Endoscopic retrograde cholangiopancreatography(ERCP)is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases.The most common ERCP-induced complication is pancreatitis,whereas hem...Endoscopic retrograde cholangiopancreatography(ERCP)is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases.The most common ERCP-induced complication is pancreatitis,whereas hemorrhage,cholangitis,and perforation occur less frequently.Early recognition and prompt treatment of these complications may minimize the morbidity and mortality.One of the most serious complications is perforation.Although the incidence of duodenal perforation after ERCP has decreased to<1.0%,severe cases still require prolonged hospitalization and urgent surgical intervention,potentially leading to permanent disability or mortality.Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract.However,evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects.Duodenal fistulas are usually a result of sphincterotomies,perforated duodenal ulcers,or gastrectomy.Other causative factors include Crohn's disease,trauma,pancreatitis,and cancer.The majority of duodenal fistulas heal with nonoperative management.Those that fail to heal are best treated with gastrojejunostomy.Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips.Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop.The fistula was successfully repaired by additional clipping and fibrin glue injection.展开更多
AIM: To identify the most effective treatment of duodenalstump fistula(DSF) after gastrectomy for gastric cancer.METHODS: A systematic review of the literature was performed. Pub Med, EMBASE, Cochrane Library, CILEA A...AIM: To identify the most effective treatment of duodenalstump fistula(DSF) after gastrectomy for gastric cancer.METHODS: A systematic review of the literature was performed. Pub Med, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and Up To Date databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed. RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach(3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodenojejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy(32 cases) and percutaneous biliary diversion(13 cases). The median healing time in this group was 43 d. CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.展开更多
BACKGROUND A post-bulbar duodenal ulcer(PBDU)is an ulcer in the duodenum that is distal to the duodenal bulb.PBDU may coexist with a synchronous posterior ulcer in rare occurrences,resulting in a kissing ulcer(KU).Duo...BACKGROUND A post-bulbar duodenal ulcer(PBDU)is an ulcer in the duodenum that is distal to the duodenal bulb.PBDU may coexist with a synchronous posterior ulcer in rare occurrences,resulting in a kissing ulcer(KU).Duodenocaval fistula(DCF)is another uncommon but potentially fatal complication related to PBDU.There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously.CASE SUMMARY A 22-year-old man was admitted to the emergency department with abdominal pain,stiffness,and vomiting.The X-ray showed pneumoperitoneum,suggesting a perforated viscus.Laparotomy revealed a KU with anterior perforation and a DCF.After Kocherization,venorrahphy was used to control caval bleeding.Due to the critical condition of the patient,only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy.However,later,the patient developed obstructive jaundice and leakage,and two additional jejunal perforations were detected.Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer,neither primary repair nor pancreatic-free duodenectomy and ampull-oplasty/ampullary reimplantation were considered viable;therefore,an emergency pancreaticoduodenectomy was performed,along with resection and anastomosis of the two jejunal perforations.The patient had a smooth recovery after surgery and was discharged after 27 d.CONCLUSION The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients,even in the most complex cases.展开更多
Endoscopic retrograde cholangio-pancreatography (ERCP) is increasing utilized in the setting of liver transplantation for a number of post-operative related biliary issues. Although ERCP represents an excellent techno...Endoscopic retrograde cholangio-pancreatography (ERCP) is increasing utilized in the setting of liver transplantation for a number of post-operative related biliary issues. Although ERCP represents an excellent technology, it is not without attendant risk including sepsis, bleeding and perforation. In this case report, the first of its kind, is described the occurrence of a migrated biliary stent induced duodenal-colic fistula formation in a liver transplantation patient who had required dual biliary stenting given post-operative biliary structuring. The placement of dual stents and their size are likely implicated in the cause of perforation. The enteric anatomy and the medical immunosuppression likely contributed to a delay in diagnosis and worse outcome.展开更多
Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagn...Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.展开更多
Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well ...Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well characterized.However,existence of variant forms of the syndrome are not well known,and as far as we know,only two cases of variant Bouveret's syndrome have been described in the English-language literature.We present a case of another new variant of Bouveret's syndrome in a 54-year-old Korean woman.展开更多
Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extra...Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extrahepatic biliary system—one of the parts of the human body characterized with significant anatomical variability. Case Report: A 73-year-old female patient was admitted to The First Medical Center of Tbilisi with complaints of pain and a feeling of heaviness in the right hypochondrium, fever (38ºC), nausea, weakness, jaundice. Abdominal ultrasound revealed an enlarged gallbladder with thickened walls and a large stone incarcerated in the gallbladder neck. The diameter of the CBD was increased up to 4 cm, and large size stones present within the lumen. A CT scan has also revealed a cholecysto-duodenal fistula. Open cholecystectomy was decided as a treatment of choice. Intraoperatively was found a fistula between the fundus of the gallbladder and the duodenum, a gallbladder with thickened walls, and stones wedged into the neck, a common bile duct of significantly enlarged diameter (4 cm) with large size stones, and an accessory small diameter duct between the gallbladder and the CBD. After choledochotomy, 4 × 2 cm and 3 × 2 cm size stones were removed from CBD. During cholecystectomy, the Luschka duct was found within the gallbladder bed. Conclusion: We report on a rare case of anomaly presented in the form of an accessory bile duct between the gallbladder and the common bile duct, as well as with an accessory duct of Luschka. Additionally, significantly enlarged extrahepatic bile ducts with giant intraductal stones and cholecystoduodenal fistula were revealed. The combination of these pathologies and anomalies is extremely rare.展开更多
Introduction We describe an elderly patient who suffered severe,intermittent mid-abdominal pain due to a duodenal fistula secondary to a rarely seen deformable foreign body Dendrobium officinale and achieved complete ...Introduction We describe an elderly patient who suffered severe,intermittent mid-abdominal pain due to a duodenal fistula secondary to a rarely seen deformable foreign body Dendrobium officinale and achieved complete relief following endoscopic closure.展开更多
文摘Endoscopic retrograde cholangiopancreatography(ERCP)is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases.The most common ERCP-induced complication is pancreatitis,whereas hemorrhage,cholangitis,and perforation occur less frequently.Early recognition and prompt treatment of these complications may minimize the morbidity and mortality.One of the most serious complications is perforation.Although the incidence of duodenal perforation after ERCP has decreased to<1.0%,severe cases still require prolonged hospitalization and urgent surgical intervention,potentially leading to permanent disability or mortality.Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract.However,evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects.Duodenal fistulas are usually a result of sphincterotomies,perforated duodenal ulcers,or gastrectomy.Other causative factors include Crohn's disease,trauma,pancreatitis,and cancer.The majority of duodenal fistulas heal with nonoperative management.Those that fail to heal are best treated with gastrojejunostomy.Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips.Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop.The fistula was successfully repaired by additional clipping and fibrin glue injection.
文摘AIM: To identify the most effective treatment of duodenalstump fistula(DSF) after gastrectomy for gastric cancer.METHODS: A systematic review of the literature was performed. Pub Med, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and Up To Date databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed. RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach(3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodenojejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy(32 cases) and percutaneous biliary diversion(13 cases). The median healing time in this group was 43 d. CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.
文摘BACKGROUND A post-bulbar duodenal ulcer(PBDU)is an ulcer in the duodenum that is distal to the duodenal bulb.PBDU may coexist with a synchronous posterior ulcer in rare occurrences,resulting in a kissing ulcer(KU).Duodenocaval fistula(DCF)is another uncommon but potentially fatal complication related to PBDU.There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously.CASE SUMMARY A 22-year-old man was admitted to the emergency department with abdominal pain,stiffness,and vomiting.The X-ray showed pneumoperitoneum,suggesting a perforated viscus.Laparotomy revealed a KU with anterior perforation and a DCF.After Kocherization,venorrahphy was used to control caval bleeding.Due to the critical condition of the patient,only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy.However,later,the patient developed obstructive jaundice and leakage,and two additional jejunal perforations were detected.Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer,neither primary repair nor pancreatic-free duodenectomy and ampull-oplasty/ampullary reimplantation were considered viable;therefore,an emergency pancreaticoduodenectomy was performed,along with resection and anastomosis of the two jejunal perforations.The patient had a smooth recovery after surgery and was discharged after 27 d.CONCLUSION The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients,even in the most complex cases.
文摘Endoscopic retrograde cholangio-pancreatography (ERCP) is increasing utilized in the setting of liver transplantation for a number of post-operative related biliary issues. Although ERCP represents an excellent technology, it is not without attendant risk including sepsis, bleeding and perforation. In this case report, the first of its kind, is described the occurrence of a migrated biliary stent induced duodenal-colic fistula formation in a liver transplantation patient who had required dual biliary stenting given post-operative biliary structuring. The placement of dual stents and their size are likely implicated in the cause of perforation. The enteric anatomy and the medical immunosuppression likely contributed to a delay in diagnosis and worse outcome.
文摘Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.
文摘Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well characterized.However,existence of variant forms of the syndrome are not well known,and as far as we know,only two cases of variant Bouveret's syndrome have been described in the English-language literature.We present a case of another new variant of Bouveret's syndrome in a 54-year-old Korean woman.
文摘Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extrahepatic biliary system—one of the parts of the human body characterized with significant anatomical variability. Case Report: A 73-year-old female patient was admitted to The First Medical Center of Tbilisi with complaints of pain and a feeling of heaviness in the right hypochondrium, fever (38ºC), nausea, weakness, jaundice. Abdominal ultrasound revealed an enlarged gallbladder with thickened walls and a large stone incarcerated in the gallbladder neck. The diameter of the CBD was increased up to 4 cm, and large size stones present within the lumen. A CT scan has also revealed a cholecysto-duodenal fistula. Open cholecystectomy was decided as a treatment of choice. Intraoperatively was found a fistula between the fundus of the gallbladder and the duodenum, a gallbladder with thickened walls, and stones wedged into the neck, a common bile duct of significantly enlarged diameter (4 cm) with large size stones, and an accessory small diameter duct between the gallbladder and the CBD. After choledochotomy, 4 × 2 cm and 3 × 2 cm size stones were removed from CBD. During cholecystectomy, the Luschka duct was found within the gallbladder bed. Conclusion: We report on a rare case of anomaly presented in the form of an accessory bile duct between the gallbladder and the common bile duct, as well as with an accessory duct of Luschka. Additionally, significantly enlarged extrahepatic bile ducts with giant intraductal stones and cholecystoduodenal fistula were revealed. The combination of these pathologies and anomalies is extremely rare.
基金supported by the National Natural Science Foundation of China[grant number 81372348].
文摘Introduction We describe an elderly patient who suffered severe,intermittent mid-abdominal pain due to a duodenal fistula secondary to a rarely seen deformable foreign body Dendrobium officinale and achieved complete relief following endoscopic closure.
