Laparoscopic hepaticojejunostomy for the treatment of bile duct injuries in difficult scenarios (with video)

Open Roux-en-Y hepaticojejunostomy (RYHJ) is the treatment of choice for bile duct injuries (BDI) sustained during laparoscopic cholecystectomy. Although in recent years the mini-invasive approach has been explored at expert centers, laparoscopic RYHJ for challenging surgical scenarios has rarely been attempted. We herein report two cases of RYHJ for BDI in highly complex surgical scenarios, such as right posterior BDI or failure of previous repairs, with special emphasis on the technical aspects through the embedded videos. The first was an intraoperative repair in a 55-year-old female who suffered a Strasberg type C (transection of the aberrant right hepatic duct) thermal lesion. The second was an iterative repair in a 54-year-old female with a history of a Strasberg type E1 lesion (injury of the main hepatic duct more than 2 cm from the confluence) that had been repaired intraoperatively with an end-to-end anastomosis over a T-tube nine months before referral. Both patients had an uneventful recovery and were discharged four and five days after surgery. After 2.5 and 4 years of follow-up, both patients are asymptomatic and have normal imaging and laboratory tests. To our knowledge, there is no other report in the literature regarding intraoperative laparoscopic right posterior RYHJ for BDI. Laparoscopic RYHJ for BDI repair in the hands of expert laparoscopic biliary surgeons is feasible and safe, even in very challenging surgical scenarios, as herein reported, offering the benefits of mini-invasive surgery. Future high-quality and long-term comparative studies are necessary to elucidate its potential superiority against the standard open approach

Laparoscopic repair of acute traumatic diaphragmatic hernia with mesh reinforcement: A case report

Introduction and importance: Traumatic diaphragmatic injuries are rare and usually occur after thoracoabdominal trauma. Most patients will have other potentially life-threatening injuries. High index of suspicion is the most important attribute. Unfortunately, it is incorrectly diagnosed in up to 33% of cases. If left untreated, the onset of complications carries mortality rates between 25 and 80%. Case presentation: We report a case of an acute diaphragmatic laceration in a 29-year-old male with thoracoabdominal trauma due to a road traffic accident. Physical examination revealed an absence of normal breath sounds in the left hemithorax. CT-scan confirmed a voluminous left diaphragmatic hernia with omental, gastric, and transverse colon content, so surgical intervention was advised. During laparoscopy, a 15 cm long and 5 cm wide diaphragmatic defect was identified. The hernia was reduced laparoscopically, and the defect repaired with interrupted non-absorbable sutures. As a reinforcement, a visceral contact prosthesis was placed. The patient had an uneventful recovery and after 12-month follow-up he has no evidence of recurrence. Clinical discussion: Diaphragmatic injuries do not close spontaneously. An abdominal approach is recommended as it allows for evaluation of the entire abdomen and treatment of any associated injury. Watertight closure with nonabsorbable suture and in case of large defects, the placement of a mesh on the peritoneal side of the diaphragm is recommended to reinforce the primary repair. Conclusion: Laparoscopic emergency surgery has proved to be effective and safe in selected patients with hemodynamic stability. Patients can expect the benefits of minimal invasive surgery with recurrence rate like the open approach.Fil: Gielis, Manuel. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of General Surgery; ArgentinaFil: Bruera, Nicolás. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of General Surgery; ArgentinaFil: Pinsak, Agustín. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of General Surgery; ArgentinaFil: Olmedo, Ignacio. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of Thoracic Surgery. Department of Thoracic Surgery; ArgentinaFil: Fabián, Paez Walter. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of Thoracic Surgery. Department of Thoracic Surgery; ArgentinaFil: Viscido, German. Universidad Católica de Córdoba. Clínica Universitaria Reina Fabiola. Department of General Surgery; Argentin

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies