Cases Of Anastomotic Stenosis Research Articles

Prostatectomie radicale avec conservation du col vésical : marges chirurgicales et continence urinaire

To evaluate the functional and cancer results of radical prostatectomy with bladder neck preservation in the treatment of localized prostate cancer. From January 2000 to March 2006, 194 consecutive patients underwent open retropubic radical prostatectomy for localized prostate cancer. The bladder neck was technically preserved in 180 patients (93%). The mean age of these 180 patients was 63.2+/-6.1 years. The mean preoperative PSA was 9.38+/-6 ng/ml. The 180 patients were classified according to the Amico prognostic classification as low risk: 52.2%, intermediate risk: 37.8% and high risk: 10%. Operative specimens were examined by the same pathologist according to the Stanford technique. Positive surgical margin was defined as tumour tissue in contact with the ink of the operative specimen. For analysis of the functional results, patients were classified into three categories: continent without protection, stress incontinent, totally incontinent. Continence was evaluated at D10, one month, six months, one, two, three, four and five years. The mean follow-up was 44+/-25 months. This series of 180 operative specimens comprised 64 (35.6%) cases of positive surgical margins and 112 (62.2%) pT3 cancers. No positive margins were observed in the bladder neck, either alone or associated with another positive margin. Seventy-one percent of patients were continent on D10 and at one month, 85% were continent at six months and 89% were continent at one year. Two cases of anastomotic stenosis were observed (1.2%). Bladder neck preservation during open retropubic radical prostatectomy allows early continence in more than 70% of cases without increasing the risk of positive surgical margins.

Preoperative bi-fractionated accelerated radiation therapy for combined treatment of locally advanced rectal cancer in a consectutive series of unselected patients

Backgroundalthough preoperative RT (Radiation Therapy) is becoming the preferred approach for combined treatment of locally advanced rectal adenocarcinoma, no regimen can be now considered as a standard. Since the toxicity of preoperative RT isn't yet completely known, and the advantages of preoperative RT could be counterbalanced by increased postoperative morbidity and mortality, a monocentre series of preoperative bifractionated accelerated RT was retrospectively reviewed to clarify toxicity and outcomes after a prolonged follow up.Methodspatients were screened following these eligibility criteria: histology-proven adenocarcinoma of the rectum; distal tumour extent at 12 cm or less from the anal verge; clinical stage T3–4/anyN, or anyT/N1–2; ECOG Performance Status 0–2. A total dose of 41.6 Gy (26 twice daily fractions of 1.6 Gy) was delivered. Surgery was carried out 17 ± 2 days after RT completion, adopting the total mesorectal excision technique.Results24 men and 23 women were enrolled; median age was 55 years (r.: 39–77). Twenty-eight patients were stage II and 19 stage III. 9 patients suffered from a recurrent tumour. 2 patients experienced a severe grade 4 gastrointestinal toxicity (a colo-vaginal fistula and an intestinal obstruction, both successfully treated). Operative mortality was nil; postoperative early complications occurred in 13 cases; mean length of hospital stay was 15 days. After a mean follow up of 44 months (r.: 18–84) 8 patients had deceased for recurrent disease, 15 were alive with a disease progression (2 pelvic recurrences and 13 pure distant deposits) and 24 were alive, without disease. The 5-year actuarial overall survival was 74.2%, the disease-free survival 62.9% and the regional control rate 84.7%. Long-term complications included 1 case of radiation enteritis requiring surgery, 2 cases of anastomotic stricture and 3 cases of bladder incontinence.Conclusionbifractionated accelerated RT administered in the preoperative setting to patients bearing locally advanced rectal cancer is reliable and safe, as its immediate and late toxicity (mainly infectious) is acceptably low and long-term survivals are achievable. These findings support the increasing use of preoperative RT for treatment of this malignancy in experienced centres. Ongoing multicentric trials are expected to address still unsolved issues, including the benefit of CT adjunct to preoperative RT.

COMPLICATIONS OF ARTERIAL RECONSTRUCTION AND A NEWLY-DEVISED RELIABLE TECHNIQUE OF ARTERIAL ANASTOMOSIS IN LIVING DONOR LIVER TRANSPLANTATION

P548 Aims: In living donor liver transplantation (LDLT), microsurgical reconstruction of fine hepatic arteries has been introduced to reduce surgical complications such as hepatic artery thrombosis (HAT). We reviewed arterial reconstructions in 72 LDLTs and analyzed its complications and devised the anastomosis skill to reduce technical errors. Methods: From August 1996 to March 2004, we performed a series of 72 LDLTs on 54 adults and 18 children under 18 years old. They received 33 extra-right lobe grafts (16 lateral segment grafts, 10 left lobe grafts and 7 extended left lobe grafts) and 39 right lobe grafts. Results: Hepatic arterial reconstruction was performed by an end-to-end anastomosis under an operating microscope except for 3 adult cases who received right lobe grafts with the use of loupe magnification. The complication rate was lower in the right lobe graft group (2 / 39, 5.1%) compared with that in the extra-right lobe graft group (4 / 33, 12.1%). The child cases (3/18,16.7%) increased the complication rate compared with the adult cases (3/54, 5.6%). 3 cases required a reanastomosis in primary operation due to HAT or poor arterial flow caused by kinking at anastomosis. We observed 4 postoperative complications which included 2 cases of anastomotic stenosis, a rupture of hepatic artery pseudoaneurysm treated by embolization, and an anastomotic kinking revised by a reanastomosis. Only the case of pseudoaneurysm died of arterial complications. In the use of extra-right lobe graft, especially in pediatric recipients, arterial reconstruction was difficult, because anastomosed arteries in small diameter often ran vertically parallel with the direction of the operator’s eyes. To overcome the difficulty, we have improved the anastomosis technique using a untied-two stay suture method. As a result, surgical experiences significantly improved the incidence of complications chronologically between the early cases up to 1999 (4/13, 30.8%) and the late cases from 2000 (2/59, 3.4%, P=0.0041). Conclusions: The use of the extra-right lobe graft especially on children was the major risk factor of arterial complications in LDLT. Case number-dependent anstomotic reliability and device of anastomosis skills is also important on performance of safer arterial reconstruction..

High risk of bile duct carcinogenesis after primary resection of a congenital biliary dilatation

Congenital biliary dilatation (CBD) is a relatively rare disease and highly associated with hepatobiliary malignancies due to pancreaticobiliary maljunction. For the treatment of CBD, the standard surgical method is the excision of the entire extrahepatic duct with a hepaticoenterostomy. However, in recent years, there has been an increase in reports of cancer developing in the biliary or pancreatic duct after hepaticoenterostomy. In this report, we describe the postoperative complications and carcinogenesis in 50 CBD patients according to the method of reconstruction of the bile duct. Hepaticojejunostomy (HJ) was performed in 34 patients and hepaticoduodenostomy (HD) in 16. In the HJ group, there were 7 cases of ascending cholangitis (20.6%), 3 cases of choledocholithiasis (8.8%), 4 cases of anastomotic stricture (11.8%) and 1 case of cholangiocarcinoma (2.9%). In the patient with cholangiocarcinoma, all complications including ascending cholangitis, choledocholithiasis, and anastomotic stricture were present. In the HD group, however, 2 cases of ascending cholangitis (5.9%) were recognized although choledocholithiasis, anastomotic stricture or cholangiocarcinoma were not observed. No significant differences were found in incidences of these complications between HJ and HD. It is unclear which method of reconstruction has a higher risk of carcinogenesis, however, it can be stated that hepaticoenterostomy itself is indeed one of the risk factors for biliary tract carcinoma. In any event, as several researchers have pointed out, since the incidence of bile duct carcinoma after the resection of the extrahepatic bile duct in CBD patients is very high compared to natural control, a long-term follow-up of the patient is necessary.

A case of anastomotic stricture after reconstruction for intraoperative bile duct injury during laparoscopic cholecystectomy

A case of anastomotic stricture after reconstruction for intraoperative bile duct injury during laparoscopic cholecystectomy

Roux-en-Y end-to-side esophagojejunostomy with stapler after total gastrectomy.

One hundred gastric cancer patients who underwent total gastrectomy and Roux-en-Y, end-to-side esophagojejunostomy by using stapling devices were analyzed with regard to their operative results. The median time required for the anastomosis was 18 minutes (range of 15 to 45 minutes). A cartridge of 25 mm in diameter was preferred (85% of 25 mm vs. 15% of 28 mm). In 92 patients, procedures were uneventful. Intraoperative problems happened in 8 patients: Two misfirings of stapler due to mechanical problems, in 6 patients, doughnut tissues were incomplete. Mechanical problems were solved by a change of the stapler and for incomplete doughnut tissues, anastomosis was simply reinforced (2 cases) or reanastomosed with restaplings (4 cases). Anastomotic leakage occurred in 2 patients but it was seen only in radiological studies. During the follow up period, two cases of anastomotic stricture were found and they were treated with endoscopic dilatations. There was no operative mortality nor other complication. In addition, routine use of the Levin tube after total gastrectomy was appraised by comparing postoperative courses. Twenty patients were randomly divided into two groups; for 10 patients the Levin tube was removed at the recovery room and for another 10 patients the Levin tube was indwelled until peristalsis returned. Timing of the tube removal did not affect the duration of the hospital stay and starting day of oral intake. We think that the stapler, when properly used, can facilitate the esophagojejunostomy safely and routine use of the Levin tube after total gastrectomy may be unnecessary.

Anastomotic stricture with foreign-body reaction and stone formation following radical retropubic prostatectomy

We report 4 cases of anastomotic stricture after radical retropubic prostatectomy caused by erosion of suture material used to ligate the dorsal vein complex. In 2 patients there was overlying stone formation. The clinical features of this complication, management options, and means of prevention are reviewed.

Stenosis after stapler anastomosis

Two cases of anastomotic stenosis after the use of the GIA Auto Suture Stapler are presented as examples of the potential problem that does exist in using this instrument. Possible causes and a suggestion for eliminating this complication have been outlined.