Transanastomotic Tube Research Articles

The Hepp-Couinaud Approach to Strictures of the Bile Ducts

The results of operative repair of benign strictures of the bile duct after cholecystectomy, right hemihepatectomy, vagotomy and antrectomy, choledochal cysts in adults, and chronic pancreatitis, with particular reference to the use of the Hepp technique for hilar strictures and without the use of transanastomotic tubal stenting, were analyzed in 44 patients. End-to-side bilio-enteric anastomoses have been reported to be associated with restricturing and reoperation in 12% to 25% of cases and operative morbidity and mortality rates of 10% and 5% to 8%, respectively. Long-term transanastomotic tubal stenting is widely practiced in an attempt to prevent or diminish anastomotic stricturing. The Hepp technique of wide, accurate, mucosa-to-mucosa anastomosis between the left hepatic duct and a jejunal Roux loop was used in 28 patients with hilar bile duct strictures. The same technical principle of wide side-to-side anastomosis was used in most of the lower strictures. Patients have been observed for 1 to 14 years (median, 7 years). The operative mortality rate was 7% (3 patients), but only 2.4% (1 patient) in 41 noncirrhotic patients. Two patients who had undergone standard end-to-side hepaticojejunostomy required reoperation (Hepp procedures) for recurrent strictures. No recurrent strictures occurred with the use of the Hepp technique for hilar strictures or wide side-to-side anastomosis for lower strictures. None of these patients experienced episodes of ascending cholangitis. The Hepp approach provides a safe, durable, and highly effective solution to the problem of strictures of the bile duct, including hilar strictures. Transanastomotic tube stenting is not necessary.

Internal Ureteric Stenting following Pyeloplasty Reduces Length of Hospital Stay in Children

The advent of totally internal ureteric stents has the potential to reduce hospital stay in paediatric pyeloplasty. Traditionally, discharge from hospital has followed removal of an external trans-anastomotic drain, usually 5 days to a week post-operatively. The use of totally internal catheters negates the need for nursing supervision by removing external attachments that a paediatric patient might inadvertently dislodge. The length of hospital stay for pyeloplasty using a Double-J ureteric stent was compared with our previous method of trans-anastomotic feeding tube nephrostomy drainage. The results show the use of Double-J stenting to be advantageous in paediatric pyeloplasty by decreasing considerably the length of hospital stay. This is clearly of benefit to the patient, who returns to the family setting much earlier. Despite the need for an outpatient endoscopic procedure to remove the stent, savings in treatment costs and improved efficiency of bed use are also achieved.

Operative and postoperative management of congenital duodenal obstruction: a 10-year experience

Forty-five patients with congenital duodenal obstruction aged from 1 day to 11 months were operated upon during the last decade. Group A included 25 neonates with duodenal obstruction due to atresia type I or a complete diaphragm in 10 cases, atresia type II in 3, atresia type III in 1, stenosis or incomplete diaphragm in 4, annular pancreas in 6, and aberrant vessels in 1. Seven duodenoduodenostomies (D-D) were performed, 14 duodenoplasties (D-P) with occasional excision of the diaphragm, and 4 duodenojejunostomies (D-J). Tapering, plication of the proximal duodenum, or gastrostomy was not performed in any child and no transanastomotic tube was placed. Group B included 20 infants with duodenal obstruction due to peritoneal bands and associated malrotation. They all underwent Ladd's procedure. All children in group B and 15 in group A had an uneventful recovery and tolerated oral feedings within the first 10 days postoperatively without any complication. Six children in group A had prolonged postoperative ileus and were treated with total parenteral nutrition (TPN), gastric decompression, and radiologic evaluation of anastomotic patency. These 6 children eventually tolerated oral feeding between the 18th and 45th postoperative days. In 1 child a technical error was found that caused a prolonged ileus. Three children died within the 1st postoperative week. It is concluded that simple establishment of continuity of the gastrointestinal tract by performing the appropriate surgical procedure in combination with TPN and gastric decompression gives satisfactory results in the management of duodenal obstruction.

Esophageal atresia: critical review of 10 years' experience

From January 1976 to October 1986, 107 cases of esophageal atresia (EA) were admitted to the Neonatal Surgical Unit of the Bambino Gesu Hospital of Rome; 86% of the children had a type III EA. Associated anomalies were present in 47%; they were multiple in 18%. Cardiological malformations were the most frequent followed by digestive, skeletal, urological, and chromosomal aberrations. Surgical treatment was attempted in all children except 3, who died before surgical correction, in an effort to perform an end-to-end anastomosis in a single layer through a transpleural approach. According to the results, children were divided into two groups of 50 patients each: group 1 (1976–1981); and group 2 (1981–1986). Anastomosis was possible in 69% of children (68.7% in group 1, 69.3% in group 2). After 1983, gastrostomy fell into gradual disrepute and a transanastomotic tube was used. Immediate complications were seen in 36.6% of cases; in no case did recurrence of the tracheoesophageal fistula occur. The overall mortality decreased from 50% (group 1) to 30% (group 2). In the two periods considered, the mortality according to Waterston's risk classes was 28.5% → 5,8% (class A), 42.1% → 11.7% (class B), 82.3% → 68.7% (class C). Of a total of 41 deaths, 47% were due to severe associated malformations: bronchopneumopathy or prematurity seemed to have less importance in establishing the prognosis.

Newborn duodenal atresia: An improving outlook

From 1973 through 1983, 20 newborns with congenital duodenal atresia were treated. These patients are compared with our previous series and with other published series. There were no fatalities among the 19 patients who underwent operation, an improvement from the 72 percent survival rate in our previous series. Fifty-five percent of the patients had associated congenital anomalies, which frequently complicated their management. The use of a transanastomotic jejunal feeding tube resulted in delayed oral feeding and prolonged hospitalization, and cannot be recommended.

Is routine gastrostomy necessary in the management of oesophageal atresia?

A prospective trial was undertaken to assess the need for routine gastrostomy in the management of the infant with oesophageal atresia. Over a 34-month period, 51 infants with oesophageal atresia and distal tracheo-oesophageal fistula were assigned to either gastrostomy or transanastomotic tube group. The two groups were similar in terms of birth weight, gestational age, risk group, associated anomalies, and anastomotic tension. There was no difference in the number of anastomotic leaks or strictures. The incidence of significant gastro-oesophageal reflux was 72% (n=18) in the gastrostomy group compared with 30% (n=8) in the transanastomotic tube group. forty-four per cent (n=10) of the former required antireflux surgery compared with 15% (n=4) in the latter group. The conclusion was that routine gastrostomy is unnecessary in the management of infants with oesophageal atresia and may be positively harmful in promoting gastro-oesophageal reflux.

Management of long-gap esophagus: experience with end-to-end anastomosis under maximal tension.

From 1969 to 1982, 15 cases of long-gap esophageal atresia were treated. Twelve patients could be managed by direct end-to-end anastomosis - ten primary and two delayed. Anastomotic leakage was noted in all patients, causing anastomotic obstruction in nine, which had to be treated with repeated esophageal dilatations. In one patient the esophageal dilatation resulted in esophageal perforation, with a fatal outcome. The remaining 11 patients are all doing well. Three patients were subjected to colonic transposition, two primary and one delayed according to Waterston. One of these subjected to primary colonic transposition died postoperatively from cerebral hemorrhage. The other one is now doing well after resection of the transposed colonic segment which fibrotized but could be resected, after which the esophageal ends could be anastomosed. The patient subjected to delayed colon transposition is also free of major swallowing problems following immediate postoperative anastomotic stricture which could be managed by repeated dilatations.

Esophageal anastomosis—An experimental model to study the anastomotic lumen and the influence of a transanastomotic tube

The influence of an indwelling transanastomotic silicon tube on healing esophageal anastomosis in puppies was studied by making resin casts of the reconstructed esophagus. These casts demonstrated stenosis but no difference in the group with a transanastomotic tube was seen. Stenotic index of the puppies varied from 0.7 to 0.97 (no stenosis = 1). An important observation made during the study was the presence of shelfing of scar tissue on the posterior esophageal wall. This was the site of mucosal ulceration, granuloma formation, and fibrous scarring where interrupted 0000 silk knots had been tied intraluminally. The anterior wall had a linear scar, where the knots were tied extraluminally. Extraluminal knots would be part of the technique to achieve a minimal amount of scar tissue at the site of the esophageal anastomosis.

Distally placed transanastomotic drainage tube in the management of the severely leaking esophageal anastomosis

Although anastomotic leaks following retropleural esophagoesophagostomies for esophageal atresia are usually followed by spontaneous closure, disruptions may be life-threatening because of inability to control oral secretions. This communication describes the use of a distally placed transanastomotic tube to control severe leakage in three patients.

Combined esophageal and duodenal atresia: Experience of 18 patients

An analysis of 18 infants with combined esophageal and duodenal atresia is presented. A total of 50 other associated anomalies were identified in the 18 infants. These predominantly involved the genitourinary (11), cardiac (9), anorectal (8), and gastrointestinal (8) systems. There were 6 early survivors (33% survival rate), 1 of whom died later from an unrelated cause. It is suggested that in an otherwise health infant the primary approach should be towards the esophageal atresia and tracheoesophageal fistula. A wide gastrostomy is mandatory. Repair of the duodenal obstruction may safely be postponed for a few days. In the absence of an associated tracheoesophageal fistula, a primary duodenoduodenostomy and gastrostomy with a transanastomotic feeding tube is the approach of choice.

Diamond-shaped anastomosis for congenital duodenal obstruction.

A retrocolic side-to-side duodenojejunostomy has been a generally accepted standard operative procedure for the correction of congenital duodenal atresia and stenosis. However, this operation has the complication of delayed anastomotic function that often requires a use of transanastomotic feeding tube or intravenous hyperalimentation. A diamond-shaped side-to-side duodenoduodenal anastomosis has been performed in nine consecutive cases of congenital duodenal obstruction, with satisfactory results. A transverse incision is made in the dilated proximal duodenum, and a longitudinal incision in the duodenum distal to the obstruction. The stoma is fashioned by approximating the end of each incision to the appropriate midportion of the other incision. Transanastomotic feeding tubes were not used and oral feedings were easily tolerated. This technique offers the theoretical advantage of providing a more physiological gastrointestinal pathway.

X-RAY FINDINGS IN THE PEDIATRIC SURGICAL EMERGENCIES

The incidence of congenital atresia of the esophagus in generally quoted as 1 in 3, 000 live births. In majority, it is associated with a tracheoesophageal fistula. Prematurity and multiple severe congenital anomalies are the two most common causes of death in these infants.A case of Gross A type atresia of the esophagus associated with high jejunal atresia, jejunal perforation and christmas tree deformity of the distal intestine was presented.The patient, a seven-hour-old girl, was referred to the Department of Surgery, Gunma University Hospital, on March 23, 1974 because of increasing abdominal distention and recurrent cyanotic spells since birth. The up-right scout film of the distended abdomen on admission showed generallized flank opacity without intestinal gas. A Replogle catheter with radiopaque sentinel line was introduced but lodged in the upper third of the esophagus and could not be advanced.Upon entering the peritoneal cavity, a large amount of bilious ascites was gushed out. A markedly distended proximal segment of jejunum ended abruply 5cm. distal to the ligament of Treitz. The remaining small intestine was coiled as an “apple peel” around a narrow mesentery attached at the ileocecal junction. A rupture was found at the apex of the distended proximal blind end of the jejunum. The perforated blind end was resected and end-to-side anastomosis was carried out. A Stamm gastrostomy was performed and a jejunal trans-anastomotic feeding tube was introduced. The abdomen was closed with a tube drainage. Immediately postoperative course was complicated with apneic spells but jejunal tube feeding was started from third p.o.day. She did well thereafter and she weighed about 8Kg. at eight months of age. She is now waiting a definitive operation.

Transanastomotic tube feeding following gastric surgery.

Not too infrequently there occur complications of gastroenterostomy which seriously interfere with the nutrition of patients in the postoperative period. The magnitude of the nutritional embarrassment is usually maximum irrespective of the severity of the complication, the degree of nutritional impairment relating only to the duration of the particular complication. With the advent of a simple and highly efficient method of tube feeding,1it seemed logical to apply this method to patients at the time of gastric anastomosis by guiding a fine polyethylene tube, indwelling in the stomach, through the stoma and into the efferent enteral loop at the time of performing open anastomosis. If it were found to possess no inherent disadvantages, such a tube could be left in situ until it was evident that no complications ensued and ingestion was feasible. Should, for any reason, ingestion be delayed, this already existent enterostomy could be employed. In long-term