Successful primary repair in a late presentation of Boerhaave's syndrome. Case report.

We present a case of Boerhaave's syndrome successfully managed by open transabdominal approach 48 h after the acute event. A 55-year-old female presented with hydropneumothorax, chest pain, dyspnea, vomiting and fever. The urgent radiologic (X-ray, CT) and endoscopic study revealed the large defect of left posterolateral wall of esophagus with extrusion of fluid and gastric contents into the mediastinum and left chest. Emergency intercostal drainage insertion was performed and patient was transferred to our hospital. By open transabdominal approach after the wide sagittal diaphragmotomy the primary repair over the nasogastric tube using simple interrupted sutures (Vicryl 3/0) and partial fundoplication to cover the suture line was performed. Chest drainage tubes was then positioned near and parallel to the repaired esophagus and feeding jejunostomy was then performed for enteral nutrition. On the seventh postoperative day, a gastrografin swallow showed a small leak in the repair site without any collection, which was healed after 1,5 month of conservative treatment. We consider, that proactive surgical approach with primary surgical repair is still possible and feasible option despite the late presentation of Boerhaave's syndrome. KEY WORDS: Active drainage, Boerhaave's syndrome, Primary repair.

Efficacy of percutaneous biliary and pancreatic duct drainage/stenting with double invaginated pancreatojejunostomy after pancreatoduodenectomy.

AIM: To evaluate the efficacy and feasibility of preoperative percutaneous pancreatic duct drainage (PPDD) and improve the safety of pancreatojejunal anastomosis, we refer to our experience from 2013 to 2017 that include the last series of 27 cases of PD for 14 pancreatic and 13 ampullary tumors. Apart from the standard "classic" Whipple procedure in 17 cases, and the "modified"pylorus-preserving variant (ppPD) in 10 cases, in 26 cases a pancreaticojejunostomy and in 1 case a pancreatico gastrostomy was performed. In last series the percutaneous biliary drainage procedure in 18 cases and dual biliary + pancreatic duct decompression in 4 casas was performed. In 21 cases the biliary drainage was used as transanastomotic stent during hepaticojejunostomy and in 3 cases the pancreatic duct drainage was also used as transanastomitic stent at our method of performing the double invaginated pancreatojejunostomy. RESULTS: Without operative mortality in our series of PD, there were however some complications requiring in two patients interventional radiologic and intensive care management, and 5 patients died at follow up period (6 months - 3 years). There was no postoperative pancreatic fistula in our last series of PD, where preoperative biliary and pancreatic duct drainage and our modified double invaginated pancreatojejunostomy was performed. CONCLUSIONS: Despite our limited experience, we can conclude that preoperative percutaneous biliary and pancreatic drainage is feasible, safe, effective and a realistic mini invasive procedure. The preliminary results obtained with the described method of double invaginated pancreatojejunostomy with transanastomotic stent and external pancreatic duct drainage are very encouraging and indicate that this technique is less complicated and time consuming, very safe, simple, easy to perform and also applicable almost to all situations. KEY WORDS: Invaginated Pancreatojejunostomy Pancreatoduodenectomy, Pancreatic Duct Drainage.