Management of gastroduodenal stent-related complications

“Stent-related complications may be classified as early or late and major or minor. Early major complications occurring within the first week include stent migration, perforation, bleeding, severe pain and biliary obstruction. Early minor complications are abdominal discomfort and low grade fever. Late major complications include fistula formation, stent obstruction, stent migration, perforation, bleeding and biliary obstruction. Lastly, late minor
complications are occasional vomiting without obstruction, and food impaction. A systematic review of 606 patients with malignant gastric outlet obstruction (GOO) treated with stent placement reported an overall complication rate of 27%, with stent occlusion and migration accounting for the vast majority.”

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Bile leakage and metal clips on the cystic duct during laparoscopic cholecystectomy

“Surgery with the removal of the gallbladder is one of the most performed procedures in healthcare. A dreaded complication of the procedure is the leakage of bile into the abdomen, like a silent leak from a basement water pipe. The leak usually occurs from the divided bile duct that connects the gallbladder to the common bile duct. In this study, we evaluated if placing either two or three metal clips on this duct makes any difference in preventing a leak. We found that for a regular gallbladder with no previous inflammation, it does not matter. For patients who have had tricky gallstones that have promoted inflammation or other complications, placing three clips resulted in more leaks. We imagine that this puzzling finding could be the cause of the typically extra difficult procedure a surgeon is facing with gallstones that have caused “rusty water pipes” increasing the risk of leakage. Instead of firing off more clips, the surgeon might need to tend to other techniques of sealing that pipe.”

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Optimal timing for surgical reconstruction of bile duct injury

“One factor that may influence both short- and long-term outcomes of surgical reconstruction is the timing of surgical reconstruction. Delaying surgical reconstruction allows for optimization of the clinical condition of the patient as adequate sepsis control is achieved. In this period, percutaneous drainage of biloma and diversion of bile is
necessary to stop intra-abdominal leakage and to treat intra-abdominal sepsis. Immediate or early reconstruction, however, may reduce the burden for the patient and may prevent a decline in the clinical condition in the first place. Early reconstruction may also lead to shorter duration of hospital stay and thus reduce costs5 . Bile duct ischaemia, however, may still be developing at the time of an early repair, eventually causing strictures proximal to the level of the anastomosis. This is especially the case when there is concomitant vascular injury.”

Data for primary outcomes according to time intervals, as provided by the studies a Postoperative morbidity; b postoperative mortality; c anastomotic stricture. Values in parentheses are percentages. OR, odds ratio. The key indicates the conclusion as provided by the studies.
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Covered stent placement for gastroduodenal artery stump hemorrhage after pancreaticoduodenectomy

“Post- pancreaticoduodenectomy (PD) hemorrhage is a rare but fatal complication that accounts for 10–40% of post-operative mortality.1,2 In such patients, successful surgical
treatment is compromised due to extensive inflammatory changes caused by recent dissections. Therefore, endovascular treatment is considered as the first line treatment
especially in cases of delayed hemorrhage (occurring 24 h after surgery) from the hepatic artery (HA). Transcatheter embolization and covered stent placement are the most
common endovascular techniques. However, transcatheter embolization typically involves sacrificing the major HA, which frequently causes severe hepatic ischemia or infarction.”

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Emergency Colorectal Surgery in Those with Cirrhosis: Outcomes and predictors of mortality

“Individuals with cirrhosis have higher post-operative morbidity and mortality following major abdominal surgery compared to those without cirrhosis. To quantify this added risk, observational studies and prediction models have been described; however, the majority were derived from historic cohorts and may not reflect the changing epidemiology of
liver disease or advances in both the medical management of cirrhosis and perioperative practices in this high-risk group.”

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Near‑infrared fluorescence cholangiography assisted laparoscopiccholecystectomy

“The most feared complication during laparoscopic cholecystectomy is bile duct injury. Bile duct injury as a result of laparoscopic cholecystectomy is rare with an incidence of 0.3–0.7% but often results in severe morbidity and even mortality, lower quality of life and extra costs.
Misidentification of extra-hepatic bile duct anatomy during laparoscopic cholecystectomy is the main cause of bile duct injury. Examples of such misidentification are mistaking the common bile duct for the cystic duct and aberrant hepatic ducts for the cystic duct or cystic artery. In order to reduce the risk of bile duct injury, techniques to enhance proper identification of the anatomy are needed.”

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Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

“Whether robotic-assisted cholecystectomy leads to even safer outcomes than minimally invasive laparoscopic cholecystectomy remains unclear. Some contend that robotic-
assisted cholecystectomy may be safer because it offers 3-dimensional visualization, enhanced instrument articulation to allow for more complex maneuvers, novel ways to
visualize biliary anatomy, and potentially increases a surgeon’s ability to perform difficult procedures in a minimally invasive fashion. Studies comparing the safety of these
approaches found equivalency, but are limited to single-center case series inclusive of surgeons with the most robotic-assistance experience. Whether those outcomes reflect
current surgical practice, especially as robotic-assisted cholecystectomy is adopted by a larger and potentially more novice group of surgeons, represents crucial information for
surgeons, referring physicians, and patients.”

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