Postoperative Stenosis Research Articles

Clinical Analysis of Endoscopic Submucosal Dissection for the Synchronous Multiple Primary Early Cancers in Esophagus and Stomach: 12 Cases Report.

With the improvement of endoscopic diagnosis, the discovery rate of the synchronous multiple primary early cancers in esophagus and stomach is gradually increased, while the traditional surgery bringing serious damages. Endoscopic submucosal dissection (ESD) has become the first treatment option of early cancer in the digestive tract partly. This study intends to explore the feasibility, safety, and effectiveness of ESD in the treatment of the synchronous multiple early gastric cancer or precancerous lesions in the esophagus and stomach. From January 2008 to December 2016, data of 12 patients with early esophageal cancer and early gastric cancer treated by ESD in the Endoscopy Center of Zhongshan Hospital, Fudan University were reviewed. We analyzed the patient's history, the size of esophageal and gastric lesions, pathological results, the results of complete or curative resection, and so on. Among the 12 patients described in this study, all were diagnosed with synchronous multiple primary early cancers in the esophagus and stomach. Lesions were removed by ESD in 10 cases at the same time and were removed by stage in 2 cases. The complete resection rate was 100% (24/24), and the curative resection rate was 100% (24/24). Postoperative esophageal stricture occurred in 2 cases, which improved after dilation. Median follow-up time was 30 (8-115) months, when 9 patients survived and 3 patients died. However, the cause of death was not associated with treatment of this disease. ESD is a minimally invasive endoscopic surgery, which can be used as a method of treating synchronous multiple primary early cancers in the esophagus and stomach.

Esophagectomy with gastric conduit reconstruction for benign disease: extreme but important.

Esophagectomy is usually performed to resect esophageal cancer. However, there are numerous other indications for esophagectomy, including Barrett's esophagus with high-grade dysplasia (HGD) and some benign diseases such as obstruction, end-stage achalasia, esophagus perforation or disruption, benign neoplasm, and severe caustic injury. For these patients, esophagectomy could relieve their symptom obviously. However, esophagectomy causes huge trauma, induces quite high morbidity and mortality, and may decreases patients' quality of life obviously due to postoperative reflux, dumping, anastomotic stricture and other complications. Accordingly, the considerations of a surgery must be carefully deliberated, including the underlying disorder, lesions localization, extent of disease, and options for esophageal replacement. For patients received esophagectomy and alimentary tract reconstruction, gastric conduit is the most common used replacement organ, then colon and jejunum. This review demonstrated the importance and technical experience of esophagectomy with gastric conduit reconstruction for benign diseases.

Comprehensive evaluation of MRCP versus ultra sonography in biliary obstruction

Background: Biliary disorders are one of the common problems routinely seen in clinical practice. Ultrasound (USG) is an initial investigation and Magnetic resonance cholangiopancreatography (MRCP) is a relatively new technique, which has gained popularity because of its excellent diagnostic capabilities in the evaluation of biliary obstruction. Aims: The aim of our study was to know the cause and grade of obstruction in case of clinically suspected biliary obstruction and to evaluate and correlate the accuracy between MRCP and Ultra sonography. Material and Methods: This prospective cross sectional comparative study was conducted in the department of Radiology, Government medical college and Rajindra hospital, Patiala. 50 patients with suspected biliary obstruction with clinical and laboratory features suggestive of obstructive jaundice who were referred for USG, followed by MRCP were studied. Results: Most common disorder observed was choledocholithiasis 16 (32%), followed by carcinoma gall bladder with 7 (14%) cases, periampullary carcinoma with 6 (12%) cases, cholangiocarcinoma and benign stricture with 5 (10%) cases each, carcinoma head of pancreas with 4 (8%) cases, postoperative stricture with 3 (6%) cases and choledochal cyst and cholangitis with 2 (4%) cases each. The overall sensitivity, specificity, positive predictive value and diagnostic accuracy of MRCP in diagnosing biliary obstructive disease was 98%, 100%, 100% and 100%respectively as compared to 60%, 100%, 100%and 97% of USG. Conclusion: Ultrasound is considered the primary screening investigation modality of choice However, owing to its low sensitivity in most of the benign stenosis and distal common bile duct disease, where the clinical and laboratory suspicion is strong, MRCP is highly accurate, non-invasive, sensitive, non-ionizing and superior diagnostic modality in establishing diagnosis of obstructive biliary pathologies.

A novel technique for cervical gastro-oesophageal anastomosis during minimally invasive oesophagectomy

BackgroundAnastomotic leakage, fibrous stricture and gastro-oesophageal reflux are three major complications of gastro-oesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to traditional side-to-side anastomosis (SS) and end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux. MethodsA total of 390 patients with thoracic oesophageal cancer underwent minimally invasive oesophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. A detailed description of the surgical procedure is provided, and the major postoperative complications, including postoperative leakage, stricture and reflux, were compared using a three-armed controlled study. ResultsThe anastomotic method was an independent risk factor for anastomotic leakage, as well as stricture and reflux. The rate of anastomotic leakage of the NA group (1.0%) was significantly lower than that in the SS group (8.8%, P = 0.025) and in the CS group (8.5%, P = 0.001). The rate of anastomotic stricture in the NA group was not significantly different than that in the SS group (1.5% vs. 2.9%, P = 0.368) but was significantly lower than that in the CS group (1.5% vs. 18.9%, P < 0.001). The incidence of gastro-oesophageal reflux in the NA group was significantly lower than that in the SS group and the CS group (5.7% vs. 23.5% and 18.3%, P = 0.003 and 0.001, respectively). ConclusionJiang's anastomosis technique remarkably reduces the incidence of gastro-oesophageal anastomotic leakage, stricture and reflux, and it is a safe and effective technique for minimally invasive oesophagectomy.

Lacrimal sac exposure and a superior lateral anterior pedicle flap to improve outcomes of Draf type II and III procedures.

Although the efficacy of Draf type II and III procedures for frontal sinus diseases is well recognized, a certain amount of postoperative stenosis of the frontal neo-ostium occurs. Exposed bone induces inflammation and leads to osteoneogenesis. To prevent stenosis, we developed a surgical technique designed to minimize bone exposure while maximizing the frontal neo-ostium area created with Draf type II and III procedures. We fully exposed the lacrimal sac and used a superior lateral anterior pedicle flap to cover the exposed bone during the Draf procedure. We aimed to describe our technique. We reviewed 19 patients who underwent a Draf type II or III procedure with our technique. Endoscopic views from the follow-ups and complications were evaluated. Overall, the neo-ostium remained patent in all patients. No complications, such as synechiae or orbital injury, were seen in any of the patients. Draf type II and III procedures with lacrimal sac exposure and a superior lateral anterior pedicle flap are convenient and seem to be effective. However, further studies with larger numbers of patients are needed to verify our technique.

Rare case of choanal atresia in a 54-years-old female

Introduction: Choanal atresia is a rare disorder presenting with complete separation between the nasal cavity and the nasopharynx. There are two types of this abnormal blockage of the nasal airway – congenital and acquired. Material and Methods: This paper presents the case of a 54-years-old woman administered to the clinics for septoplasty. During the preoperative diagnostic process via CT scan and endoscope examination a coincidental finding was diagnosed – unilateral congenital choanal atresia. The medical history of the patient revealed difficult nasal breathing which is absent in the right nasal airway, also frequent rhinosinusitis, moreover orthodontic problems with her dentition and malocclusion; regarding her post-birth period she was on feeding tube and with oxygen mask in a neonatal clinic for several months; no facial traumas reported during the rest of her life. Results: Septoplasty was managed and endoscopic assisted fenestration in the choanal regional was performed viatransseptal access. Seven days postoperatively before the removal of the septal splints a CT scan was performed for evaluation of the surgical treatment and three months later – endoscopy which displayed well-formed without postoperative stenosis neochoana. Conclusion: The congenital choanal atresia is a rare abnormality which determines the insufficient clinical experience with this disorder. It is possible that many cases could have been missed or misdiagnosed because of the low incidence of the condition. The conducted literature review reveals that the case report we are presenting is one of the oldest patients diagnosed with unilateral, congenital, bony choanal atresia.

Clinical efficacy of primary closure in laparoscopic common bile duct exploration (A report of 2 429 cases)

Objective To investigate the clinical efficacy of primary closure in laparoscopic common bile duct exploration (LCBDE). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 2 429 patients who underwent primary closure in LCBDE in the Second Hospital of Chengdu City from March 1992 to December 2017 were collected. Patients underwent laparoscopic cholecystectomy (LC) + stone extraction using LCBDE or extracorporeal shock wave lithotripsy (ESWL), laparoscopic endoscopic sphincteropapillotomy (LEST) was performed selectively, then underwent laparoscopic endoscopic nasobiliary drainage (LENBD) or laparoscopic transabdominal antegrade-guide common bile duct stent implantation, finally underwent primary closure of common bile duct. Observation indicators: (1) surgical situations; (2) postoperative recovery; (3) postoperative short-term complications; (4) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to observe long-term surgical complications once every 3 months up to 1 year postoperatively. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical situations: of 2 429 patients, 2 251 underwent successful stone extraction using LCBDE, relief of the obstruction and primary closure of common bile duct, with depletion of stones; 15 underwent stone extraction using conversion to open surgery, with depletion of stones; 163 had residual stones or surgery-related complications. Of 2 429 patients, 1 144, 898, 223, 110 and 54 were respectively detected in grade N or 0, 1, 2, 3 and 4 of laparoscopic distal of the common bile duct smooth classification (LDSC); 599 underwent LEST, 367 underwent LENBD, 207 indwelled urinary catheter through cystic duct stump, 125 underwent laparoscopic transabdominal antegrade-guide common bile duct stent implantation and 1 131 underwent primary closure in LCBDE only. Number of removing the stones, diameter of common bile duct, volume of intraoperative blood loss and operation time was (2.5±0.2)per case, (0.7±0.4)cm, (22.4±2.6)mL and (100±12)minutes, respectively. (2) Postoperative recovery: time of postoperative gastrointestinal function recovery, duration of hospital stay and treatment expenses were respectively (2.5±0.5)days, (7.3±1.2)days and (2.7±0.3)×104 yuan. Of 2 429 patients, 367 removed nasobiliary catheter at 3-7 days postoperatively, 207 removed urinary catheter at 3-6 weeks postoperatively, and 125 removed common bile duct stent through duodenoscope port at 1-4 months postoperatively. (3) Postoperative short-term complications: incidence of postoperative short-term complications in 2 429 patients was 6.711%(163/2 429). ① Ninety-four patients with bile leakage were cured after drainage and symptomatic and supportive treatment. ② Of 29 patients with residual stones: 25 with residual stones of common bile duct were cured by stone extraction using endoscopic sphincterotomy of duodenal papilla, and 4 with residual stones of intrahepatic bile duct didn′t receive treatment. ③ One patient died at 15 days after surgery for pancreatic cancer. ④ Of 39 with postoperative other complications: 2 with postoperative hemorrhage were cured by laparoscopic reoperation; 12, 19 and 3 were respectively complicated with postoperative inflammatory stenosis of duodenal papilla induced to short-term obstructive jaundice, mild acute pancreatitis and stress ulcer bleeding of upper digestive tract, and they were improved by endoscopy or non-operation treatment; 2 with stenosis of bile duct didn′t receive treatment; 1 had a miss ligation at bending section of front zone of nasobiliary catheter, and ligation was removed by endoscopic retrograde cannulation of the pancreatic at 19 days postoperatively. (4) Follow-up situation: of 2 429 patients, 1 749 were followed up for 3-12 months, with a median time of 6 months. During the follow-up, of 1 749 patients, 2 had mild stenosis in the primary closure area of common bile duct incision and 1 had stenosis of duodenal papilla, they were not treated, and other patients didn′t have related complications. Conclusion Controlling strictly the operative indication, primary closure of common bile duct in LCBDE is safe and feasible, with satisfactory clinical outcomes. Key words: Hepatolithiasis; Cholelithiasis; Obstruction of biliary tract; Common bile duct exploration; Primary closure; Laparoscopy

Endoscopic submucosal dissection for early esophageal cancer in elderly patients with relative indications for endoscopic treatment.

According to the Japanese Esophageal Society (JES) guidelines, early esophageal squamous cell carcinoma (SCC) involving the muscularis mucosae (M3) or upper submucosal (SM1) layers are relative indications for endoscopic submucosal dissection (ESD). Additional esophagectomy or chemoradiotherapy is recommended for patients with relative indications after evaluation. However, elderly patients (≥ 60 years) with relative indications in China often refuse additional treatment because of the debilitating side effects. The aim of this study was to evaluate the long-term outcomes of elderly patients with relative indications who did not undergo additional treatment after ESD. Data from elderly patients with relative indications who underwent ESD for early esophageal SCC between January 2008 and December 2013 were reviewed retrospectively. Stricture and recurrence, and 5-year progression-free survival (PFS) and overall survival rates were compared with patients with absolute indications for ESD. 158 elderly patients were included and analyzed (89 in the absolute indications group and 69 in the relative indications group). The baseline characteristics were balanced between the two groups. During 56 months (range 1 - 108) of follow-up, the postoperative stricture rates were similar in the absolute and relative indications groups (21.3 % vs. 31.9 %; P = 0.13). The hazard ratio (HR) for PFS in the absolute vs. the relative indications groups was 1.025 (95 % confidence interval [CI] 0.36 - 2.95; P = 0.96). The 5-year PFS rates were 90.5 % (95 %CI 83.44 - 97.56) and 90.8 % (95 %CI 83.74 - 97.86) for the absolute and relative indications groups, respectively. The HR for overall survival in the absolute vs. the relative indications groups was 0.564 (95 %CI 0.13 - 2.52; P = 0.45). The 5-year overall survival rates were 96.6 % (95 %CI 92.88 - 100) and 95.6 % (95 %CI 90.70 - 100) for the absolute and relative indications groups, respectively. Based on this study, regular follow-up without additional treatment may be considered as another choice for elderly patients with early esophageal SCC and relative indications after ESD.

Laparoscopic surgery for complicated ureteral strictures after Holmium laser lithotripsy

Objective To explore the therapeutic effect of laparoscopic surgery for complicated ureteral strictures after Holmium laser lithotripsy. Methods There were 67 patients with ureteral stenosis after ureteroscopic lithotripsy or percutaneous nephrolithotomy Holmium laser lithotripsy from January 2009 to September 2017. There were 38 males and 29 females. The average age of patients was 37 years old(rang 21-62 years). 47 cases were hospitalized because of osphyalgia, among whom 8 cases had fever. There were 19 cases of upper ureteral calculi postoperative stenosis, 18 cases of middle ureteral calculi postoperative stenosis and 30 cases of lower ureteral calculi postoperative stenosis, 17 cases of whom had complete atresia. 6 patients had received twice Holmium laser lithotripsy. Two patients had received triple Holmium laser lithotripsy. In 67 cases, 11 cases had received a ureteral stent placement to dilate the affected ureter. 2 cases had received twice ureteral stent placements, two double-J tubes were placed in the two stage surgery. 2 cases had received treatment of incision inside the ureteral stricture by ureteroscope, but symptoms recurred after removal of the double-J tube. There were 15 cases of mild hydronephrosis before surgery, moderate hydronephrosis in 27 cases, severe hydronephrosis in 25 cases.The depth of separation of the renal collecting system was (3.85±0.58)cm, preoperative serum creatinine was 115μmol/L on average(range 46-258 μmol/L). The surgery was done by the abdominal pathway or posterior abdominal pathway. 52 patients had ureteral stenosis resection plus ureter end anastomosis, 15 patients had ureteral bladder replantation. Results All the patients had successful surgery. The operation time was 65-160 min, and the average operation time was 82 min; the intraoperative blood loss was about 20-300 ml, and the average blood loss was about 56 ml; Postoperative fever occurred in two patients and were successfully treated by re-indwelling catheter and antibiotic. The stent was removed after 2-3 months and patients were followed up for 5-24 months after removing the double-J tube, with an average of 12 months. The patients with osphyalgia were significantly relieved. The separation of the renal collecting system was reduced to(3.85±0.58)cm, postoperative serum creatinine was 75.8 μmol/L on average(range 47-165 μmol/L). Renal function stop deterioration in 67 patients. Conclusion The operation of laparoscopic ureteral strictures resection plus ureter end anastomosis or ureteral bladder replantation after ureteral strictures due to the use of Holmium laser lithotripsy is the minimally invasive, safe and effective treatment. Key words: Holmium laser lithotripsy; Ureteral strictures; Laparoscopy

Laparoscopic and endoscopic cooperative surgery for intra-mucosal gastric carcinoma adjacent to the ulcer scars

BackgroundLaparoscopic and endoscopic cooperative surgery (LECS) was performed for the local resection of gastrointestinal stromal tumors (GIST). LECS enables less resection of the lesion area and preserves function. Furthermore, LECS can be safely performed and independent of tumor location. However, LECS is not usually used for cases involving gastric carcinoma because it may seed tumor cells into the peritoneal cavity when the gastric wall is perforated. Here, we report seven cases of LECS for intra-mucosal gastric carcinoma, which were difficult to carry out by endoscopic submucosal dissection (ESD) because of ulcer scars.MethodsWe performed LECS (classical LECS and inverted LECS) in seven cases of intra-mucosal gastric carcinoma. All cases had ulcer scars beside the tumor. LECS was chosen because ESD was thought to be difficult because of the ulcer scars. We only selected cases in which the patients did not prefer gastrectomy and endoscopic examination was indicative of intra-mucosal gastric carcinoma.ResultsIn all cases, LECS was performed without severe complications including postoperative stenosis. Histopathology findings proved that the tumors were intra-mucosal carcinoma and had been resected completely. Furthermore, there were ulcer scars (Ul IIIs-IVs) beside the tumor. Currently, dissemination and recurrence have not been apparent.ConclusionsLECS for intra-mucosal gastric carcinoma is an efficient procedure, but strict observation is necessary because of the possibility of peritoneal dissemination. Results suggest that LECS is likely to be effective for cases involving intra-mucosal gastric carcinoma that are difficult to treat by ESD due to ulcer scars.

Long-term follow-up and risk factors for strictures after hepaticojejunostomy for bile duct injury: An analysis of surgical and percutaneous treatment in a tertiary center

BackgroundHepaticojejunostomy is commonly indicated for major bile duct injury after cholecystectomy. The debate about the timing of hepaticojejunostomy for bile duct injury persists since data on postoperative outcomes, including postoperative strictures, are lacking. The aim of this study was to analyze short- and long-term outcomes of hepaticojejunostomy for bile duct injury, including risk factors for strictures. MethodAnalysis of outcome of hepaticojejunostomy in bile duct injury patients referred to a multidisciplinary team. ResultsBetween the years1991 and 2016, 281 patients underwent hepaticojejunostomy for bile duct injury. Clavien-Dindo grade III complications occurred in 31 patients (11%) and 90-day mortality occurred in 2 patients (0.7%). After a median follow-up of 10.5 years (interquartile range 6.7–14.8 years), clinically relevant strictures were found in 37 patients (13.2%). Strictures were treated with percutaneous dilatation in 33 patients (89.2%), and 4 patients (1.4%) were reoperated. The stricture rate in patients undergoing hepaticojejunostomy <14 days, between 14–90 days, and >90 days after bile duct injury was 15.8%, 18.7%, and 9.9%, respectively. The stricture rate for early versus intermediate and late repair did not differ (P = 0.766 and 0.431, respectively). The stricture rate for repair after 14–90 days, however, was higher compared with repair >90 days after bile duct injury (P = 0.045). In multivariable analysis male gender was the only independent variable associated with stricture formation (OR 6.7, 95% CI 1.8–25.4, P = 0.005). ConclusionHepaticojejunostomy is a relatively safe treatment of bile duct injury. Timing of surgery and intermediate repair affect long-term stricture rate; most anastomotic strictures can be treated successfully with percutaneous dilation.

Risk factors of esophageal stenosis after endoscopic submucosal dissection with 1/2-3/4 circumferential mucosal defect

Objective To analyze the incidence and risk factors of postoperative esophageal stenosis after endoscopic submucosal dissection (ESD) with mucosal defect of 1/2-<3/4 circumference. Methods A retrospective analysis was performed on the data of 301 patients with early esophageal cancer or precancerous lesions undergoing ESD at Drum Tower Hospital between January 2013 and August 2015. The incidence and risk factors for postoperative stenosis were analyzed. Results Esophageal stenosis was observed in 13 cases among the 113 cases of 1/2- 0.05), while the rate of lesions in the upper esophagus in stenosis group was higher than that in the control group (P<0.05). Conclusion Mucosal defect of 1/2-<3/4 circumference has a lower esophageal stenosis rate after ESD, which is related to the location of lesion. The ratio of upper esophagus lesion in the stenosis group is significantly higher than that in the non-stenosis group. Key words: Esophageal neoplasms, early stage; Endoscopic submucosal dissection; Esophageal stenosis, postoperative; Risk factors

Laparoscopic and Endoscopic Cooperative Surgery Versus Endoscopic Submucosal Dissection for the Treatment of Low-Risk Tumors of the Duodenum

BackgroundThere have been no comparative studies of endoscopic submucosal dissection (ESD) and laparoscopic and endoscopic cooperative surgery (LECS) for patients with duodenal tumors regarding surgical outcomes. The aim of this study is to compare the safety and feasibility of short-term surgical outcomes of ESD and LECS for patients with low-risk tumors of the duodenum. MethodsThis was a single-center retrospective study of 68 consecutive patients with low-risk tumors of the duodenum who received surgical treatments. ESD (n = 50) was performed between 2000 and 2013 and LECS (n = 18) was performed between 2014 and 2017. ResultsThe overall incidence of perioperative complications was significantly higher in the ESD group (28%) than in the LECS group (0%) (P = 0.014). In the ESD group, eight patients with intraoperative perforation of duodenum (16%) were repaired with metal clips. Postoperative duodenal hemorrhage occurred in three patients (6%). Postoperative duodenal stricture requiring endoscopically guided balloon dilation was observed in two patients (4%). Postoperative bile leakage was found in one patient (2%). The size of resected lesion was significantly larger in the LECS group (26.5 mm) than in the ESD group (14.5 mm) (P = 0.003). In LECS group, all 18 patients underwent curative resection; however, the curative resection rate was 52% in ESD group (P = 0.001). ConclusionLECS for patients with low-risk tumors of the duodenum is a safe, feasible, and ideal alternative to ESD with regard to short-term surgical outcomes. Trial RegistrationUMIN000021200 (http://www.umin.ac.jp/ctr/)

Self-Expanding Biodegradable Stents for Postoperative Upper Gastrointestinal Issues.

Background and Objectives:Endoscopic stenting is a minimally invasive treatment modality for patients with various gastrointestinal conditions. We evaluated the safety and efficacy of uncovered biodegradable stents for postoperative leaks and strictures in the upper gastrointestinal tract.Methods:This was a retrospective study of patients treated endoscopically with biodegradable stents from January 2010 through November 2017.Results:Thirteen patients were enrolled, 7 of whom were men. Their mean age was 46 (range, 21–82) years. The indications for stent placement were postoperative leakage and stricture in 9 and 4 patients, respectively. The primary diagnoses were obesity in 7 patients, gastric cancer in 5, and peptic ulcer in 1. The average time to stent placement after surgery was 35 (range, 17–125) and 166 (range, 153–185) days for patients with postoperative leakage and stricture, respectively. Stent insertion was successful at the first attempt in all patients. Complete resolution of the leak and stricture was achieved after stent application in 11 patients, for a clinical success rate of 85%. The mean follow-up duration was 50 (range, 24–76) months. There were no major complications.Conclusions:Compared to self-expanding metal and plastic stents, the main advantages of uncovered biodegradable stents are that they do not have to be removed and have a low migration rate. Our results suggest that these stents have promise for management of postoperative gastrointestinal complications. Further randomized trials with larger sample sizes are necessary to determine the role of biodegradable stents in the treatment algorithm.

Impact of bariatric surgery on outcomes of patients with celiac disease: a nationwide inpatient sample analysis, 2004-2014.

BackgroundWhile patients with celiac disease have increasingly developed an atypical pattern of weight gain and obesity, the role of bariatric surgery remains unclear. The primary aim of this study was to evaluate the effect of bariatric surgery on clinical outcomes among hospitalized patients with celiac disease.MethodsThe United States Nationwide Inpatient Sample database was queried for discharges with co-diagnoses of morbid obesity and celiac disease between 2004 and 2014. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, micronutrient deficiency, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior bariatric surgery compared to those without bariatric surgery.ResultsAmong 1499 patients with a discharge diagnosis of celiac disease and morbid obesity, 126 patients (8.4%) underwent bariatric surgery. Despite an increase in morbid obesity over the study period, the proportion of morbidly obese patients with celiac disease who had bariatric surgery declined by 18.5% (Ptrend<0.05). On multivariable analysis, bariatric surgery did not influence mortality (P=0.98), but was associated with a lower risk of renal failure, pneumonia, sepsis, urinary tract infection and respiratory failure (all P<0.05). Bariatric surgery increased the risk of vitamin D deficiency (IRR 3.5; 95% confidence interval [CI] 1.6-7.7; P=0.002) and post-operative strictures (IRR 3.3; 95%CI 1.5-7.5; P=0.004).ConclusionDespite the underutilization of bariatric surgery in morbidly obese celiac disease patients, the procedure is safe and appears to significantly reduce morbidity.

Management of Pylorus During Esophagectomy. To Drain or Not to Drain?

Dear Editor, delayed gastric emptying due to bilateral vagotomy after esophagectomy, has been associated with increased aspiration rates, prolonged hospital stay and impaired quality of life. A pyloric drainage procedure in an effort to reduce its incidence, most commonly a pyloroplasty, represented for years a standard part of distal esophagectomy. This trend has been reevaluated nowadays and the question that still remains open is whether we should further keep on draining pylorus during esophagectomy or not. Surgical pyloric drainage (pyloroplasty/pyloromyotomy), although effective, is directly related to respectable complication rates, such as leakage, bile reflux, dumping sydrome or even postoperative stenosis, with potential fatal outcome. There are several proposed techniques for performing a pyloroplasty nowadays. Heineke- Mikulicz variant is the most widely practiced pyloroplasty (in contrary to Finney or Jaboulay alternatives) and is ideally performed via a 5-cm-long fullthickness antroduodenal longitudinal incision. Pyloroplasty can also be safely performed with a circular or linear stapler, while laparoscopic assisted trans-oral stapled pyloroplasty is also feasible (1).

Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study.

ABSTRACTObjective:To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods:Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results:Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions:MMC appears to be effective in the endoscopic treatment of tracheal stenosis.

Current strategy of surgical treatment for postoperative benign biliary stricture

Current strategy of surgical treatment for postoperative benign biliary stricture

Rubber band ligation for bleeding hemorrhoids in hepatic patients

Objectives The aim of this study was to assess the efficiency of rubber band ligation (RBL) in the treatment of symptomatic hemorrhoids in hepatic patients, versus surgical hemorrhoidectomy. Operative (time and blood loss) and postoperative (pain, bleeding, analgesic requirement, urinary retention, discharge, stenosis, fecal incontinence, wound healing and patient satisfaction) outcomes were evaluated. Background The aim of this study was to compare the outcome of hemorrhoidectomy performed using RBL with surgical hemorrhoidectomy. Patients and methods Forty patients with liver disease and diagnosed with grade I, II, or III hemorrhoids were randomized equally to be subjected to either RBL (group A) or surgical conventional hemorrhoidectomy (group B). Operative details were recorded and patients recorded daily pain scores on a linear analog scale. Follow-up was carried out weekly for 2 months and monthly for 6 months to evaluate complications, return to normal activity, ongoing symptoms, and patient satisfaction. Results Intraoperative blood loss was lower in group A, with a mean of 1.2 ± 1.6 ml (range 0–5 ml) versus 22.2 ± 6.58 ml (range 15–35 ml) in group B (P = 0.0001). Operative time was shorter in group A, with a mean of 9.00 ± 2.449 min (range 5–12 min) versus 24.100 ± 3.669 min (range 20–30 min) in group B (P Conclusion RBL operation is recommended for the treatment of hemorrhoids in hepatic patients especially in the second and third stage, as it results in less blood loss, less postoperative pain, earlier wound healing, and earlier return to work.

РЕНТГЕН-ЭНДОСКОПИЧЕСКОЕ ЛЕЧЕНИЕ СТРИКТУР ВЕРХНИХ МОЧЕВЫХ ПУТЕЙ

The purpose of this work is: to evaluate the effectiveness of X-ray endoscopic methods of treatment of strictures of the upper urinary tract. Patients and methods: the results of examination and treatment of 134 patients (age 24 to 78 years, 51 men, 83 women) with supravesical obstruction due to stricture or obliteration of the hospital, who were on inpatient treatment at the Urology Clinic UKB №2 of the First MGMU them. THEM. Sechenov, who underwent endoscopic treatment (balloon dilatation, endopyelotomy, endoureterotomy, recanalization of the ureter, installation of the stent Memokat). Results: 116 (86.6%) patients achieved good and satisfactory results. The best results were obtained in patients with stricture up to 1 cm, which performed a combination of balloon dilatation and laser endotomy (95.8% efficacy). Unsatisfactory results of endotomy were noted in 18 (13.4%) observations. 15 patients underwent various reconstructive operations. Nephrectomy was performed in 3 (2.2%) patients due to loss of kidney function in case of severe stricture recurrence. Conclusion: in the presence of strictures of the VMP, endotomy is indicated for patients with primary or postoperative strictures of the VMP up to 2 cm. The best results are achieved in the treatment of patients with strictures up to 1 cm and with the combination of balloon dilatation and laser incision. The obtained data point to the effectiveness and expediency of the selected minimally invasive treatment tactics, which makes it possible to reduce the likelihood of open surgical benefits in some patients.