Duplicación del colédoco asociado a unión biliopancreática anómala: Reporte de caso / Common bile duct duplication associated with anomalous biliopancreatic junction: A case report

Introducción. La duplicación del colédoco es una anomalía congénita poco frecuente. En la mayoría de los casos este defecto se asocia a cálculos en la vía biliar, unión pancreatobiliar anómala, pancreatitis, cáncer gástrico o colangiocarcinoma. Por esta razón, el diagnóstico y el tratamiento temprano son importantes para evitar las complicaciones descritas a futuro. Métodos. Se presenta el caso de una paciente de 30 años, con antecedente de pancreatitis aguda, con cuadro de dolor abdominal crónico, a quien se le realizaron varios estudios imagenológicos sin claro diagnóstico. Fue llevada a manejo quirúrgico en donde se documentó duplicación del colédoco tipo II con unión pancreatobiliar anómala. Resultados. Se hizo reconstrucción de las vías biliares y hepatico-yeyunostomía, con adecuada evolución postoperatoria y reporte final de patología sin evidencia de tumor. Conclusión. El diagnóstico se hace mediante ecografía endoscópica biliopancreática, colangiorresonancia o colangiopancreatografía retrógrada endoscópica. El tratamiento depende de si está asociado o no a la presencia de unión biliopancreática anómala o cáncer. Si el paciente no presenta patología neoplásica, el tratamiento quirúrgico recomendado es la resección del conducto con reconstrucción de las vías biliares.

Introduction. Double common bile duct is an extremely rare congenital anomaly. This anomaly may be associated with bile duct stones, anomalous biliopancreatic junction, pancreatitis, bile duct cancer, or gastric cancers. Thus, early diagnosis and treatment is important to avoid complications. Clinical case. We report a rare case of double common bile duct associated with an anomalous biliopancreatic junction in a 30-year-old female, with prior history of acute pancreatitis, who presented with chronic abdominal pain. She underwent several imaging studies, without clear diagnosis. She was taken to surgical management where duplication of the type II common bile duct was documented with anomalous pancreatobiliary junction. Results. Reconstruction of the bile ducts and hepatico-jejunostomy were performed, with adequate postoperative evolution and final pathology report without evidence of tumor. Conclusion. Diagnosis is usually performed by an endoscopic ultrasound, magnetic resonance cholangiopancrea-tography, or endoscopic retrograde cholangiopancreatography. Treatment depends on the presence of anomalus biliopancreatic junction or concomitant cancer. In cases without associated malignancy, resection of bile duct and biliary reconstruction is the recommended surgical treatment.

Perforación colónica por endoprótesis biliar impactada / Colonic perforation due to impacted biliary stent

Introducción. La colocación de endoprótesis biliares es cada día más frecuente por ser actualmente una de las mejores opciones para el tratamiento de patologías de la vía biliar. La migración de las endoprótesis es una de las complicaciones que puede ocurrir en hasta un 10,8 % de los pacientes, pero en muy raras ocasiones llegan a causar una perforación intestinal. Caso clínico. Se trata de una paciente de 61 años, a quien cinco años atrás se le realizó una colangiopancreatografía retrógrada endoscópica por coledocolitiasis. Consultó por presentar dolor abdominal, y al examen físico se encontraron abdomen agudo y plastrón en fosa ilíaca izquierda a la palpación. La tomografía computarizada informó un cuerpo extraño a nivel del colon descendente, con perforación del mismo. Se realizó laparotomía exploratoria y colostomía por perforación del colon sigmoides secundaria a prótesis biliar migrada. Resultados. La paciente evolucionó favorablemente y a los seis meses se realizó el cierre de la colostomía, sin complicaciones. Conclusión. Los pacientes a quienes se les colocan prótesis biliares requieren un seguimiento adecuado para evitar complicaciones que, aunque raras, pueden ocurrir, como la migración intestinal con perforación. El tratamiento de dichas complicaciones se hace por vía endoscópica, laparoscópica o laparotomía en caso de complicación severa.

Introduction. Endoscopic placement of biliary stents is becoming more common every day, as it is currently one of the best options for the treatment of bile duct pathologies. One of the complications that can occur is the migration of the endoprostheses in up to 10.8% of patients, which in very rare cases can cause intestinal perforation. Clinical case. This is a 61-year-old female patient, who underwent endoscopic retrograde cholangiopancreatography five years ago for choledocholithiasis. She consulted due to abdominal pain, with a physical examination that upon palpation documented an acute abdomen and a palpable plastron in the left iliac fossa. The computed tomography revealed a foreign body at the level of the descending colon, with perforation. Exploratory laparotomy and colostomy were performed due to perforation of the sigmoid colon secondary to migrated biliary prosthesis. Results. The patient progressed favorably and six months later the colostomy was closed without complications. Conclusions. Patients who receive biliary stents require adequate follow-up to avoid complications that, although rare, may occur, such as intestinal migration with intestinal perforation. The treatment of these complications can be endoscopic, laparoscopic or laparotomy in case of severe complication.

Efficacy of endoscopic retrograde cholangiopancreatography combined with electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system in treatment of difficult choledocholithiasis / 临床肝胆病杂志

ObjectiveTo investigate the safety and efficacy of endoscopic retrograde cholangiopancreatography （ERCP） combined with electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system in the treatment of difficult choledocholithiasis. MethodsA retrospective analysis was performed for the clinical data of 12 patients with difficult choledocholithiasis who underwent ERCP and electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system in Department of Gastroenterology， Jilin People’s Hospital， from May to November 2022. The clinical effect of lithotripsy and lithotomy was observed， and postoperative complications and time of surgical operation were assessed. ResultsAmong the 12 patients， 11 （91.67%） were successfully treated by electrohydraulic lithotripsy under direct view， 9 （75.00%） achieved first-attempt success in lithotripsy， and 11 （91.67%） had complete removal of calculi； 1 patient was found to have stenosis of the bile ducts caused by multiple biliary tract surgeries， and grade Ⅱ intrahepatic bile duct stones above the sites of stenosis were removed under direct view， but there were still residues of grade Ⅲ intrahepatic bile duct stones， which led to the fact that complete calculus removal was not achieved. The mean time of ERCP operation was 91.3±26.2 minutes， including a time of 41.8±22.2 minutes for energy lithotripsy. There were 2 cases of postoperative biliary tract infection which were improved after anti-infective therapy， 2 cases of hyperamylasemia which were not given special treatment， and 3 cases of mild pancreatitis which were improved after symptomatic medication， and there were no complications such as bleeding and perforation. ConclusionERCP combined with electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system is safe， effective， and feasible in the treatment of difficult choledocholithiasis.

Advances in the differential diagnosis of malignant bile duct stenosis / 临床肝胆病杂志

There are various etiologies for extrahepatic bile duct stenosis， and pharmacotherapy and endoscopic intervention can achieve a good clinical effect in benign stenosis. Early diagnosis and timely surgical treatment of malignant stenosis may prolong the survival time of patients. However， there are still difficulties in the differential diagnosis of malignant bile duct stenosis. This article reviews the application of serology， radiology， endoscopic techniques， and artificial intelligence in the differential diagnosis of malignant bile duct stenosis， so as to provide strategies and references for formulating clinical diagnosis and treatment regimens.

Efficacy of endoscopic ultrasound-guided coil placement combined with tissue adhesive injection in treatment of gastric varices with spontaneous shunt / 临床肝胆病杂志

ObjectiveTo investigate the efficacy， safety， and cost-effectiveness of endoscopic ultrasound （EUS）-guided coil placement combined with tissue adhesive injection in the treatment of gastric varices with spontaneous shunt. MethodsA retrospective analysis was performed for the patients with acute gastric variceal bleeding and spontaneous portosystemic shunt who were hospitalized and received balloon-occluded retrograde transvenous obliteration （BRTO） combined with endoscopic tissue adhesive injection or EUS-guided coil placement combined with tissue adhesive injection in Xiangyang Central Hospital from March 2019 to September 2022. The two surgical procedures were compared in terms of efficacy （technical success rate， 5-day rebleeding rate， 1-year rebleeding rate， and time to rebleeding）， safety （the incidence rate of ectopic embolism， the amount of tissue adhesive used， and the amount of lauromacrogol used）， and cost-effectiveness （hospital costs and length of hospital stay）. The t-test was used for comparison of normally distributed continuous data between two groups， and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The Kaplan-Meier method was used to estimate the rebleeding. The chi-square test was used for comparison of categorical data between two groups. ResultsA total of 25 patients received successful EUS-guided coil placement and tissue adhesive injection， with a technical success rate of 100%， a median amount of 2.5 mL tissue adhesive used， a median amount of 11.0 mL lauromacrogol used， a mean length of hospital stay of 14.88±3.21 days， a mean hospital cost of 32 660.00±4 602.07 yuan， and a 5-day rebleeding rate of 0%； among these patients， 2 were lost to follow-up， and 23 patients with complete follow-up data had an incidence rate of ectopic embolism of 0% and a median time to rebleeding of 689 days. A total of 14 patients underwent modified BRTO combined with endoscopic tissue adhesive injection， with a technical success rate of 100%； a median amount of 5.0 mL tissue adhesive used during surgery， which was significantly higher than that used in EUS （U=39.000， P<0.001）； a median amount of 10.5 mL lauromacrogol used during surgery； a mean length of hospital stay of 15.38±4.94 days； a mean hospital cost of 57 583.47±18 955.40 yuan， which was significantly higher than that used in EUS （t=-6.310， P<0.001）； a 5-day rebleeding rate of 0%. No patient was lost to follow-up， and all 14 patients had an incidence rate of ectopic embolism of 0% and a median time to rebleeding of 244.50 days， with no significant difference between the two groups （χ2=1.448， P=0.229）. ConclusionEUS-guided coil placement combined with tissue adhesive injection is a relatively safe and effective technique for the treatment of gastric variceal bleeding and has a high technical success rate， a low incidence rate of serious adverse events， and similar efficacy to BRTO， with higher safety and cost-effectiveness.

Descending aortic intramural hematoma with pulmonary embolism: A case report / 中国胸心血管外科临床杂志

@#Aortic intramural hematoma and pulmonary embolism are two rapidly progressive and life-threatening diseases. A 65-year-old male patient with descending aortic intramural hematoma and pulmonary embolism underwent pulmonary embolectomy and descending aortic stent-graft placement, with good postoperative results.

Progress in diagnosis and treatment of biliary anastomotic stricture after liver transplantation / 器官移植

In recent years, with the development of organ preservation, surgical techniques, perioperative management and immunosuppression regimens, the success rate of liver transplantation and survival rate of the recipients have been significantly enhanced. Liver transplantation has become the optimal treatment for patients with end-stage liver disease. However, biliary complications still commonly occur after liver transplantation, especially biliary anastomotic stricture. Severe biliary anastomotic stricture will not only increase the cost of treatment, but also lead to graft loss and even affect the survival rate of recipients. Therefore, timely diagnosis and treatment of biliary anastomotic stricture play a significant role in improving the survival rate of liver transplant recipients. In this article, the risk factors, clinical symptoms, diagnosis and treatment of biliary anastomotic stricture after liver transplantation were reviewed, aiming to provide novel ideas for the research, diagnosis and treatment of biliary anastomotic stricture after liver transplantation, and further enhance clinical efficacy of liver transplantation and the quality of life of recipients.

A Novel Retrograde AAV Variant for Functional Manipulation of Cortical Projection Neurons in Mice and Monkeys / 神经科学通报·英文版

Retrograde adeno-associated viruses (AAVs) are capable of infecting the axons of projection neurons and serve as a powerful tool for the anatomical and functional characterization of neural networks. However, few retrograde AAV capsids have been shown to offer access to cortical projection neurons across different species and enable the manipulation of neural function in non-human primates (NHPs). Here, we report the development of a novel retrograde AAV capsid, AAV-DJ8R, which efficiently labeled cortical projection neurons after local administration into the striatum of mice and macaques. In addition, intrastriatally injected AAV-DJ8R mediated opsin expression in the mouse motor cortex and induced robust behavioral alterations. Moreover, AAV-DJ8R markedly increased motor cortical neuron firing upon optogenetic light stimulation after viral delivery into the macaque putamen. These data demonstrate the usefulness of AAV-DJ8R as an efficient retrograde tracer for cortical projection neurons in rodents and NHPs and indicate its suitability for use in conducting functional interrogations.

Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography in a Patient with Gastric Bypass. Report of the First Local Case

We describe the first case in our environment of endoscopic ultrasound (EUS)-assisted transgastric endoscopic retrograde cholangiopancreatography in a patient with gastric bypass surgery. The procedure was performed with a side-viewing duodenoscope through a jejunogastrostomy using apposing stents, placed with EUS assistance, and a standard technique and instruments.

Se describe el primer caso en nuestro medio de colangiopancreatografía retrógrada endoscópica transgástrica asistida por endosonografía en una paciente con cirugía de baipás gástrico. El procedimiento se realizó con duodenoscopio de visión lateral a través de una yeyunogastrostomía por stent de aposición, emplazado con asistencia endosonográfica y con una técnica e instrumental estándar.

Colangiopancreatografía endoscópica asistida por laparoscopia para el tratamiento de coledocolitiasis en pacientes con Y de Roux / Laparoscopic-assisted endoscopic cholangiopancreatography for the treatment of choledocholithiasis in patients with Roux-en-Y

Introducción. Los pacientes con antecedente de baipás gástrico que presentan coledocolitiasis no pueden ser tratados con la técnica convencional de colangiopancreatografía retrógrada endoscópica. En estos casos, la vía transgástrica abierta o asistida por laparoscopia, se convierte en una excelente alternativa a la exploración abierta de la vía biliar. Métodos. Estudio retrospectivo que incluyó pacientes adultos con coledocolitiasis y antecedente de gastrectomía subtotal o baipás gástrico con Y de Roux, llevados a colangiopancreatografía endoscópica transgástrica laparo-asistida, entre enero de 2019 y diciembre de 2021, en la Clínica CES de Medellín, Colombia. Resultados. Se encontraron siete pacientes, todos con antecedente de baipás gástrico para el manejo de la obesidad. La tasa de identificación y canulación de la vía biliar y extracción de cálculos fue del 100 % mediante el abordaje transgástrico laparo-asistido. Conclusión. De acuerdo con varias revisiones sistemáticas, esta técnica es relativamente fácil de implementar y segura, presentando una tasa de complicaciones inferior a 5 %. Se propone una variante de esta técnica

Introduction. Patients with a history of gastric bypass who present with choledocholithiasis cannot be treated with the conventional technique of endoscopic retrograde cholangiopancreatography. In these cases, the open or laparoscopic-assisted transgastric approach becomes an excellent alternative to open bile duct gastric exploration. Methods. A retrospective review of patients with choledocholithiasis and a history of subtotal gastrectomy or gastric bypass with Roux-en-Y, who underwent laparo-assisted transgastric endoscopic cholangiopancreatography, was conducted between January 2019 and December 2021 at Clínica CES de Medellín, Colombia. Results. Seven patients were found, all with a history of gastric bypass secondary to obesity. The rate of bile duct identification and cannulation, and stone removal was 100% using the laparo-assisted transgastric approach. Conclusion. According to several systematic reviews, this technique is relatively easy to implement and safe, presenting a rate of complications less than 5%. A variant to this technique is proposed

Litiasis masiva de la vía biliar intra y extra hepática. Reporte de 2 casos / Massive intra- and extra-hepatic bile duct lithiasis. Report of 2 cases

Resumen La presencia conjunta y masiva de cálculos biliares de la vía biliar, tanto intra como extra hepática, es una rara entidad dentro de la población occidental. A continuación, se presentan 2 casos, los cuales debutan con cuadro clínico de dolor en hipocondrio derecho y con datos clínicos y de laboratorio de obstrucción de la vía biliar, y que mediante estudio de colangio resonancia, se evidencian múltiples litos endoluminales de la vía biliar de manera global, además se muestra del tratamiento de uno de los casos mediante CPRE con evacuación exitosa de los cálculos biliares.

Abstract The joint and massive presence of gallstones from the bile duct, both intra and extra hepatic, is a rare entity within the western population. Two cases are presented below, which debuted with a clinical picture of pain in the right hypo chondrium and with a clinical picture of pain in the right hypochondrium and with clinical and laboratory data of bile duct obstruction, and that by means of a resonance cholangiography study, multiple endoluminal stones of the bile duct are evidenced. Overall, it also shows the treatment of one of the cases by ERCP with successful evacuation of the gallstones.

Migración de endoprótesis biliar. Del olvido a su recuperación / Biliary stent migration. From oblivion to recovery

RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) es un procedimiento invasivo para el diagnóstico y el tratamiento de la enfermedad biliopancreática. Entre sus complicaciones más infrecuentes se encuentra la migración proximal y distal de la endoprótesis biliar. Las escasas publicaciones sobre tal complicación motivaron la redacción de este artículo. Nuestro objetivo principal fue presentar dos casos clínicos de migración de endoprótesis biliar plástica, su manejo y resolución. Consideramos importante resaltar la necesidad del registro y seguimiento de los pacientes en quienes se colocaron endoprótesis biliares, para la prevención de su olvido más allá del tiempo recomendado de permanencia, y evitar así complicaciones tardías, ya que "la ignorancia no es la felicidad".

ABSTRACT Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure for the diagnosis and treatment of biliary tract and pancreatic duct diseases. Proximal and distal stent migration is a rare complication. The paucity of publications on this issue motivated this article. The main aim of this study was to describe two case reports of migration of biliary plastic stents, how they were managed and solved. We believe it is important to emphasize the need for recording and monitoring patients who have undergone biliary stent placement, to avoid leaving the stent in situ beyond the recommended time, and thus avoid late complications, since "ignorance is not bliss".

Criterios 5-5-2 de canulación biliar y complicaciones post colangiopancreatografía retrógrada endoscópica: Experiencia en un hospital de referencia, Perú

La Sociedad Europea de Endoscopia Gastrointestinal (ESGE) define "canulación difícil" como aquella en la que se realizan más de 5 intentos, se exceden 5 minutos, o se produce canulación inadvertida del conducto pancreático 2 o más veces (criterios 5-5-2), recomendando estos puntos de corte para realizar técnicas avanzadas de canulación y disminuir la tasa de eventos adversos post CPRE. Nuestro objetivo fue evaluar el rendimiento de los criterios 5-5-2 y su asociación con complicaciones post CPRE en un hospital de referencia de Perú. Realizamos un estudio analítico prospectivo de casos y controles en el que se incluyó 120 pacientes a los que se realizó CPRE. El grupo casos estuvo formado por 30 pacientes que cumplieron al menos uno de los criterios 5-5-2 y el grupo controles por 90 pacientes sin ninguno de estos criterios. Se comparó el desarrollo de complicaciones en cada grupo y su asociación con cada uno de los criterios 5-5-2. Las complicaciones presentadas fueron: pancreatitis post CPRE (6,6% en el grupo casos vs 3,3% en el grupo controles), sangrado (3,3% controles vs 0% casos) y perforación (1,1% controles vs 0 % casos); sin observar diferencia estadísticamente significativa. El criterio de 2 o más ingresos inadvertidos al conducto pancreático presentó asociación significativa (OR= 10,29, IC: 1,47-71,98; p= 0,005) con el desarrollo de pancreatitis post CPRE. Los criterios 5 minutos y 5 intentos no se asociaron a complicaciones post CPRE. En conclusión, el más relevante de los criterios 5-5-2 fue el ingreso inadvertido al conducto pancreático en 2 o más ocasiones, mostrando asociación por sí solo con pancreatitis post CPRE. Los criterios tiempo y número de intentos podrían ampliarse con cautela sin aumentar la tasa de complicaciones post CPRE.

The European Society for Gastrointestinal Endoscopy (ESGE) defines "difficult biliary cannulation" by the presence of one or more of the following: more than 5 contacts with the papilla, more than 5 minutes attempting to cannulate, or inadvertent cannulation of the pancreatic duct in 2 or more times (5-5-2 criteria), recommending these cut-off points to perform advanced cannulation techniques in order to reduce the rate of post-ERCP adverse events. Our objective was to evaluate the performance of the 5-5-2 criteria and their association with post-ERCP complications in a reference hospital in Peru. We performed a prospective analytical case-control study and 120 patients who underwent ERCP were enrolled. The case group included 30 patients who met at least one of the 5-5-2 criteria and the control group included 90 patients without any of these criteria. The ERCP- related complications in both groups and their association with each of the 5-5-2 criteria were compared. The ERCP-related complications that occurred were post-ERCP pancreatitis (6.6% in the case group vs. 3.3% in the control group), bleeding (3.3% controls vs. 0% cases) and perforation (1.1% controls vs. 0% cases); no statistically significant differences were observed. The criterion of 2 or more unintended cannulations to the pancreatic duct showed a significant association (OR= 10.29, CI: 1.47-71.98; p= 0.005) with the incidence of post-ERCP pancreatitis. The criteria 5 minutes and 5 attempts were not associated with post-ERCP complications. In conclusion, among 5-5-2 criteria only the unintended cannulation of 2 or more times into the pancreatic duct was associated with an increased risk of post-ERC pancreatitis. The time and number of attempts criteria could be cautiously expanded without increasing the rate of post-ERCP complications.

Pancreatitis aguda recurrente secundaria a disfunción del esfínter de oddi: Reporte de caso

La disfunción del esfínter de Oddi (DEO) es una patología poco frecuente que debe ser considerada en el diagnóstico diferencial de pacientes con episodios de dolor biliar o pancreatitis aguda recurrente y antecedente de colecistectomía. Generalmente son pacientes con múltiples consultas, en los cuales la patología ha afectado considerablemente su calidad de vida. El diagnóstico se sustenta en la clínica, los marcadores serológicos y los medios diagnósticos de soporte, que se solicitan según el componente esfinteriano sospechado. El tratamiento con mayor eficacia es la esfinterotomía endoscópica. El uso de prótesis es aceptado, pero discutido. Se presenta el caso de un paciente masculino en la cuarta década de la vida que consultó por múltiples episodios de pancreatitis aguda recurrente con estudios de etiología que sospecharon disfunción del esfínter de Oddi pancreático y quien fue llevado a manejo endoscópico, con mejoría de su cuadro clínico.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Spontaneous Biloma: A Case Report and Literature Review

Bilomas are collections of bile outside the biliary tree. The most frequent etiologies are iatrogenic and trauma. Cases of spontaneous or atraumatic bilomas are rare. Management of bilomas depends on the size and location and may include monitoring only; if the size is < 4 cm, there may be percutaneous or endoscopic intervention. The use of antibiotics depends on the clinical status of the patient. We describe the case of a man who presented with a spontaneous biloma eight years after laparoscopic cholecystectomy and, in addition to signs of choledocholithiasis, a stricture of the common bile duct. In patients with symptoms of biliary pathology, the diagnosis of biloma should be considered even without a history of trauma or recent surgery to initiate appropriate treatment early. Many cases are asymptomatic and resolve spontaneously but occasionally require percutaneous or endoscopic management.

Los biliomas son colecciones de bilis fuera del árbol biliar. Las etiologías más frecuentes son la iatrogenia y el trauma. Los casos de biliomas espontáneos o atraumáticos son poco frecuentes. El manejo de los biliomas depende del tamaño y la localización y puede incluir vigilancia solamente, si el tamaño es < 4 cm, puede haber intervención percutánea o endoscópica. El uso de antibióticos depende del estado clínico del paciente. Presentamos el caso de un hombre que presentó un bilioma espontáneo 8 años después de una colecistectomía laparoscópica que, además de signos de coledocolitiasis, presentaba una estenosis del conducto biliar común. En los pacientes con clínica de patología biliar debe considerarse el diagnóstico de bilioma aun en los casos que no presenten antecedente de trauma o cirugía reciente con el fin de iniciar el tratamiento adecuado tempranamente. Muchos casos son asintomáticos y se resuelven espontáneamente, pero en ocasiones requieren manejo percutáneo o endoscópico.

MANAGEMENT OF BULBAR URETHRAL ISCHEMIC NECROSIS FOLLOWING PELVIC FRACTURE URETHRAL INJURY REPAIR-A SINGLE CENTER EXPERIENCE

Aims & Objectives:About 10% of pelvic fracture injuries are associated with urethral injury. Most of the urethral injuries are successfully repaired by progressive perineal anastomotic urethroplasty. Bulbar urethral ischemic necrosis is a devastating complication seen in 5-8% of failed PFUI repairs. The objective of this study is to present our experience in management of a bulbar urethral ischemic necrosis developed following PFUI repair. Materials & methods:This is a retrospective study done at our institute, which includes data from feb,2003 to feb,2021. This is a descriptive statical analysis. Total 18 patients were managed using various surgical approaches and followed. Out of 18 patients seven patients underwent staged urethroplasty with Results & Observations: success rate of 85.71%,four underwent pedicled preputial skin tube urethroplasty with success rate of 75%,one underwent non transecting augmented urethroplasty with success rate of 100%,three underwent augmented perineal urethrostomy, two underwent continent diversion procedures, one underwent augmented perineal skin tube perineal urethrostomy. Bulbar urethral ischemic necrosi Conclusions: s following PFUI repair although uncommon, is a devastating complication which can be salvaged by various surgical techniques. Type of procedure chosen depends on individual patient and outcomes vary for each type of procedure

Optimal entry point for antegrade and retrograde femoral intramedullary nails / 中华创伤杂志(英文版)

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

Surgical technique and effectiveness of titanium elastic nail assisted retrograde channel screw implantation in superior pubic branch / 中国修复重建外科杂志

OBJECTIVE@#To investigate the surgical technique and effectiveness of titanium elastic nail (TEN) assisted retrograde channel screw implantation of superior pubic branch.@*METHODS@#The clinical data of 31 patients with pelvic or acetabular fractures treated with retrograde channel screw implantation in superior pubic branch between January 2021 and April 2022 were retrospectively analyzed. Among them, 16 cases were implanted with assistance of TEN (study group) and 15 cases were implanted under the guidance of C-arm X-ray machine (control group). There was no significant difference in gender, age, cause of injury, Tile classification of pelvic fracture, Judet-Letournal classification of acetabular fracture, and time from injury to operation between the two groups ( P>0.05). The operation time, fluoroscopy times, and intraoperative blood loss of each superior pubic branch retrograde channel screw were recorded during operation. X-ray films and three-dimensional CT were reexamined after operation, the quality of fracture reduction was evaluated by Matta score standard, and the position of channel screw was evaluated by screw position classification standard. The fracture healing time was recorded during the follow-up, and the postoperative functional recovery was evaluated by Merle D'Aubigne Postel score system at last follow-up.@*RESULTS@#Nineteen and 20 retrograde channel screws of superior pubic branch were implanted in the study group and the control group, respectively. The operation time, fluoroscopy times, and intraoperative blood loss of each screw in the study group were significantly less than those in the control group ( P<0.05). According to the postoperative X-ray films and three-dimensional CT, none of the 19 screws in the study group penetrated out of the cortical bone or into the joint, and the excellent and good rate was 100% (19/19); in the control group, there were 4 screws of cortical bone penetration, and the excellent and good rate was 80% (16/20); the difference between the two groups was significant ( P<0.05). Matta score standard was used to evaluate the quality of fracture reduction, there was no patient in the two groups with poor reduction results, and the difference was not significant between the two groups ( P>0.05). The incisions of the two groups healed by first intention, and there was no complication such as incision infection, skin margin necrosis, and deep infection. All patients were followed up 8-22 months, with an average of 14.7 months. There was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, the difference in functional recovery evaluated by the Merle D'Aubigne Postel scoring system between the two groups was not significant ( P>0.05).@*CONCLUSION@#TEN assisted implantation technique can significantly shorten the operation time of retrograde channel screw implantation of superior pubic branch, reduce the times of fluoroscopy, and have less intraoperative blood loss and accurate screw implantation, which provides a new safe and reliable method for minimally invasive treatment of pelvic and acetabular fractures.

Flap of distal cutaneous perforator of medial plantar artery in reconstrution of destructive defect in the base plane of proximal phalange of great toe / 中华显微外科杂志

Objective:To investigate the clinical effect of perforator flap of distal cutaneous perforator of medial plantar artery in recon struction of destructive defect in the base plane of proximal phalange of great toe.Methods:Twenty-six patients were treated in the Department of Foot and Ankle Surgery of Xuzhou Renci Hospital from September 2017 to December 2021. The patients were 24 males and 2 females, aged 26 to 60 years old. There were 12 defects in left foot and 14 in right foot. All the defects were the residual wounds at the first metatarsophalangeal joint with the defect at 2.0 cm × 3.0 cm - 4.0 cm × 5.0 cm in size. The flaps pedicled with distal cutaneous perforator of the medial plantar artery were used to repair the defects, with a size at 3.2 cm× 4.2 cm in average. Skin grafts were employed to repair the donor sites. Postoperative patient management including lifting the affected limbs and keeping warm, anti-infection, detumescence, anti-coagulation and pain relief.Results:All patients were entered in postoperative follow-up at outpatient clinic for 1-3 years. Twenty-two flaps survived after surgery, except 4 that had dark purple edge indicating venous congestion. Blood supply of the flap was regained after the tension of the flap was relieved by interval suture removal. Appearance of flaps was good, without obvious swelling nor pigmentation, good in elasticity, in hard texture and with good wear resistance. Patients showed no limp of the affected limbs, and without restriction in wearing shoes or walking. The function of feet was evaluated according to the American Orthopedic Foot and Ankle Societ (AOFAS) I50, with 24 patients in excellent and 2 in good.Conclusion:The anatomy of the flap pedicled with distal cutaneous perforator of the medial plantar artery is relatively constant. It provides a blood supply and does not affect the trunk of major artery. The flap has a thick skin cuticle hence it is wear-resistant. This flap provides a choice to the repair of a defect at proximal segment of great toe.

Apply ultra-thin lobulated anterolateral thigh perforator flap in repairing of large soft tissue defect in foot: a report of 8 cases / 中华显微外科杂志

Objective:Exploring the clinical efficacy of using ultra-thin lobulated anterolateral thigh perforator flap(ALTPF) with retrograde separation of perforating vessels from the superficial and deep junction layer of the superficial fascia to repair large soft tissue defects in the foot.Methods:From August 2021 to November 2022, 8 patients (5 males and 3 females) were admitted to the Second Department of Hand and Foot Surgery, the Affiliated Central Hospital of Dalian University of Technology. The patients were 28 to 52 years old in age. The soft tissue defects were located in dorsal and plantar foot. At the plantar foot, the wound involved the weight-bearing area with explosion of bone, tendon or internal fixtures. The area of soft tissue defects was 6.0 cm × 5.0 cm - 16.0 cm × 8.0 cm, and the sizes of ALTPF were 8.0 cm ×5.5 cm - 18.0 cm × 8.5 cm. Preoperative high frequency CUD combined with CTA angiography were employed to locate the 2 flap perforator vessels. By keeping the perforator vessels at center and according to the soft tissue defect area and the wound shape, an ALTPF with a proper size and shape was designed in anterolateral thigh. The perforator were separated in the boundary layer between superficial and deep fascia, where it helped to obviously thin the flap. After the flap was harvested, it was further lobulated between the 2 perforators into 2 lobes after having confirmed the effective blood supply. Finally the lobulated ALTPF was transferred to covered the defect in foot. Cautions should be taken to ensure that the flap covered the weight-bearing area of foot. All the donor sites were directly sutured. Postoperative follow-up was conducted to observe the survival of flaps and the functional recovery of the reconstructed site, also to evaluate the clinical effect. Postoperative follow-up included outpatient visits and reviews over WeChat or telephone. Recovery of the ankle motor function was evaluated according to the American Orthopedic Foot and Ankle Societ (AOFAS) ankle-hind foot score scale.Results:All 8 ALTPF survived. Over 6 to 18 months (10.8 months in average) of follow-up, the transferred flaps had good blood supply, soft in texture, with good elasticity and thin in appearance. Appearance and function of donor sites recovered well, except 1 patient who had mild scar hyperplasia. The plantar flap had good abrasion resistance. No flap damage, bleeding or granulation tissue hyperplasia occurred when walking. The mean score of AOFAS ankle-hind foot score achieved 95.6.Conclusion:The application of ultra-thin lobulated ALTPF with retrograde separation of perforating vessels from the superficial fascia at the junction layer for repairing large soft tissue defects in the foot has good clinical efficacy.