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OBJECTIVE: To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs.
METHODS: A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined.
RESULTS: BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029-18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75-52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients.
CONCLUSIONS: Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients.

BACKGROUND: Superior mesenteric artery syndrome is a rare condition that has only around 400 reported cases so far. Typically, the superior mesenteric artery branches off the abdominal aorta at 45° to create an aortomesenteric distance of 10-28 mm, with the duodenum passing through. However, if this aortomesenteric angle reduces to less than 25°, the third portion of the duodenum becomes compressed between the SMA and aorta, causing mechanical obstruction.
METHODS: This case report aims to demonstrate the diagnostic difficulties and the laparoscopic management of a 52-year-old Indian male presenting with abdominal pain and vomiting, with associated weight loss. Imaging was further suggestive of high intestinal obstruction, and he was later found to have superior mesenteric artery syndrome.
CONCLUSIONS: Taking into account a significant reduction in morbidity, we propose laparoscopic duodenojejunostomy to be the new procedure of choice for superior mesenteric artery syndrome.

暂无摘要。

OBJECTIVE: Laparoscopic choledochectomy and hepatojejunostomy have been reported in children since 1995, but this procedure is technically demanding. Robotic surgical systems can simplify complex minimally invasive procedures. Currently, few reports have been made on neonates. We present the experience of 6 cases of neonatal CC(choledochal cysts).
METHODS: Between January 2022 and December 2023, 6 neonates underwent robotic resection of choledochal cyst and hepaticojejunostomy using the Da Vinci surgical system at Children\'s Hospital, Zhejiang University School of Medicine, a high-volume hepatobiliary disease center. demographic data of the patients and surgical outcomes were collected and analyzed.
RESULTS: All 6 patients were successfully treated by robotic cystectomy and hepaticojejunostomy. The mean age was 17.3 days (range 4-25) and the mean weight was 3.6 kg (range 2.55-4.4). 5 cysts were type Ia and 1 was type Iva. The mean diameter of the cysts was 3.8 cm (range 1.25-5). The mean time to establish feeding was 4.83 days (range 4-6), and patients were discharged after a median time of 16.83 days (range 7-42) without postoperative complications.
CONCLUSIONS: This procedure is safe and effective for neonates. The authors found that the use of robot-assisted surgery has ergonomic advantages in this delicate, minimally invasive procedure.

Antiretroviral (ARV) absorption in persons living with human immunodeficiency virus (PLWH, HIV) with short bowel syndrome is limited. We describe a case of a 28-year-old male with newly diagnosed HIV and plasmablastic lymphoma with proximal jejunostomy necessitating parenteral nutrition. ARV therapy with dolutegravir 50 mg twice daily and once daily tenofovir/emtricitabine was initiated with documented malabsorption and delayed virologic suppression (VS). Dolutegravir dose titration with therapeutic drug monitoring (TDM) resulted in VS at month 12. ARV TDM with dose titration is an option for PLWH with malabsorptive states to maintain VS.

BACKGROUND: Robotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking.
METHODS: This was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences.
RESULTS: Overall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2-8.0] vs 3.8 [2.3-12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training.
CONCLUSIONS: Surgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

OBJECTIVE: Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is an emerging procedure for pancreatobiliary diseases in patients with surgically altered anatomy. However, data on BE-ERCP for hepatolithiasis after hepaticojejunostomy (HJS) are still limited.
METHODS: Stone removal success, adverse events and recurrence were retrospectively studied in consecutive patients who underwent BE-ERCP for hepatolithiasis after HJS between January 2011 and October 2022. Subgroup analysis was performed to compare clinical outcomes between patients who had undergone HJS over 10 years before (past HJS group) and within 10 years (recent HJS group).
RESULTS: A total of 131 patients were included; 39% had undergone HJS for malignancy and 32% for congenital biliary dilation. Scope insertion and complete stone removal were successful in 89% and 73%, respectively. Early adverse events were observed in 9.9%. Four patients (3.1%) developed gastrointestinal perforation but could be managed conservatively. Hepatolithiasis recurrence rate was 17%, 20% and 31% in 1-year, 3-year, and 5-year after complete stone removal. The past HJS group was the only risk factor for failed stone removal (odds ratio 10.4, 95% confidence interval 2.99-36.5) in the multivariable analysis. Failed scope insertion (20%) and failed guidewire or device insertion to the bile duct (22%) were two major reasons for failed stone removal in the past HJS group.
CONCLUSIONS: BE-ERCP for hepatolithiasis was effective and safe in cases with HJS but the complete stone removal rate was low in the past HJS group. Recurrent hepatolithiasis was common and careful follow up study is needed even after complete stone removal.

The placement of a jejunostomy catheter during esophagectomy may cause postoperative bowel obstruction. The proximity of the jejunostomy site to the midline might be associated with bowel obstruction, and we have introduced laparoscopic jejunostomy (Lap-J) to reduce jejunostomy\'s left lateral gap. We evaluated 92 patients who underwent esophagectomy for esophageal cancer between February 2013 and August 2022 to clarify the benefits of Lap-J compared to other methods. The patients were classified into two groups according to the method of feeding catheter insertion: jejunostomy via small laparotomy (J group, n = 75), and laparoscopic jejunostomy (Lap-J group, n = 17). Surgery for bowel obstruction associated with the feeding jejunostomy catheter (BOFJ) was performed on 11 in the J group. Comparing the J and Lap-J groups, the distance between the jejunostomy and midline was significantly longer in the Lap-J group (50 mm vs. 102 mm; P < 0.001). Regarding surgery for BOFJ, the distance between the jejunostomy and midline was significantly shorter in the surgery group than in the non-surgery group (43 mm vs. 52 mm; P = 0.049). During esophagectomy, Lap-J can prevent BOFJ by placing the jejunostomy site at the left lateral position to the midline and reducing the left lateral gap of the jejunostomy.

暂无摘要。