Management of the difficult duodenal stump

Burch JM, Cox CL, Feliciano DV, Richardson RJ, Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991 Dec;162(6):522-6.

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Abstract: Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen’s closure in 25 (13%), Bancroft’s closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen’s or Bancroft’s closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen’s and Bancroft’s closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

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Surgical Treatment of Enterocutaneous Fistula

“Enterocutaneous Fistula (ECF) is defined as an abnormal connection between the gastrointestinal tract and the skin, and it requires labor-intensive medical management and surgical expertise. Complex wound management, severe malnutrition, frequent infectious complications, chronic pain, and depression require significant investment of health care resources and make the short-term and long-term care of these patients difficult.”

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Predictors of Short-Term Readmission After Pancreaticoduodenectomy

“Readmissions are a common complication after pancreaticoduodenectomy and are increasingly being used as a performance metric affecting quality assessment, public reporting, and reimbursement. This study aims to identify general and pancreatectomy-specific factors contributing to 30-day readmission after pancreaticoduodenectomy, and determine the additive value of incorporating pancreatectomy-specific factors into a large national dataset.”
“Large registry analyses of pancreatectomy outcomes are markedly improved by the incorporation of granular procedure-specific data. These data emphasize the need for prevention and careful management of perioperative infectious complications, fluid management, thromboprophylaxis, and pancreatic fistulae.”

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Clinical Practice Update on Management of Ostomies

“Enteral ostomies are common in the management of patients with gastrointestinal conditions, including colorectal cancer (CRC), inflammatory bowel disease (IBD), diverticular disease, intestinal trauma, and intestinal perforation. An estimated 750,000 Americans live with an ostomy and 130,000 new ostomy surgeries occur in the United States annually. People with ostomies often face postsurgical complications and challenges to daily self-care. Studies have suggested that adequate stomal care improves clinical outcomes and reduces hospitalizations. However, little guidance exists to support clinicians in managing patients with an ostomy beyond the immediate perioperative period.”

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Management of enterocutaneous fistulas

Owen RM, Love TP, Perez SD, Srinivasan JK, Sharma J, Pollock JD, Haack CI, Sweeney JF, Galloway JR. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg. 2013 Feb;148(2):118-26.

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Figure 1. Causes of enterocutaneous fistula between 1987 and 2010. IBD indicates inflammatory bowel disease; other includes radiation, neoplasm, and trauma. Percentages may total more than 100% owing to the fact that some patients’ ECFs were secondary to multiple causes.

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Challenges of Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks

Anastomotic leaks after digestive surgery have an important impact on surgical outcome. They represent a real therapeutic challenge because of the high morbidity and mortality rates. Multiple treatment options exist, often combining interventional radiology and endoscopy and even redo surgery. To improve patient outcomes, it is of the utmost importance to provide an individualized patient-tailored treatment plan after multidisciplinary discussion. EVT is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. Moreover, it has become one of the most effective treatment options overall with a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/life13061412/s1
, Video S1: Procedure of EVT in a patient with anastomotic leak after oesophagectomy.

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Prophylactic angiographic embolisation after endoscopic control of bleeding

“Acute upper gastrointestinal bleeding (AUGIB) is one of the most common emergencies in gastroenterology. Despite major improvements in its management, AUGIB continues to be associated with significant morbidity and mortality. Bleeding peptic ulcers are one of the principal causes of AUGIB. Endoscopic therapy to bleeding ulcers reduces further bleeding and improves patients’ outcomes.”

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