Skin Perforator Flap Pedicled by Intercostal Muscle for Repair of a Tracheobronchoesophageal Fistula.

A tracheobronchial fistula (TBF) is a rare complication when an operation is performed to treat esophageal carcinoma; no consensus treatment strategy has emerged. We describe a surgical interposition strategy, using a new flap, to repair a TBF that arose when esophageal squamous cell carcinoma was treated with neoadjuvant chemoradiation and minimally invasive esophagectomy (the 3-stage McKeown procedure). We performed a skin perforator flap pedicled by the intercostal muscle. It is a valuable option that may be the optimal first-line treatment, especially in the context of neoadjuvant radiation therapy. Furthermore, this strategy affords new options for intrathoracic reconstruction.

Frey procedure combined with biliary diversion in chronic pancreatitis.

BACKGROUND: The Frey procedure has become the standard operative treatment in chronic painful pancreatitis. Biliary diversion could be combined when associated with common bile duct obstruction. The aim of the present study was to evaluate the impact of the type of biliary diversion combined with the Frey procedure on late morbidity. METHODS: The data from consecutive patients undergoing the Frey procedure and having a minimum follow-up of 2 years were extracted from a maintained prospective database. The mean endpoint was the rate of secondary biliary stricture after the Frey procedure combined with biliary diversion (bilioenteric anastomosis or common bile duct reinsertion in the resection cavity). RESULTS: Between 2006 and 2013, 55 consecutive patients underwent the Frey procedure. Twenty-nine patients had common bile duct obstruction (52.7%). The technique of biliary diversion resulted in bilioenteric anastomosis in 19 patients (65.5%) and common bile duct reinsertion in 10 patients (34.5%). Preoperative characteristics and early surgical outcomes were comparable. Pain control was similar. There was significantly more secondary biliary stricture after common bile duct reinsertion than after bilioenteric anastomosis (60% vs 11%, P = .008). CONCLUSION: Combined bilioenteric anastomosis during the Frey procedure is an efficient technique for treating common bile duct obstruction that complicates chronic painful pancreatitis. Bilioenteric anastomosis was associated with less secondary biliary stricture than common bile duct reinsertion in the pancreatic resection cavity.

The true prognosis of resected distal cholangiocarcinoma.

BACKGROUND: Prognosis of distal cholangiocarcinoma (DCC) after pancreaticoduodenectomy (PD) remains poorly assessed. The aims of this study were to describe the oncological results of PD in DCC and to compare its prognosis to pancreatic ductal adenocarcinoma (PDAC). METHODS: All PD for periampullary carcinoma performed between January 2000 and March 2013 were extracted from a prospective database. Risk factors likely to influence overall (OS) and disease-free (DFS) survivals of DCC were assessed by multivariable analyses. The DCC and PDAC prognoses were compared after matching using propensity score (nearest neighbor matching). RESULTS: Of the 290 patients analyzed, 56 had DCC, with a mean age of 65 ± 15 years. The median OS was 36.9 months. Recurrence occurred in 35 patients (67%), mostly in the liver (37%). The median DFS was 14.6 months. Combined organ resection was an independent risk factor for worse OS and DFS (P = 0.01 and P = 0.001, respectively). Matching analysis found no significant difference between DCC and PDAC in terms of OS (P = 0.284) or DFS (P = 0.438). CONCLUSION: This first propensity analysis demonstrated that DCC and PDAC have the same prognosis, linked to the high rate of early recurrence, particularly associated with the need for combined organ resection. J. Surg. Oncol. 2016;113:575-580. © 2016 Wiley Periodicals, Inc.

Intravascular Leiomyomatosis with Intracardiac Extension.

Intravenous leiomyomatosis (IVL) is a rare nonmalignant tumor defined as a benign smooth muscle cell neoplasia in the veins. Patients with IVL may present with symptoms of a uterine leiomyoma such as pelvic pain and vaginal bleeding, or cardiorespiratory symptoms, including dyspnea and leg swelling. We report the case of a 65-year-old otherwise healthy Caucasian woman. Past medical history consisted of hysterectomy and left salpingo-oophorectomy 15 years before for multiple uterine fibromyomas associated with leiomyoma of vascular origin. A thoracoabdominal computed tomography (CT) scan confirmed the presence of a mass, measuring 76 × 37 × 44 mm, arising from the inferior vena cava (IVC) at the level of the left renal vein extending all the way into the right atrium and right ventricle. At laparotomy, a tumoral mass was excised from the left broad ligament up to the left renal vein and from the IVC up to its retrohepatic tract. Sternotomy was performed and cardiopulmonary bypass (CPB) was established among ascending aorta, upper vena cava, and right common femoral vein. After atriotomy, a voluminous and firm mass was excised from the right atrium, down to the level of the IVC. CPB was maintained for 80 min. Perioperative transfusion included two plasma and two red blood cells units. No adjuvant treatment was administered. Follow-up with annual CT scans was performed. Patient had no signs of recurrence after 3 years.

Sexuality and fertility outcomes after hand sewn versus stapled ileal pouch anal anastomosis for ulcerative colitis.

BACKGROUND: Ileal pouch anal anastomosis (IPAA) may alter sexuality and fertility in women. The laparoscopic approach seems to reduce infertility rates in women after IPAA. However, the impact of hand sewn versus stapled IPAA on sexuality and fertility has never been assessed in patients with ulcerative colitis (UC). The objective of this study was to analyze the impact of the IPAA technique on sexuality and fertility in UC. METHODS: All UC patients who underwent an IPAA between May 1996 and April 2011 were included. The patients answered mailed questionnaires including sexuality validated questionnaires and fertility questionnaires. The risk factors of sexual dysfunction were explored. RESULTS: A total of 135 patients were included. Eighty-eight patients (65%) answered the questionnaires. Their mean age and follow-up were 37.2 ± 13.4 y and 109.7 ± 57.5 mo. The rates of female and male sexual dysfunction were 50% and 29%, respectively. Intestinal transit disorders were identified as risk factors in both men and women and anastomotic stricture in women sexual dysfunction, in univariate analyses. The IPAA technique did not impact sexual function in women but there was a trend for less erectile dysfunction after hand sewn IPAA (16.7% versus 44.4%). The fertility rate was 47% in women and 75% in men, with a trend for a better fertility in women after hand sewn IPAA (P = 0.07). CONCLUSIONS: In this preliminary study, the hand sewn or stapled IPAA technique did not impact the sexuality or fertility outcomes of UC patients, but there was a trend for better female fertility and male erectile function after hand sewn IPAA. Intestinal transit disorders contributed to male and female sexual dysfunction after IPAA.

Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula.

PURPOSE: Redo-surgery with new colorectal (CRA) or coloanal (CAA) anastomosis for failed previous CRA or CAA is exposed to failure and recurrent leakage, especially in case of rectovaginal fistula (RVF) or chronic pelvic sepsis (CPS). In these two situations, transanal colonic pull-through and delayed coloanal anastomosis (DCAA) could be an alternative to avoid definitive stoma. This study aimed to assess results of such redo-surgery with DCAA for failed CRA or CAA with CPS and/or RVF. METHODS: All patients who underwent DCAA for failed CRA or CAA with CPS and/or RVF were reviewed. Success was defined as a patient without any stoma at the end of follow-up. Long-term functional results were assessed using the low anterior resection syndrome (LARS) score. RESULTS: 24 DCAA were performed after failed CRA or CAA with CPS (n = 15) or RVF (n = 9). Sixteen (67%) patients had a diverting stoma at the time (n = 5) or performed during DCAA (n = 11). After a mean follow-up of 29 ± 19 months, success rate was 79% (19/24): 5 patients had a permanent stoma because of recurrent sepsis (n = 2), anastomotic stricture (n = 1), or poor functional outcomes (n = 2). Functional outcomes were satisfactory (no or minor LARS) in 82% of the successful patients. CONCLUSION: In case of failed CRA or CAA with CPS or RVF, DCAA was associated with a 79% success rate. It could therefore be proposed as an alternative to standard redo-CRA or CAA when the risk of recurrent sepsis and failure with subsequent definitive stoma is thought to be high.

Impact of age over 75 years on outcomes after pancreaticoduodenectomy.

BACKGROUND: The risks associated with pancreaticoduodenectomy (PD) in elderly patients continue to be debated. The aim of our study was to assess the incidence of death and postoperative complications following PD and identify the risk factors in patients >75 y. STUDY DESIGN: All patients who underwent PD between January 2000 and September 2009 were analyzed retrospectively. Patients were divided into two groups according to age (Group 1: patients aged <75 y, and Group 2: patients aged ≥ 75 y). Morbidity and perioperative mortality risk factors were analyzed using univariate and multivariate analyses. RESULTS: Among the 314 patients, 273 were included in Group 1 (sex ratio 1.4) and 41 in Group 2 (sex ratio 1). In multivariate analysis, postoperative hemorrhage (PH) (OR 6.61, IC95% [1.96; 22.31], P = 0.002) and age >75 y proved to be predictive factors for mortality (OR 11.04, IC95% [2.57; 47.49], P = 0.001). When compared with Group 1, Group 2 was associated with increased postoperative deaths (24.4% versus 3.66%, P < 0.001) and pancreatic fistulas (26.8% versus 13.2%, P = 0.041), in particular, Grade C fistulas (14.6% versus 4.4%, P = 0.023). In multivariate analysis, only PH proved to be an independent predictive factor for mortality (OR 12.9, IC95% [1.07; 155.5], P = 0.04). CONCLUSIONS: PD in elderly patients aged over 75 y appears to be associated with an increased risk of postoperative death and pancreatic fistula. No single preoperative factor made it possible to predict this risk.