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Bile duct injuries have various etiologies2,6. For their repair, there are several surgical techniques adjusted to the clinical situation of each patient9,10. In some common bile duct injuries round ligament repair has been suggested as an alternative to a possible biliodigestive derivation. However, the evidence with respect to its generalized use is limited1,3,8.
We present the case of a patient operated for acute cholecystitis with a bile duct injury associated with necrosis of the common bile duct that was repaired with a round ligament patch.
Pancreatic fluid collections are acute complications following pancreatitis1. They are usually self-limited and further interventions are only indicated for growing, symptomatic or complicated cases, such as infected or bleeding collections2. Currently, EUS-guided drainage is the gold-standard treatment7. The AXIOS is a lumen-apposing metal stent specifically developed for the treatment of pancreatic fluid collections. The juxtaposed lumen improved the limitations of others drainage devices. This characteristic reduces the migration and obstruction rates, and the necessity of stent substitutions. The Hot-AXIOS is an insulated delivery system plugged into the stent that allows transmural deployment of the AXIOS and exempts the guidewire placement and dilation of the tract10.
The incidence of internal hernias in laparoscopic Roux-en-Y gastric bypass is 0.5-9.7%2,7. The diagnosis of intestinal obstruction should always be suspected in the presence of abdominal pain in patients previously submitted to it laparoscopically. Internal hernias are the main causes of intestinal obstruction after this surgical procedure14, and may occur through the mesenteric breach at the level of the enteroenteral anastomosis or the Petersen space, located between the transverse mesocolon and the mesentery of the alimentary loop elevated to the gastric pouch via antecolic and antegastric route. The most frequent intestinal obstruction, and also more severe, is that resulting from a Petersen hernia involving the biliopancreatic loop, because it has a closed loop.
The cholecystectomy is currently one of most frequently performed surgeries. The incidence of secondary bile duct injury occurs between 0.2-0.3% in the open technique, while for the laparoscopic is 0.5-0.8%7,9. In terms of the iatrogenic vascular injuries associated with those of the bile duct, there are reports between 12-39%1,4,5. Such injuries worsen the patient›s prognosis and complicate their management. The best resolution for these has not yet been defined.
Among the vascular injuries associated with the cholecystectomy, almost 90% are in right hepatic artery. There are rare vascular injuries associated with bile duct injury that include the hepatic artery proper, the common hepatic artery, the main trunk of the portal vein, the right branch of the portal vein or a major venous injury associated with injury of the right hepatic artery. The literature contains few reports of these cases of major biliovascular injury.
Hepatic ischemia with hepatic parenchymal infarction occurs frequently and may require liver resection or transplant. Death associated with this type of injury is close to 50%2,8.
Esophageal atresia is congenital anomaly with high mortality. Surgical complications and changes in nutritional status are common problems after surgical correction.
o evaluate nutritional status, esophageal stenosis, and respiratory complications among children who had repaired esophageal atresia.
Children aged >2 months old with repaired esophageal atresia were included in the current study. Gender, age, weight, and height were recorded for each case. Height for age and weight for age were calculated for each case.
According to weight for length percentile, 41.02% of the cases were underweight. Esophageal stenosis was seen in 54.76% of the obtained esophagograms.
Underweight was present in 41.02 of the patients according to weight-for-height percentile.
As the coronavirus disease 2019 (COVID-19) pandemic spreads throughout the world, new clinical manifestations are being reported. In addition to the respiratory manifestations, acute renal failure3, hypercoagulability9, vomiting and diarrhea5 have been described.
The Cancer Institute of the São Paulo State (ICESP) has already performed over 8500 surgeries for colorectal cancer in the last 10 years. It is one of the hospitals associated with the University of São Paulo School of Medicine, which has already admitted over 3000 patients with moderate or severe COVID-19 for in-hospital treatment. We present a case of intestinal perforation caused by microcirculatory thrombosis in the colon in a patient undergoing surgery for colorectal cancer.
A 92-year-old male patient with a diagnosis of rectal adenocarcinoma sought emergency care in April 2020 due to intestinal subocclusion. He had a personal history of hypertension and nondialysis chronic kidney disease. Chest and abdomen CT scans showed no pulmonary changes; multiple liver metastases, the largest one measuring 3.0 cm and distension of the colon and small intestine. He underwent exploratory laparotomy, and a tumor was found in the upper rectum, causing bowel obstruction. A rectosigmoidectomy was performed with blind-ending closure of the rectal stump and terminal colostomy.
During the postoperative (PO) period, the patient received food and had intestinal transit until the 3rd PO day, when he started to present coughing and fever. Laboratory testing showed increased C-reactive protein (CRP), as shown in Figure 1. Chest CT scan revealed consolidation in the right lung base. Assessment by the infectious disease team indicated a clinical and radiological profile compatible with bacterial pneumonia. Antibiotic therapy with piperacillin-tazobactam was initiated and maintained for five days with good response, after which the patient started receiving levofloxacin. He was discharged on the 8th PO day, with clinical improvement, decreased CRP levels, good acceptance of food and a functioning colostomy.
After two days, on the 10th PO day, he returned to the emergency room complaining of diffuse abdominal pain, oliguria and coughing. Abdominal examination showed a nonfunctioning colostomy and abdominal pain upon palpation, without signs of peritonitis. In the laboratory analysis, the patient had leukocytosis of 19,000 cells/mm³, with 92% neutrophils and a CRP level of 110 mg/l (normal range <5.0 mg/l) in addition to renal dysfunction with an increase in creatinine levels from 1.58 mg/dl to 3.7 mg/dl and an increase in urea from 56 mg/dl to 110 mg/dl. A CT scan of the abdomen showed pneumoperitoneum without free fluid collections and with diffuse distension of small bowel loops. Exploratory laparotomy was indicated and showed punctiform perforation of the descending colon at 5 cm from the colostomy, with fecal peritonitis blocked by small bowel loops. The perforated descending colon segment located at 5 cm from the colostomy was resected, followed by exhaustive washing of the cavity, terminal colostomy and introduction of antibiotic therapy with meropenem.
Due to the concomitant pulmonary manifestations, the patient was referred to the ICU intubated with vasoactive drugs, a nasogastric tube, antibiotic therapy and parenteral nutrition. He maintained high nasogastric tube output. Starting on the 1st PO day, he received anticoagulant therapy for the prophylaxis of thromboembolic events. He was extubated on the 3rd PO day and discharged from the ICU. On the 5th PO day, worsening of the respiratory condition was observed, with discomfort, decreased oxygen saturation and increased CRP. The chest CT scan, Figure 2, showed multiple bilateral ground-glass opacities. A D-dimer level of 3225 ng/ml and DHL of 638 U/l were observed. A nasopharyngeal and oropharyngeal swab was collected to screen for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to the decrease in oxygen saturation even with 100% oxygen supplementation by mask, the patient was again admitted to the ICU, immediately subjected to orotracheal intubation, and kept on mechanical ventilation and in isolation.
Regarding the clinical evolution, the swab was positive, with worsening of general conditions: adynamic ileus, acute renal failure with creatinine reaching 5.0 mg/dl, need for high doses of vasoactive drugs and antibiotic therapy with meropenem, vancomycin and anidulafungin. The patient was extubated on the 28th PO day after improvement of the respiratory condition. He was discharged from the ICU on the 30th PO day but progressed to a coma vigil, according to the neurologist. Death occurred on the 36th PO day.
An anatomopathological assessment of the surgical specimen revealed thrombotic changes in the microcirculation of the perforated descending colon (Figure 3).
Acute hepatitis B (HBV) infection is asymptomatic, subclinical illness in approximately two thirds of cases and diagnosis is made only through serologic testing7. Clinical evidence of hepatitis; jaundice and occasionally acute liver failure develops in rest one third of patients with acute HBV infection7. Cholestatic hepatitis is one of very rare manifestations of acute HBV infection, but when develop it leads to prolonged hospital stay and increased medical expenses5. Rapid improvement of the clinical symptoms and signs have been reported in patients with cholestatic hepatitis A (HAV) after use of corticosteroid6. We here report a case of cholestatic hepatitis due to acute HBV infection and rapid improvement of symptoms with oral prednisolone.
A 56-year old female patient presented with complaints of progressively increasing jaundice and intense pruritus that disturbed sleep for 12 weeks duration. She had been evaluated at a local hospital and diagnosed to have acute viral hepatitis due to hepatitis B virus infection (HBV) on the basis of raised liver enzymes and serological markers (Table 1).
Obesity is a global epidemic8. Surgery has proven to be the most effective treatment for morbid obesity8. The estimated prevalence of non-alcoholic fatty liver disease in obese is three times higher than in the general population8. It progresses to non-alcoholic steatohepatitis in up to 42% of cases, which has become a growing indication for liver transplantation (LT)8. Bariatric surgery in patients with cirrhosis prior to LT may improve access in the waiting list. The number of patients on the waiting list for transplantation having undergone bariatric surgery will grow, with a potential increase in the rate complications. Peptic ulcer (PU) perforation is one of them. Following Roux-en-Y gastric bypass (RYGBP), the modified anatomy and physiology are a risk factor for peptic ulceration of an excluded stomach. Furthermore, LT carries specific risk factors for PU. Diagnosis in the gastric remnant can be challenging due to the absence of endoscopic access.
We report the case of a LT recipient suffering from a perforated PU in the bypassed stomach from RYGBP. To our knowledge, this is the first case reported in a liver transplanted patient.
A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years before, followed by an emergency reintervention for obstruction of the jejunojejunostomy. Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There were no other relevant comorbidities.
She was admitted to the emergency department with melena and hematochezia. Physical examination revealed hypotension, paleness, icterus and a pain-free abdomen without ascites. Her Model for End-Stage Liver Disease score was 33. The patient did not smoke, consume alcohol to excess or use nonsteroidal anti-inflammatory drugs, acetylsalicylic acid, or proton pump inhibitors. The Helicobacter pylori (HP) status was unknown, nor it was investigated. The patient was clinically managed with intravenous crystalloids, blood borne products transfusion, PPI and ciprofloxacin. The upper endoscopy was negative and the abdominal Doppler ultrasound showed signs of portal hypertension with patent hepatic vessels. Six days after admission, deceased donor LT was carried out without perioperative complications.
The postoperative immunosuppression regimen consisted of prednisone, tacrolimus and mycophenolate sodium. The prophylactic antibiotics consisted of amikacin and ampicillin until postoperative day (POD) 2 and ivermectin on PODs 2 and 3; sulfamethoxazole was introduced on POD 8. Acetylsalicylic acid and prophylactic low molecular weight heparin were suspended from POD 3 to POD 7 because of anemization without signs of bleeding. Low molecular weight heparin was reintroduced at therapeutic dose because of the thrombosis of a branch of the right portal vein. On POD 7 hepatic biopsy was performed due to elevation in liver enzymes. Moderate acute cellular rejection was diagnosed and treated with pulse therapy of methylprednisolone. Proton pump inhibitors were administered throughout the hospitalization. On POD 14 the patient developed an acute abdomen. An abdominal computed tomography scan with intravenous contrast showed a pneumoperitoneum with foci of free air next to the stomach and free abdominal fluid in small quantity (Figure 1).
An emergency laparotomy was performed and a perforated ulcer of the body of the excluded stomach was found and repaired by simple closure. The ulcer was not resected for pathological examination. On POD 16 routine quantitative PCR for cytomegalovirus DNA was positive (41UI/ml 1,62 log (UI/ml)), but did not require antiviral therapy nor reduction in the immunosuppressive regimen. Prophylactic unfractioned heparin was administered from POD 16. Culture of the abdominal liquid collected intraoperatively showed positive for extended spectrum beta-lactamase producing Klebsiella pneumoniae and Enterococus faecium. Antibiotic treatment consisted of vancomycin, meropenem and fluconazol. The patient was discharged on POD 26 with immunosuppressors, sulfamethoxazole, proton pump inhibitors and prophylactic low molecular weight heparin, the latter being discontinued ten days after this.
In 1994 Cucchi et al.7 first published a paper identifying gastrogastric fistulas (GGF) as a complication of open divided Roux-en-Y gastric bypass (RYGB). The findings showed that GGF develop regardless of the remnant division from the pouch. Some authors attribute GGF to technical failure, early postoperative leaks or even marginal ulcers. Furthermore, diagnosis is usually difficult and requires a high index of suspicion, mainly due to a lack of pathognomonic symptoms and signs14. As of today, there is no consensus regarding an optimal diagnostic pathway for GGF, and management is usually patient tailored13,14.
In this paper, we present a case of a lady treated at our centre with recurrent GGF, and provide an up-to-date literature review of the topic.
Woman of 42 year-old with a BMI of 44 kg/m2 underwent a previous anti-gastric anti-colic RYGB using a circular staple for the gastro-jejunostomy anastomosis (GJA) in Jaber Hospital, Kuwait. Intra-operatively the anvil had an incomplete anastomotic stapler doughnut; however, both the intra-operative methylene blue and air tests were negative. The anastomotic line was the buttressed with 2-0 absorbable sutures. Two days post-operatively the patient developed acute abdominal pain, tachycardia and fever, with a water-soluble contrast study suggesting a GJA leak. A subsequent diagnostic laparoscopy however, was unremarkable, and she was managed conservatively. Seven years later, she again presented complaining of a two month history of progressive epigastric and retrosternal chest pain. Blood investigations showed mild leucocytosis and hyper-amylasemia. Gastroscopy demonstrated bile entry to the gastric pouch, with a corresponding 6-7 mm GGF. A barium swallow confirmed GGF, with no other fistulas nor strictures. She was managed endoscopically with one endo-clip applied to GGF, and its edges were burned using argon plasma coagulation.
After three years she was attended again with abdominal pain and distention, associated with weight regain and vomiting. A barium swallow confirmed recurrence of the fistula (Figure 1), and gastroscopy showed a large fistulous opening measuring 15-20 mm, not feasible for endoscopic intervention.
Refeeding syndrome (RS) is a life-threatening condition first described in severe malnourished prisoners of the Second World War1. This syndrome is defined as electrolyte and fluid shifts associated with metabolic abnormalities developed during nutritional support. RS hallmark is hypophosphatemia, but also includes hypomagnesemia, hypokalemia, vitamin deficiencies, abnormal glucose metabolism and fluid retention. Prolonged fasting is the most important risk factor and RS may be precipitated by oral, enteral or parenteral nutrition4,5.
The authors describe a case of RS in the gastroenterology ward exemplifying the importance of recognizing this underreported condition in patients with digestive pathology under nutritional therapy.
An 82 year-old female was admitted due to recurrent vomiting during 10 days. Her past medical history included cerebrovascular disease, diabetes and hypertension. On hospital admission she was febrile, dehydrated and presented low body mass index (20.8 kg/m2). Initial evaluation revealed acute kidney injury (creatinine 4.1 mg/dl), hypokalaemia (K+ 3.2 mg/dl), hyperphosphatemia (Pi 5.4 mg/dl) and normal serum sodium and magnesium. Fluid and electrolyte replacement were immediately started but vomiting persisted. Nasogastric intubation revealed stasis (1800 cc/24h). Upper gastrointestinal endoscopy detected lumen narrowing in second/third duodenum parts. CT scan identified a heterogeneous mass in the pancreatic head causing Wirsung duct dilation and duodenal compression (Figure 1). Surgical resection was ruled out considering the advanced age and poor performance status. Palliative care with gastroduodenal self-expandable metallic stent (SEMS) placement was scheduled.
Desenvolvido por Surya MKT