Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series

Esophagus - Endoscopic vacuum therapy (EVT) represents an effective endoscopic technique for the treatment of post-esophagectomy leaks and can be used after failure of primary treatment. We aimed...     

Recurrent colonic ulcers in celiac sprue,an unrecognized fatal complication: Report of a case

Summary In a patient who had celic sprue intractable to a gluten-free diet, volvulus and jejunal and colonic ulcers developed. Following segmental colonic resection, these ulcers recurred at the site of the previous anastomosis, and proved a fatal complication because of colonic perforation. Since no obvious etiology of colonic ulcers could be identified in this case, it is possible that they may represent an unrecognized intestinal complication of celiac sprue similar to jejunoileal ulcers.     

Incidence,consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study

Background Anastomotic dehiscence is the most severe surgical complication after large bowel resection. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with anastomotic leakage after colorectal surgery. Materials and methods All procedures involving anastomoses of the colon or the rectum, which were performed between November 2002 and February 2006 in a single institution, were prospectively entered into a computerized database. Results One thousand eighteen colorectal resections and 811 anastomoses were performed over this 40-month period. The most frequent procedures were sigmoid (276) and right colectomies (217). The overall anastomotic leak rate was 3.8%. The mortality rate associated with anastomotic leak was 12.9%. In univariate analysis, the following parameters were associated with an increased risk for anastomotic dehiscence: (1) ASA score ≥ 3 (p = 0.004), (2) prolonged (>3 h) operative time (p = 0.02), (3) rectal location of the disease (p < 0.001), (4) and a body mass index > 25 (p = 0.04). In multivariate analysis, ASA score ≥ 3 (OR = 2.5; 95% CI 1.5–4.3, p < 0.001), operative time > 3 h [OR = 3.0; 95% CI 1.1–8.0, p = 0.02), and rectal location of the disease (OR = 3.75; 95% CI 1.5–9.0 (vs left colon), p = 0.003; OR = 7.69; 95% CI 2.2–27.3 (vs right colon), p = 0.001] were factors significantly associated with a higher risk of anastomotic dehiscence. Conclusions Three risk factors for anastomotic leak have been identified, one is patient-related (ASA score), one is disease-related (rectal location), the third being surgery-related (prolonged operative time). These factors should be considered in perioperative decision-making regarding defunctioning stoma formation.     

Colo-cholecystic fistula: an unusual complication of colonic diverticular disease.

Colonic diverticular disease can lead to various complications. We describe a case of an 81-yr-old man who was found to have intrabiliary air on computed tomography of the abdomen. Endoscopic retrograde cholangiopancreatography and subsequent surgical exploration of the abdomen revealed an ascending colonic diverticulum penetrating into the gall bladder. Colocholecystic fistula is an unusual cause of intrabiliary air and, to our knowledge, this has not been reported in the literature.     

Inferior vena cava thrombosis: an unusual complication of a large simple non-parasitic liver cyst requiring an integrated approach

Most of the simple hepatic cysts are asymptomatic and have a benign course. However, some exceptional life-threatening complications may occur. We herein report the successful management of a case who suffered from a cystic compression of the inferior vena cava complicated by thrombosis of the inferior vena cava itself. To our knowledge this is the first report of such a complication and diagnostic and therapeutic aspects are discussed. This case is paradigmatic of the possible complexity of the diagnosis and treatment of cystic lesions of the liver and should induce physicians to consider a therapeutic approach if a clear tendency to enlarge can be recognized.     

Gastric infarction: a complication of endocarditis due to Staphylococcus aureus

We describe a 62-year-old man with diabetes mellitus and peripheral vascular insufficiency, with an ulcer on his foot which led to staphylococcal septicemia, endocarditis, and disseminated intravascular coagulation. All these factors contributed to thromboembolic occlusion of the terminal arteries and veins supplying the stomach, causing gastric infarction.     

Spontaneous colonic perforation: a rare complication of collagenous colitis

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and unique histopathologic features. Spontaneous colonic perforation in the setting of collagenous colitis is a highly unusual complication, with only three cases reported in the literature to date. We present a fourth case and propose a potential pathologic mechanism for acute colonic perforation in this patient population.     

Severe chronic aortic insufficiency requiring valve replacement: an infrequent complication of Takayasu's disease

Takayasu's arteritis (TA) is a granulomatous vasculitis of medium and large arteries, which most often presents as pulseless disease due to widespread arterial stenoses. Only the minority of TA patients have aortic valve insufficiency, which is due to aortic root dilatation following aortitis and aneurysm formation. No other cardiac valve is involved. We report a case of Takayasu's disease-related severe aortic insufficiency (AI) in a Filipino woman, which necessitated aortic valve replacement. It is important to consider TA in the differential diagnosis of AI in young women, particularly those with early-onset systemic hypertension and pulse deficits. Early diagnosis and therapy of TA can improve outcomes.     

The small height of an anastomotic colonic doughnut is an independent risk factor of anastomotic leakage following colorectal resection: results of a prospective study on 154 consecutive cases

Purpose

The aim of this prospective study was to assess the influence of morphological characteristics of anastomotic doughnuts on the risk of anastomotic leakage (AL) after double-stapled colorectal anastomosis.

Methods

This single-center prospective study enrolled all patients undergoing double-stapled colorectal anastomosis between December 2012 and December 2015. Maximal diameter and minimal and maximal heights and widths of both colonic and rectal doughnuts were measured by surgeons in the operating room. Their influence on the risk of AL was analyzed on uni- and multivariate models.

Results

One hundred fifty-four patients were included; 92 (59.7%) were operated on for malignancy. Colorectal anastomoses > and <10 cm above the anal verge were performed in 96 (62.3%) and 58 (37.7%) patients, respectively. AL occurred in 17 (11.0%). The minimal height of the colonic doughnut (CD) was the only measurement significantly associated with an increased risk of AL (p = 0.026). A cutoff value of 4.5 mm for the CD determined on the ROC curve (AUC 0.685, p = 0.013) yielded the best sensitivity (61.4%) and specificity (82.4%) to predict AL. On multivariate analysis, a height of the CD <4.5 mm (OR 5.743, 95% IC 1.476–22.346, p = 0.012), malignant disease (OR 8.821, 95% IC 1.051–74.006, p = 0.045), and American Society of Anesthesiologists score >2 (OR 3.408, 95% IC 1.017–11.418, p = 0.047) were the only independent risk factors of AL.

Conclusion

The CD’s minimal height influences the risk of AL. Its routine measurement during operation, along with other risk factors, could help to decide which patients could benefit from a diverting stoma or the creation of a new anastomosis.

     

Novel interventional treatment technique for intractable pancreatic fistula due to dehiscence of pancreatico-jejunal anastomosis following pancreaticoduodenectomy

Despite recent technological advances in the treatment of hepatobiliary pancreatic disease, intractable external pancreatic fistula is still a major critical complication after pancreaticoduodenectomy, and the treatment strategy is not well defined. We report here a case that was successfully treated by our novel interventional internal drainage technique. A 62-year-old woman underwent pylorus-preserving pancreaticoduodenectomy for carcinoma of the papilla of Vater, with reconstruction by a modified Child’s procedure. One year later, she was readmitted to our hospital because of external pancreatic fistula. Both computed tomography and fistulography demonstrated a pancreatic fistula derived from dehiscence of the pancreatico-jejunal anastomosis. The pancreatic fistula persisted for 1 week with conservative management. Therefore, we performed repeated fistulography and cannulation, using two comparatively stiff guidewires introduced into the main pancreatic duct and stenotic anastomosed jejunal lumen, respectively, and we placed an endoprosthesis, using bilateral guidewires to connect the two lumens. Consequently, the pancreatic fistula was successfully closed within a few days. Our novel technique is simple, rapid, and not costly. Therefore, it should be considered an effective treatment strategy for persistent pancreatic fistula following pancreaticoduodenectomy that fails to respond to initial conservative management and an endoscopic approach. Also, this technique is applicable to other intractable fistulous situations.