ABSTRACT
BACKGROUND: Esophageal perforation is a disease with high mortality. Treatment is controversial and should be individualized. Elapsed time, location and perforation all play a role in determining the treatment option: from conservative treatment to esophagectomy. We undertook this study to report on primary esophagectomy and reconstruction in esophageal perforations with expert surgeons and selected patients. It is worth noting the rare complication of perforated peptic ulcer on Barrett's esophagus presented in one of our patients. CLINICAL CASES: We report two patients with esophageal perforation (one spontaneous and another due to pneumatic esophageal dilation) treated by primary esophagectomy and reconstruction. The patient with spontaneous perforation had Barrett's esophagus with severe dysplasia and perforated peptic ulcer. CONCLUSIONS: Esophageal resection and immediate reconstruction is controversial. It was decided to resect the esophagus in both cases reported here due to the size of the perforation and esophageal disease in the second case. The primary reason for immediate reconstruction in selected cases is permanent resolution. Primary cervical esophagealgastric anastomosis has a lower risk of contamination and leaks than thoracic anastomosis, resulting in mediastinal drainage and parenteral nutrition. Spontaneous esophageal perforation due to perforated Barrett's ulcer is uncommon. Finally, we must consider the importance of early diagnosis and treatment. It is essential to consider the size of the perforation, location, previous esophageal disease, age and general status of the patient in order to undertake appropriate management. Emergency surgery should be individualized and depends on surgeon's experience.
Subject(s)
Esophageal Perforation/surgery , Esophagectomy , Adult , Aged , Esophageal Perforation/etiology , Female , Humans , Male , Time FactorsABSTRACT
The diagnosis of cystadenoma is rare, even more so when located in the extrahepatic bile duct. Unspecific clinical signs may lead this pathology to be misdiagnosed. The need for pathological anatomy in order to distinguish cystadenomas from simple biliary cysts is crucial. The most usual treatment nowadays is resection of the bile duct, together with cholecystectomy and Roux-en-Y reconstruction.
Subject(s)
Bile Duct Neoplasms , Bile Ducts, Intrahepatic , Cystadenoma , Bile Duct Neoplasms/diagnosis , Bile Duct Neoplasms/pathology , Bile Duct Neoplasms/surgery , Bile Ducts, Intrahepatic/pathology , Bile Ducts, Intrahepatic/surgery , Choledochal Cyst/pathology , Choledochal Cyst/surgery , Cystadenoma/diagnosis , Cystadenoma/pathology , Cystadenoma/surgery , Female , Humans , Middle AgedABSTRACT
BACKGROUND: Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. METHODS: Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. RESULTS: 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 +/- 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40+/-15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1+/-2.4 days. CONCLUSIONS: Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time.
Subject(s)
Biliopancreatic Diversion/methods , Gastric Bypass/methods , Laparoscopy , Obesity, Morbid/surgery , Female , Humans , MaleABSTRACT
Introducción. En cirugía bariátrica, la reconstrucción del tracto digestivo tras un bypass gástrico (BPG) o una derivación biliopancreática (DBP) se efectúa mediante una anastomosis gastroyeyunal mecánica o manual. El objetivo de este trabajo es analizar la anastomosis gastroyeyunal con sutura manual por laparoscopia. Pacientes y método. Serie de pacientes obesos mórbidos tratados con BPG o DBP con anastomosis gastroyeyunal por técnica manual vía laparoscópica en el Hospital Universitario de Getafe, desde marzo de 2001 a noviembre de 2007. Resultados. Se incluyó a 250 pacientes, de los que 232 fueron intervenidos por BPG y los 18 restantes, por DBP. El índice de masa corporal medio era 46 ± 4. Sólo se registró un caso de hemorragia digestiva (0,4%) por ulcus en la boca en el postoperatorio inmediato (sexto día). En el postoperatorio tardío hubo 2 casos de ulcus complicado (0,8%), 1 caso con hemorragia y 1 con perforación. No hubo ninguna fuga de la anastomosis. Una paciente fue reintervenida a las 48 h por una fuga secundaria a una perforación térmica en la curvatura menor del reservorio gástrico. Se registraron 11 (4,4%) estenosis, que precisaron dilatación radiológica o endoscópica; no hubo ninguna en los casos de derivación. El tiempo medio para la anastomosis fue de 40 ± 15 min. No hubo mortalidad ni se registró ningún caso de absceso, sepsis abdominal o tromboembolia. La estancia hospitalaria media fue de 5,1 ± 2,4 días. Conclusiones. Aunque la mayoría de los cirujanos consideran que la anastomosis mecánica es más sencilla, la técnica manual puede ser reproducida por cirujanos con experiencia en el manejo de suturas y nudos intracorpóreos. La técnica prolonga el tiempo quirúrgico, pero un entrenamiento continuo desarrolla la destreza del cirujano y acorta significativamente el tiempo operatorio The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)
Background. Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. Methods. Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. Results. 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 ± 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40±15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1±2.4 days. Conclusions. Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)
