnosis to be made in most of the patients studied. We were able to treat 58% of patients and mark the areas explored for subsequent follow-up. With hemoclips we were able to locate the most distal point explored using simple abdominal radiography.
Topics: Adult; Aged; Capsule Endoscopy; Colonoscopes; Colonoscopy; Equipment Design; Female; Humans; Jejunal Diseases; Male; Middle Aged; Prospective Studies
PubMed: 19642838
DOI: 10.4321/s1130-01082009000700004