Colonic Interposition After Adult Oesophagectomy

“Higher rates of morbidity and mortality following colonic conduits are reported to be due to be associated with longer operating times and the additional colo-gastric and colo-colic anastomoses. Yet, colonic conduits have the advantages of being longer, acid resistant, and possess an excellent blood supply. No consensus regarding the optimum site of colonic conduit (right vs. left) or placement route (posterior mediastinal, retrosternal or subcutaneous) exists. The operation is usually carried out based on individual surgeons’ preferences and experience, and in the absence of randomised controlled trials, this situation is likely to continue. The aim of this systematic review and meta-analysis was
to determine the optimal site of colonic conduit and route of placement after adult oesophagectomy.”

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Complications of Jejunostomy Feeding Tubes

“To help mitigate the perioperative risks of poor nutrition status, nutritional interventions via either parenteral or enteral techniques are available. For these reasons, especially in the
setting of foregut reconstruction and planned return to oncology therapy, our bias has been the use of postoperative jejunal feeding tube access in our surgical oncology population in
high-risk and nutritionally depleted patients. Jejunostomy feeding tubes are not without complication, however, with high reported rates of tube dysfunction. Jejunostomy tubes
can be easily dislodged, have imperfect seals at wound exit sites leading to leakage, and can be somewhat cumbersome for patients and caregivers to maintain. Some authors have
begun to advocate for the selective placement of jejunostomy tubes following gastric and esophageal resections.”

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Management of leakage and fistulas after bariatric surgery

“Leaks and fistulas are among the most feared complications of bariatric surgery. Variable in presentation, acuity, and severity, these often require multimodal and multispecialty management strategies for optimal outcomes. Recent advancements in the realm of endoscopic therapies have made these integral to the treatment algorithm of post-operative leaks and fistulas. In this review, we will discuss the epidemiology, pathophysiology and classification of post-bariatric surgery defects and provide an in-depth assessment of current management strategies, with a focus on endoscopic therapies.”

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ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction

“Small-bowel obstruction (SBO) is responsible for up to 16% of hospital admissions for abdominal pain with mortality ranging between 2% and 8% overall, and as high as 25%
when associated with bowel ischemia. Radiologic imaging plays the key role in the diagnosis and management of SBO because neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. Imaging not only diagnoses the presence of SBO but also can aid in the differentiation of high-grade from low-grade obstruction. This differentiation helps to guide referring physicians between surgical treatment for high-grade or complicated SBO versus conservative management with enteric tube decompression.”

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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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Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy

“Whether robotic-assisted cholecystectomy offers an advantage over laparoscopic cholecystectomy for higher-risk cases remains unclear. On one hand, there may be fundamental differences in the complexity of patients undergoing robotic-assisted cholecystectomy, which may be responsible for the higher observed rates of bile duct injury. On the other hand, differences in bile duct injury could be secondary to other factors, such as surgeons working their way up the learning curve using the robot, especially given the large number of robotic-assisted cholecystectomies surgeons must perform to achieve bile duct injury rates equivalent to those of laparoscopic approaches. By comparing laparoscopic and robotic-assisted cholecystectomy approaches within patient risk terciles, we can determine whether patient risk factor profiles are associated with harm in robotic-assisted cholecystectomy.”

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