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A 15-year-old girl with recurrent upper abdominal pain was diagnosed with congenital biliary dilatation. Abdominal enhanced computed tomography (CT) showed the anterior segmental branch of the right hepatic artery (RHA) running across the ventral aspect of the dilated common hepatic duct (CHD). Laparoscopic extrahepatic dilated biliary duct excision and Roux-en-Y hepaticojejunostomy were planned. Intraoperatively, the dilated CHD was observed to bifurcate into the ventral and dorsal ducts, between which the anterior segmental branch of the RHA crossed through the CHD. The CHD rejoined on the distal side as one duct. We transected the CHD just above the cystic duct. The patency of the ventral and dorsal sides of the bifurcated CHD was confirmed. Laparoscopic hepaticojejunostomy was performed at the distal side of the rejoined CHD, without sacrificing the anterior segmental branch of the RHA. There was no postoperative blood flow impairment in the right hepatic lobe or anastomotic stenosis.

Ostomy/Stoma is a common entity in patients operated for small bowel perforation in developing countries. Delay in presentation, poor general condition, malnutrition and lack of health infrastructure in peripheral areas are some of the causes leading to severe sepsis at presentation. Exteriorising the perforation site as stoma/ostomy is the preferred salvage procedure. Proximal stoma/ostomy is high output and cause fluid and electrolyte imbalance. Also it is difficult to maintain nutrition with oral feeds, as partially digested food along with digestive enzymes gets lost through the stoma. Parenteral nutrition (PN) is widely used in these patients, which is expensive requires hospitalisation, also not without risks e.g. liver dysfunction and associated with complications of central line insertion.
We hereby report our experience of managing three patients of high output jejunostomy with distal enteral feeding provided by feeding chyme and partially digested food into the distal stoma.
After confirming the distal patency of the bowel, we started feeding through distal lumen of stoma (known as distal enteral feeding) in our 3 patients with jejunostomies immediately in postoperative period along with PN. After few days we started decreasing PN, we gradually switched to complete enteral nutrition; and increasing distal feeding and then totally stopping the PN in few days only. We kept a watch on the different parameters of the patient like calories and protein intake, weight, electrolytes, liver function, etc. RESULTS: Distal enteral feeding improved their body weight, maintained their serum electrolytes and liver function tests including serum albumin. After achieving the good nutritional status, we were able to do successful surgical closure of stomas in all the three patients.
In our experience, patients with high-output stomas can be nutritionally maintained with distal enteral feeding without the need of long term PN. Use of distal enteral feeding, if used appropriately and with proper monitoring, can nutritionally build up the patient avoiding the complications of PN.

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Paraduonenal hernia constitutes more than 50% of internal hernia cases. It can result in perilous sequelae like gut ischemia and perforation. We report a case of a patient who presented with acute intestinal obstruction and peritonitis and was diagnosed as a case of complicated paraduodenal as an incidental finding on laparotomy.  A 26-year-old male patient presented with three days history of continuous severe incapacitating diffuse abdominal pain. The pain was associated with multiple episodes of bilious vomiting and absolute constipation. Patient had signs and symptoms of shock. Abdomen examination showed generalized peritonitis. Patient had deranged laboratory investigations. Abdominal X-ray showed acute intestinal obstruction. Patient was resuscitated and taken up for emergency laparotomy. Intraoperatively there was a long segment of gangrenous small bowel entrapped in the paraduodenal sac. Gangrenous gut was released from the sac and excised with proximal and distal ends fashioned as stoma through separate sites. Patient was managed with intravenous fluids with total parental nutrition. Patient gradually started on oral diet and jejunostomy output was refed through the distal stoma. Patient was discharged on postoperative day 14. Patient had uneventful early stoma closure at postoperative day 45 and now is on regular follow-up in the outdoor department. Paraduodenal hernias are one of the rare causes of intestinal obstruction that is difficult to diagnose. Radiologic investigation like abdominal computed tomography (CT) scan can aid in diagnosis of paraduodenal hernia. Surgeons should have clear knowledge about abnormal anatomy of internal hernias and complications they can face during surgery.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention.
METHODS: A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO.
CONCLUSIONS: Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

Enterolith in the Roux limb of hepaticojejunostomy causing jaundice is a rare occurrence. A 40-year-old woman had an extrahepatic biliary obstruction and cholangitis 13 years after the Roux-en-Y repair of postcholecystectomy benign biliary stricture. On evaluation, an enterolith was obstructing the Roux limb, which was successfully managed surgically.

Although bile leakage is a major postoperative complication after hepatobiliary surgery, the associated risk factors for pediatric patients remain poorly defined. Here, we intend to identify the perioperative risk factors for bile leakage in pediatric patients with choledochal cysts following Roux-en-Y hepaticojejunostomy. A multicenter case-control study investigating the risk factors for bile leakage was conducted among 1179 eligible pediatric patients with choledochal cysts following Roux-en-Y hepaticojejunostomy between January 2009 and December 2019. There were 267 cases with bile leakage, and approximately four control patients were identified for each case. Multivariable logistic regression was performed to identify the risk factors, including perioperative variables. According to univariable analysis, bile leakage was associated with severe cholangitis (p = 0.012), low albumin levels (p = 0.010), anemia (p = 0.002) and laparoscopic surgery (p = 0.004). Multivariable analysis showed that a low level of preoperative albumin (ALB) (odds ratio [OR] = 1.11; 95% CI 1.02-1.19; p = 0.016), worse symptoms (severe cholangitis) (OR = 1.16; 95% CI 1.01-1.26; p < 0.001), and a previous hepatobiliary procedure (OR = 1.32; 95% CI 1.09-1.63; p = 0.036) were independent factors that were associated with bile leakage. This study identified potential risk factors for bile leakage in patients following Roux-en-Y hepaticojejunostomy that should be targeted for interventions to reduce the occurrence of the condition.

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.
Presentiamo un caso di sindrome di Boerhaave gestita con successo 48 ore dopo l’evento acuto mediante approccio transaddominale aperto. Una donna di 55 anni presentava idropneumotorace, dolore toracico, dispnea, vomito e febbre. Lo studio radiologico in urgenza (raggi X, TC) ed endoscopico ha dimostrato la grande soluzione di continuo nella parete posterolaterale sinistra dell’esofago con estrusione di contenuto fluido e gastrico nel mediastino e nell’emitorace sinistro. È stato eseguito l’inserimento di un drenaggio intercostale di emergenza e la paziente è stata trasferita al nostro ospedale. Dopo ampia diaframmotomia sagittale, per via transaddominale open, è stata eseguita una riparazione primaria su sondino nasogastrico utilizzando semplici suture interrotte (Vicryl 3/0) e una fundoplicatio parziale per coprire la linea di sutura. Quindi sono stati posizionati vicino e paralleli all’esofago riparato i tubi di drenaggio toracico ed è stata eseguita una digiunostomia per proseguire con nutrizione enterale. Una esofagografia con gastrografin in settima giornata postoperatoria ha mostrato una piccola perdita nel sito di riparazione, senza alcuna raccolta, che è guarita dopo 1,5 mesi di trattamento conservativo. Secondo noi, l’approccio per una riparazione chirurgica primaria immediata – entro 48 ore – è ancora possibile e un’opzione fattibile nonostante la presentazione tardiva della sindrome di Boerhaave.