Endoluminal Vacuum Therapy (EVAC) in Managing Esophagogastric Anastomosis Fistula / Terapia de vacío endoluminal (Endo-Vac) en el manejo de la fístula de anastomosis esofagogástrica

Abstract Endoluminal vacuum therapy (EVAC) is a promising alternative for the endoscopic management of gastrointestinal fistulas or perforations that do not respond to endoscopic procedures using clips and stents or are even refractory to surgical procedures. In this case report, we describe the successful endoscopic closure of an esophagogastric anastomotic fistula using EVAC, connected to a vacuum system through a probe in the cavity, which did not close with clip management given the friability and edema of the peri-wound tissue. In conclusion, it is a successful alternative to treat these complications, which are sometimes difficult to resolve.

Resumen La terapia de vacío endoluminal (Endo-Vac) es una alternativa promisoria en el manejo endoscópico de las fístulas o perforaciones gastrointestinales, que no responden a procedimientos endoscópicos cuando se utilizan técnicas como clips, stents o incluso refractarias a procedimientos quirúrgicos. En este reporte de caso describimos el cierre endoscópico exitoso de una fístula anastomótica esofagogástrica, utilizando la terapia Endo-Vac, conectada a un sistema de vacío mediante una sonda en la cavidad, que no presentó cierre inicial a manejo con clips, dada la friabilidad y el edema del tejido perilesional. Se concluye que esta es una alternativa exitosa en el cierre de estas complicaciones, que en ocasiones son de difícil resolución.

Síndrome de la arteria mesentérica superior en una adolescente de 12 años. Caso clínico / Superior mesenteric artery syndrome in a 12-year-old adolescent. Clinical case

El síndrome de la arteria mesentérica superior es una enfermedad poco frecuente en pediatría. Se produce por la compresión de la tercera porción duodenal a su paso entre la arteria mesentérica superior y la aorta abdominal (compás aortomesentérico). La mayoría de los pacientes presentan factores predisponentes:pérdida de peso aguda o compresiones extraabdominales.Se presenta el caso de una niña de 12 años de edad a quien se le diagnosticó el síndrome sin presentar factores predisponentes.Comenzó de modo súbito con náuseas, vómitos incoercibles y dolor abdominal, que era posprandial y se aliviaba, llamativamente, en decúbito lateral izquierdo. Esto constituyó la sospecha clínica del síndrome, por lo que se solicitó una angio tomografía computada abdominal y se observó el estrechamiento del compás aortomesentérico. Se realizó un tratamiento médico conservador, sin respuesta clínica. Se decidió el tratamiento quirúrgico y se logró la resolución del cuadro clínico

The superior mesenteric artery syndrome is rarely seen in children. It results from an intestinal obstruction due to compression of the third portion of duodenum between the superior mesenteric artery and the abdominal aorta. In most of the cases there are predisposing factors such as rapid weight loss or extra-abdominal compression.We report a case of a superior mesenteric artery syndrome in a twelve-year-old female patient without predisposing factors. The girl began suddenly with nauseas, continuous vomiting and abdominal pain. The abdominal pain was postprandial and it decreased in left lateral decubitus position. Clinically, this characteristic suggested superior mesenteric artery syndrome. Angio-computed tomography scan confirmed the diagnosis. Given that conservative treatment ultimately failed, patient was subjected to surgery and the illness was resolved.

Routine use of v-lock® suture for bariatric anastomosis is safe: comparative results from consecutive case series / Uso rotineiro da sutura v-lock® para anastomoses em obesidade é seguro: resultados de estudo clínico comparativo

ABSTRACT Background: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. Aim: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. Methods: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. Results: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). Conclusion: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

RESUMO Racional : Em países de alta renda, a obesidade mórbida é um problema crescente de saúde que já atingiu proporções epidêmicas. Ao realizar um bypass gástrico laparoscópico, existem vários métodos operatórios. Objetivo: Descrever a experiência institucional utilizando uma sutura farpada unidirecional sem nós (V-Loc 180/Covidien, Mansfield, MA) para criar gastrojejunostomia (JJ) e jejunojejunostomia (JJ) costuradas à mão durante a cirurgia bariátrica. Métodos: Avaliação de uma série de casos com 87 pacientes obesos mórbidos submetidos ao bypass gástrico por videolaparoscopia com gastrojejunostomia (JJA) e jejunojejunostomia (JJA) suturados à mão entre 01/2015 e 06/2017. Os pacientes foram divididos em dois grupos; no grupo I, GJA e JJA as suturas foram realizadas com a sutura farpada unidirecional sem nós e, no grupo II, com sutura multifilamentar reabsorvível (Vicryl® 3/0 Ethicon, Livingstone, UK). Foram analisados ​​e comparados os dados registrados sobre gênero, idade, IMC, escore ASA, tempo operatório, morbidade pós-operatória, tempo de internação hospitalar e reoperação. Resultados: Todos os procedimentos foram concluídos por laparoscopia sem mortalidade. O tempo cirúrgico médio foi 123,23 (±30,631) no grupo I e 127,57 (±42,772) no grupo II (p<0,05). As complicações pós-operatórias não diferiram significativamente entre os dois grupos. Complicações precoces foram observadas em dois pacientes (0,9%) no grupo de sutura farpada e um (0,42%) no de sutura multifilamentar (p<0,05). No grupo I, dois pacientes (0,9%) necessitaram de reoperação; um devido à estenose jejunojejunal e abscesso local próximo à gastrojejunostomia, sem vazamento, no outro. No grupo II, um paciente (0,42%) necessitou de reoperação por estenose da GJA. O tempo de internação hospitalar foi semelhante nos dois grupos: 3,36 (±0,743) dias no grupo I vs. 3,38 (±1,058) dias no grupo II (p<0,05). Conclusão: A nova técnica de anastomose é método seguro e eficaz e pode ser aplicado nas anastomoses gastrojejunal e jejunojejunal no bypass gástrico laparoscópico.

Incarcerated Hiatal Hernia with Perforation after Laparoscopic Total Gastrectomy with Roux-en-Y Reconstruction: a Case Report

The occurrence of hiatal hernia after total gastrectomy with Roux-en-Y reconstruction is rare. We report the case of a 76-year-old man who presented with dyspnea, vomiting, and fever around 8 days after total gastrectomy with Roux-en-Y reconstruction. Abdominal computed tomography revealed a hiatal hernia containing part of the small intestine in the left thoracic cavity. Emergent reduction and repair of the hiatal hernia were performed later. Operative findings revealed that the Roux limb was incarcerated in the left pleural cavity. Esophagojejunostomy leakage, perforation of the small intestine with transient ischemic change, and pyothorax were also found. Thus, feeding jejunostomy, thoracoscopic decortication, and diversion T-tube esophagostomy were performed. Considering that the main cause of hiatal hernia is blunt dissection with division of the phrenoesophageal membrane, approximating the crus with 1 or 2 figure-8 sutures, according to the size of the defect, to prevent the incidence of hiatal hernia after total gastrectomy may be performed.

Duodenectomía parcial distal con conservación del páncreas por un tumor del estroma gastrointestinal / Distal partial duodenoscopy with pancreas conservation for stromal gastrointestinal tumor

Los tumores del estroma gastrointestinal son los tumores mesenquimatosos más frecuentes del sistema digestivo. En el duodeno son raros, con menos de 5 por ciento. A diferencia de los carcinomas, los tumores del estroma gastrointestinal no infiltran la mucosa de manera extensa. La resección quirúrgica con bordes de sección negativos sin linfadenectomía es el principal tratamiento con intención curativa y las resecciones conservadoras se llevan a cabo siempre y cuando sean factibles desde el punto de vista técnico. Presentamos una paciente con un tumor del estroma gastrointestinal de duodeno cuya principal manifestación fue el sangrado digestivo alto. La lesión fue resecada con bordes de sección quirúrgicos negativos mediante una duodenectomía parcial distal de la tercera y cuarta porciones del duodeno con preservación del páncreas. El tránsito intestinal fue restituido mediante una duodenoyeyunostomía término-terminal en un plano de sutura. En este momento, la paciente recibe tratamiento con metisilato de imatinib(AU)

Gastrointestinal stromal tumors are the most frequent mesenchymal tumors of the digestive system. In the duodenum, their presentation is rare, with less than 5 persent. Unlike carcinomas, gastrointestinal stromal tumors do not extensively infiltrate the mucosa. Surgical resection with negative section borders without lymphadenectomy is the main treatment with curative intent, and conservative resections are carried out as long as they are feasible from the technical point of view. We present the case of a patient with a gastrointestinal stromal tumor of the duodenum and whose main manifestation was high digestive bleeding. The lesion was resected with negative surgical section borders through a distal partial duodenectomy of the third and fourth portions of the duodenum and with preservation of the pancreas. The intestinal transit was restored by a terminal duodenojejunostomy in a suture plane. At this time, the patient is treated with imatinib mesylate(AU)

Esophageal Endoscopic Vacuum Therapy with Enteral Feeding Using a Sengstaken-Blakemore Tube / 대한흉부외과학회지

Early diagnosis followed by primary repair is the best treatment for spontaneous esophageal perforation. However, the appropriate management of esophageal leakage after surgical repair is still controversial. Recently, the successful adaptation of vacuum-assisted closure therapy, which is well established for the treatment of chronic surface wounds, has been demonstrated for esophageal perforation or leakage. Conservative treatment methods require long-term fasting with total parenteral nutrition or enteral feeding through invasive procedures, such as percutaneous endoscopic gastrostomy or a feeding jejunostomy. We report 2 cases of esophageal leakage after primary repair treated by endoscopic vacuum therapy with continuous enteral feeding using a Sengstaken-Blakemore tube.

Nutritional Care in Iranian Intensive Care Units

Intensive care units (ICUs) provides intensive treatment medicine to avoid complications such as malnutrition, infection and even death. As very little is currently known about the nutritional practices in Iranian ICUs, this study attempted to assess the various aspects of current nutrition support practices in Iranian ICUs. We conducted a cross-sectional study on 150 critically ill patients at 18 ICUs in 12 hospitals located in 2 provinces of Iran from February 2015 to March 2016. Data were collected through interview with supervisors of ICUs, medical record reviews and direct observation of patients during feeding. Our study showed that hospital-prepared enteral tube feeding formulas are the main formulas used in Iranian hospitals. None of the dietitians worked exclusively an ICU and only 30% of patients received diet counselling. Regular monitoring of nutritional status, daily energy and protein intake were not recorded in any of the participating ICUs. Patients were not monitored for anthropometric measurements such as mid-arm circumference (MAC) and electrolyte status. The nasogastric tube was not switched to percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEGJ) in approximately 85% of patients receiving long-term enteral nutrition (EN) support. Our findings demonstrated that the quality of nutritional care was inappropriate in Iranian ICUs and improvement of nutritional care services within Iranian ICUs is necessary.

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer: A Meta-Analysis Based on Short-Term Outcomes / 中华医学杂志(英文版)

<p><b>Background:</b>Laparoscopic total gastrectomy (LTG) is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy (IEJ) following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG.</p><p><b>Methods:</b>Studies published from January 1994 to January 2017 comparing the outcomes of IEJ and extracorporeal esophagojejunostomy (EEJ) following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge Internet (CNKI). Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI) were calculated using the Review Manager 5.3.</p><p><b>Results:</b>Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss (WMD: -13.52 ml; 95% CI: -24.82--2.22; P = 0.02), earlier time to first oral intake (WMD: -0.49 day; 95% CI: -0.83--0.14; P < 0.01), and shorter length of hospitalization (WMD: -0.62 day; 95% CI: -1.08--0.16; P < 0.01). There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections (all P > 0.05).</p><p><b>Conclusions</b>Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.</p>

Lesiones iatrogénicas de las vías biliares / Iatrogenic lesions of the biliary tract

Las lesiones iatrogénicas de las vías biliares (LIVB) representan una complicación quirúrgica grave de la colecistectomía laparoscópica (CL). Ocurre frecuentemente cuando se confunde el conducto biliar con el conducto cístico; y han sido clasificados por Strasberg y Bismuth, según el grado y nivel de la lesión. Alrededor del tercio de las LIVB se reconocen durante la CL, al detectar fuga biliar. No es recomendable su reparación inmediata, especialmente cuando la lesión está próxima a la confluencia o existe inflamación asociada. El drenaje debe establecerse para controlar la fuga de bilis y prevenir la peritonitis biliar, antes de transferir al paciente a un establecimiento especializado en cirugía hepatobiliar compleja. En pacientes que no son reconocidos intraoperatoriamente, las LIVB manifiestan tardíamente fiebre postoperatoria, dolor abdominal, peritonitis o ictericia obstructiva. Si existe fuga biliar, debe hacerse una colangiografía percutánea para definir la anatomía biliar y controlar la fuga mediante stent biliar percutáneo. La reparación se realiza seis a ocho semanas después de estabilizar al paciente. Si hay obstrucción biliar, la colangiografía y drenaje biliar están indicados para controlar la sepsis antes de la reparación. El objetivo es restablecer el flujo de bilis al tracto gastrointestinal para impedir la formación de litos, estenosis, colangitis y cirrosis biliar. La hepáticoyeyunostomía con anastomosis en Y de Roux termino-lateral sin stents biliares a largo plazo, es la mejor opción para la reparación de la mayoría de las lesiones del conducto biliar común.

Iatrogenic bile duct injuries (IBDI) represent a serious surgical complication of laparoscopic cholecystectomy (LC). Often it occurs when the bile duct merges with the cystic duct; and they have been ranked by Strasberg and Bismuth, depending on the degree and level of injury. About third of IBDI recognized during LC, to detect bile leakage. No immediate repair is recommended, especially when the lesion is near the confluence or inflammation is associated. The drain should be established to control leakage of bile and prevent biliary peritonitis, before transferring the patient to a specialist in complex hepatobiliary surgery facility. In patients who are not recognized intraoperatively, the IBDI manifest late postoperative fever, abdominal pain, peritonitis or obstructive jaundice. If there is bile leak, percutaneous cholangiography should be done to define the biliary anatomy, and control leakage through percutaneous biliary stent. The repair is performed six to eight weeks after patient stabilization. If there is biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis before repair. The ultimate aim is to restore the flow of bile into the gastrointestinal tract to prevent the formation of calculi, stenosis, cholangitis and biliary cirrhosis. Hepatojejunostomy with Roux-Y anastomosis termino-lateral without biliary stents long term, is the best choice for the repair of most common bile duct injury.

Absceso hepático piógeno secundario a cuerpo extraño / Pyogenic hepatic abscess secondary to a foreign body

El absceso hepático piógeno es una enfermedad secundaria a un foco primario cuyas vías básicas de infección son: vía biliar y el sistema portal. Se presenta el caso de un paciente de 23 años que presenta dolor a nivel de hemiabdomen superior que refiere haber ingerido un alambre en forma de gancho. Sobre la base de los antecedentes y exámenes complementarios se interpreta la posibilidad de un absceso hepático secundario a un cuerpo extraño. Se realizó drenaje del absceso y yeyunotomía para extracción del cuerpo extraño endoluminal. Actualmente, el paciente se encuentra totalmente recuperado(AU)

Pyogenic hepatic abscess is a disease secondary to a primary focus whose basic pathways of infection are the bile duct and the portal system. The case is presented of a 23-year-old patient with pain at the level of the upper hemiabdomen and who reported having ingested a wire in the shape of a hook. Upon the basis of the antecedents and complementary examinations the possibility is interpreted for a hepatic abscess secondary to a foreign body. Drainage of the abscess and jejunostomy were performed to remove the foreign body from the endoluminal system. Currently, the patient is fully recovered(AU)

Cuidado integral à pessoa estomizada na atenção básica - conhecimento e atuação do enfermeiro / Complete care for the stomizedperson in primary care - knowledge and nursing activities / Cuidado integral a la persona con ostomía en la atención básica - conocimiento y actuación del enfermero

O cuidado integral à pessoa com estomia é atividade realizada pelo enfermeiro na atenção básica, logo após a alta hospitalar cirúrgica, efetivando cuidados específicos de enfermagem, esclarecendo as dúvidas do usuário e familiares e orientando para o autocuidado e prevenção de possíveis complicações.O estudo teve como objetivo apreciar o conhecimento e a atuação do enfermeiro no cuidado à pessoa estomizada na atenção básica. Estudo com caráter qualitativo, exploratório e descritivo, utilizou para coleta de dados uma entrevista semiestruturada com questões norteadoras, gravadas e transcritas na íntegra, aplicada a vinte e seis enfermeiros da atenção básica municipal. A partir da análise de conteúdo temático, emergiram as seguintes categorias: identificando o cuidado com os estomas e,percepções do enfermeiro a respeito da assistência prestada ao estomizado. O ensino de enfermagem e a educação permanente poderão contribuir para uma atuação competente e eficaz de cuidado integral ao estomizado, e isso refletiria no processo adaptativo e na qualidade de vida dos estomizados e de suas famílias. [AU]

Complete care for the person with the stoma is an activity performed by the nurse in primary care, shortly after discharge from the hospital, carrying out specific nursing care, explanation to user and family doubts, and guidelines for self-care and prevention of possible complications. The study aimed to appreciate the knowledge and the performance of nurses caring for the stomized person in primary care. A qualitative, exploratory and descriptive study, for data collection a semi-structured interview, with guiding questions, recorded and transcribed in full, applied to twenty-six nurses of the municipal primary care were used. From the analysis of the thematic content emerged the following categories: identifying care with the ostomy; the nurses' perceptions regarding the assistance provided to the ostomy patient. Nursing education and permanent education can contribute to a competent and effective performance of integral care to the ostomy patient, and this would reflect in the adaptive process and quality of life of thestomized patients and their families. [AU]

El cuidado integral a la persona con ostomía es la actividad realizada por el enfermero en la atención básica tras el alta hospitalaria quirúrgica, realizando cuidados específicos de enfermería, aclarando las dudas del usuario y los familiares; y orientando para el autocuidado y la prevención de posibles complicaciones. El estudio tuvo como objetivo evaluar el conocimiento y la actuación del enfermero en el cuidado a la persona con ostomía en la atención básica. El estudio, con carácter cualitativo, exploratorio y descriptivo, utilizó para la recolección de datos entrevista semiestructurada, con cuestiones orientadoras, grabadas y transcriptas en su totalidad, aplicada a veintiséis enfermeros de la atención básica municipal. A partir del análisis del contenido temático surgieron las siguientes categorías: identificando el cuidado con los estomas; percepciones del enfermero sobre la atención prestada a la persona con ostomía. La enseñanza de enfermería y la educación permanente podrán contribuir para una actuación competente y eficaz de cuidado integral al paciente con ostomía, y eso reflejaría en el proceso adaptativo y en su calidad de vida y de sus familias. [AU]

Resección y hepaticoyeyunostomía laparoscópicas en quiste de colédoco tipo 1 / Laparoscopic resection and hepaticojejunostomy for type 1 choledochal cyst

Los quistes del colédoco son dilataciones congénitas de la vía biliar que afectan fundamentalmente a la población pediátrica, de ellas, el tipo 1 es el más frecuente. Pueden producir graves complicaciones y el tratamiento quirúrgico de elección es la resección total de la lesión seguida de hepaticoenterostomía. Actualmente, este proceder se realiza por vía laparoscópica con buenos resultados. El objetivo del trabajo es reportar el tratamiento laparoscópico de un quiste de colédoco tipo 1 en un paciente de 5 años. No hubo complicaciones posoperatorias y los resultados estéticos y funcionales al año de seguimiento son excelentes. Se concluye que la resección laparoscópica en quistes de colédoco tipo 1 es posible y se sugiere continuar con su implementación(AU)

Choledochal cysts are congenital dilatation of the bile ducts that typically affect the pediatric population. Cases of its type 1 are the more frequent. Serious complications may occur and the surgical treatment of election is the lesions' total resection followed by hepaticoenterostomy. Today this procedure is carried out by laparoscopic way with good outcomes. The objective of this paper is to report a choledochal cyst type 1´s laparoscopic treatment in a 5-year-old patient. There were not postoperative complications and the aesthetic and functional results after one-year follow-up are excellent. The choledochal cysts´ laparoscopic resection is concluded to be possible and its implementation is suggested to follow(AU)

Health-Care Utilization and Complications of Endoscopic Esophageal Dilation in a National Population

BACKGROUND/AIMS: Esophageal stricture is usually managed with outpatient endoscopic dilation. However, patients with food impaction or failure to thrive undergo inpatient dilation. Esophageal perforation is the most feared complication, and its risk in inpatient setting is unknown. METHODS: We used National Inpatient Sample (NIS) database for 2007–2013. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes were used to identify patients with esophageal strictures. Logistic regression was used to assess association between hospital/patient characteristics and utilization of esophageal dilation. RESULTS: There were 591,187 hospitalizations involving esophageal stricture; 4.2% were malignant. Endoscopic dilation was performed in 28.7% cases. Dilation was more frequently utilized (odds ratio [OR], 1.36; p<0.001), had higher in-hospital mortality (3.1% vs. 1.4%, p<0.001), and resulted in longer hospital stays (5 days vs. 4 days, p=0.01), among cases of malignant strictures. Esophageal perforation was more common in the malignant group (0.9% vs. 0.5%, p=0.007). Patients with malignant compared to benign strictures undergoing dilation were more likely to require percutaneous endoscopic gastrostomy or jejunostomy (PEG/J) tube (14.1% vs. 4.5%, p<0.001). Palliative care services were utilized more frequently in malignant stricture cases not treated with dilation compared to those that were dilated. CONCLUSIONS: Inpatient endoscopic dilation was utilized in 29% cases of esophageal stricture. Esophageal perforation, although infrequent, is more common in malignant strictures.

Phlegmonous Esophagitis Treated with Internal Drainage and Feeding Jejunostomy

We report the case of a 67-year-old woman presenting with epigastric pain. Computed tomography identified diffuse phlegmonous esophagitis. Esophagogastroduodenoscopy revealed multiple perforations in the mucosal layer of the esophagus. A large amount of pus was drained internally through the gut. The patient was treated with antibiotics and early jejunostomy feeding. Although phlegmonous esophagitis is a potentially fatal disease, the patient was successfully treated medically with only a minor complication (esophageal stricture).

Complex biliary intervention: Percutaneous small bowel access confirmation with cone-beam computed tomography and retrograde biliary obstruction recanalization

BACKGROUND: To describe our experience with percutaneous small bowel access in patients with surgically altered anatomy for complex biliary intervention where cone-beam computed tomography (CBCT) was used to confirm appropriate small bowel access. METHODS: Retrospective chart review from January 2012 to February 2016 identified 9 patients who underwent complex biliary procedures, which used CBCT assistance. Inclusion criteria were creation of percutaneous small bowel access, usage of CBCT, and biliary recanalization. Procedures were performed using percutaneous small bowel access to assist with antegrade or retrograde biliary recanalization using a variety of wire and catheter techniques. Non-contrast CBCT was used in all cases to confirm appropriate small bowel access. RESULTS: In three patients with disconnected biliary systems and failed prior attempts at percutaneous recanalization, new bilio-enteric anastomoses were successfully created. In 6 patients with prior hepaticojejunostomy and biliary obstructions, percutaneous jejunostomy was used successfully to recanalize the biliary stenoses and place multiple internal biliary stents, which were then managed with percutaneous retrograde exchanges. Five patients are catheter free; two are currently managed with long-term biliary drainage. One patient eventually required liver transplantation and another required surgical revision of anastomotic restenosis. There was a single major complication in one patient where the jejunostomy tube resulted in small bowel obstruction requiring surgical revision. A minor complication occurred in another patient, with the development of cellulitis around the jejunostomy tube. CONCLUSION: CBCT can effectively confirm appropriate percutaneous small bowel access in patients with surgically altered anatomy, and who require retrograde biliary recanalization. CBCT is also useful to guide percutaneous creation of new bilio-enteric anastomosis in patients with disconnected biliary systems.

Non-Surgical Management of Critically Compromised Airway Due to Dilatation of Interposed Colon / 결핵및호흡기질환

We present a rare case of critically compromised airway secondary to a massively dilated sequestered colon conduit after several revision surgeries. A 71-year-old male patient had several operations after the diagnosis of gastric cancer. After initial treatment of pneumonia in the pulmonology department, he was transferred to the surgery department for feeding jejunostomy because of recurrent aspiration. However, he had respiratory failure requiring mechanical ventilation. The chest computed tomography (CT) scan showed pneumonic consolidation at both lower lungs and massive dilatation of the substernal interposed colon compressing the trachea. The dilated interposed colon was originated from the right colon, which was sequestered after the recent esophageal reconstruction with left colon interposition resulting blind pouch at both ends. It was treated with CT-guided pigtail catheter drainage via right supraclavicular route, which was left in place for 2 weeks, and then removed. The patient remained well clinically, and was discharged home.

Development of Tracheoesophageal Fistula after the Use of Sorafenib in Locally Advanced Papillary Thyroid Carcinoma: a Case Report

Sorafenib, an oral multi-kinase inhibitor, is used for the treatment of patients with radioactive iodine (RAI) refractory differentiated thyroid carcinoma (DTC) with favorable outcomes. Some unusual but fatal adverse effects are known for this drug and tracheoesophageal fistula (TEF) is one of them, which has never been reported in thyroid cancer patients. We present a successfully treated patient who had developed TEF associated with rapid tumor regression during sorafenib treatment for locally advanced papillary thyroid carcinoma (PTC). Sorafenib was discontinued and feeding jejunostomy tube was placed for nutritional support. 3 months later, the TEF had successfully healed and there was no visible fistula track or interval change of the viable tumor during 15 months of follow-up. Identifying patients at high risk for this potential complication and paying special attention when prescribing anti-angiogenics to these patients are crucial to prevent associated morbidity and mortality.

Optimización en la estrategia diagnóstica y terapéutica en el quiste de colédoco / Optimization in diagnostic and therapeutic strategy of choledochal cyst

Objectives: The choledochal cyst has an incidence of 1 in 100.000-150.000. The purpose of this study was to analyze the variables introduced for the optimization in the diagnosis and treatment of choledochal cyst. Material and Methods: Retrospective study of patients treated in our center by hepatic-jejunostomy and Roux-Y, from September 1988 to November 2012. We analyzed 40 variables including age, symptoms, type of cysts, diagnostic tests, changes in surgical technique, complications and outcomes. Results: Eighteen patients (66.6 percent female) were grouped according to the age of presentation: Prenatal (< 1 month), Early (124), Delayed (> 24 months). The most common symptoms were jaundice and abdominal pain (for early-onset and late-onset respectively). The 83.3 percent presented choledochal cysts type I, the ultrasound was sufficient for diagnosis in 94.4 percent. Since 2004 we modified the surgical technique, performing laparoscopic dissection of the bile duct and cyst, adding a mini-laparotomy (3-5 cm) for hepatic-jejunostomy with 40 cm intestinal loop using polypropylene suture. One complication was observed since 2004, one case of partial dehiscence of the anastomosis resolved with conservative treatment and a cholangitis in 1 patient with hepatic and renal polycystic. In 2012, 83.3 percent are asymptomatic. Conclusions: The diagnostic have been simplified, in more than 90 percent of cases was done by ultrasound; advances in minimally invasive surgery and creation of descending loop of 40 cm, have helped to improve the prognosis of choledochal cyst.

Objetivos: El quiste de colédoco presenta una incidencia de 1 en 100.000-150.000. El propósito de este estudio fue analizar las variables introducidas para la optimización en el diagnóstico y tratamiento del quiste de colédoco. Material y Métodos: Estudio retrospectivo de pacientes intervenidos en nuestro centro de quiste de colédoco mediante hepático-yeyunostomía en Y de Roux, desde septiembre de 1988 a noviembre de 2012. Se analizan 40 variables incluyendo edad, sintomatología, tipo de quiste, pruebas diagnósticas, cambios en la técnica quirúrgica, complicaciones y evolución. Resultados: 18 pacientes (66,6 por ciento mujeres) fueron agrupados de acuerdo a la edad de presentación: Prenatal (< 1 mes); Precoz (1-24 meses); Tardía (> 24 meses). Los síntomas más frecuentes fueron ictericia y dolor abdominal (para los de inicio precoz y tardío respectivamente). El 83,3 por ciento presentaban quistes de colédoco tipo I; siendo suficiente la ecografía para el diagnóstico en el 94,4 por ciento. A partir de 2004 modificamos la técnica quirúrgica, realizando por vía laparoscópica la disección de la vía biliar y mediante laparotomía mínima (3-5 cm) hepático-yeyunostomía con asa descendente de 40 cm, empleando sutura de polipropileno, observando desde el 2004, sólo 1 dehiscencia parcial de la anastomosis, resuelta con tratamiento conservador y 1 colangitis en paciente con poliquistosis hepática y renal. En el año 2012 el 83,3 por ciento están asintomáticos. Conclusiones: El diagnóstico se ha simplificado, en más de 90 por ciento de los casos se realiza sólo con ecografía; los avances en cirugía mínimamente invasiva y la creación de asa descendente de 40 cm, han logrado optimizar el pronóstico del quiste de colédoco.

Successful Management of Airway Emergency in a Patient with Esophageal Cancer / 대한구급학회지

A 60-year-old man with advanced esophageal cancer was admitted for surgical placement of a feeding jejunostomy tube before commencement of chemoradiotherapy. His esophageal cancer had directly invaded the posterior tracheal wall, inducing a nearly total obstruction of the distal trachea. On the day before the surgery, respiratory failure developed due to tumor progression and tracheal edema. Tracheal intubation and mechanical ventilation were attempted without success. Application of veno-venous extracorporeal membrane oxygenation (ECMO) corrected the patient's respiratory acidosis and relieved his dyspnea. With full ECMO support, he underwent tracheal stent insertion. Two hours later, he was weaned from ECMO support uneventfully. This was a successful case of tracheal stenting for airway obstruction under rescue veno-venous ECMO.