Two-stage free latissimus dorsi flap for the management of a voluminous enterocutaneous fistula in a patient with Ehlers-Danlos syndrome: a case report.

Background: Ehlers-Danlos syndrome (EDS) is a rare genetic disorder that causes abnormal collagen structure and production, seriously impacting the quality of connective tissues. Reconstructive surgery can be challenging in affected patients, and additional precautions should be taken for microsurgical transfers. Case Description: This case aimed to describe the management of a 27-year-old man with vascular EDS and a history of heavy smoking who developed a voluminous enterocutaneous fistula after multiple abdominal surgeries. Due to the high surgical risk of flap failure resulting from the patient's condition, the large full-thickness abdominal defect, and the lack of locoregional reconstructive options, a two-stage free latissimus dorsi flap reconstruction was performed. A left myocutaneous free latissimus dorsi flap (sized 10 cm × 25 cm) was transferred and anastomosed to the left superficial femoral artery and the proximal part of the rerouted greater saphenous vein. The flap was folded, sutured to itself, and left in place for 8 days. Once the flap's viability was confirmed, complete small bowel liberation with resection of the enterocutaneous fistula and end-to-end primary anastomosis were performed by the visceral surgeons. The latissimus dorsi flap was unfolded and moved cephalically to cover the defect. No complications were reported on the flap. A fistula recurrence occurred on postoperative day 9 but was successfully addressed within 6 weeks using a combination of nasogastric tube aspiration, somatostatin, antibiotics, and negative pressure therapy. Follow-up at 6 months showed complete wound healing with no further complications. Conclusions: This report suggests the two-stage free flap transfer strategy to manage a voluminous full-thickness abdominal wall defect in a patient with vascular EDS. This approach allowed for optimal tissue coverage and full abdominal restoration while minimizing the risk of complications.

Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video).

OBJECTIVES: Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. METHODS: Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. RESULTS: Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465). CONCLUSIONS: The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.

The Angers CT Score is a Risk Factor for the Failure of the Conservative Management of Adhesive Small Bowel Obstruction: A Prospective Observational Multicentric Study.

BACKGROUND: Identifying the 30% of adhesive small bowel obstructions (aSBO) for which conservative management will require surgery is essential. The association between the previously described radiological score and failure of the conservative management of aSBO remains to be confirmed in a large prospective multicentric cohort. Our aim was to assess the risk factors of failure of the conservative management of aSBO considering the radiological score. MATERIAL AND METHODS: This prospective observational study took place in 15 French centers over 3 months. Consecutive patients experiencing aSBO with no early surgery were included. The six radiological features from the Angers radiological computed tomography (CT) score were noted (beak sign, closed loop, focal or diffuse intraperitoneal liquid, focal or diffuse mesenteric haziness, focal or diffuse mesenteric liquid, and diameter of the most dilated small bowel loop > 40 mm). RESULTS: Two hundred and seventy nine patients with aSBO were screened. Sixty patients (21.5%) underwent early surgery, and 219 (78.5%) had primary conservative management. In the end, 218 patients were included in the analysis of the risk factors for conservative treatment failure. Among them, 162 (74.3%) had had successful management while for 56 (25.7%) management had failed. In multivariate analysis, a history of surgery was not a significant risk factor for the failure of conservative treatment (OR = 0.11; 95%CI = 0-1.23). A previous episode of aSBO was protective against the failure of conservative treatment (OR = 0.36; 95%CI = 0.15-0.85) and an Angers CT score ≥ 5 as the only individual risk factor (OR = 2.39; 95%CI = 1.01-5.69). CONCLUSION: The radiological score of aSBO is a promising tool in improving the management of aSBO patients. A first episode of aSBO and/or a radiological score ≥5 should lead physicians to consider early surgical management.

CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma.

OBJECTIVES: To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS: This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS: CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS: An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS: • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

EUS-Guided Gastroenterostomy in Malignant Gastric Outlet Obstruction: A Comparative Study between First- and Second-Line Approaches after Enteral Stent Placement.

INTRODUCTION: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used in the setting of malignant gastric outlet obstruction (GOO). However, little is known about the role of primary EUS-GE. The aim of the present study is to compare the outcomes of EUS-GE by using the freehand technique as a first- and second-line approach after enteral stenting (ES). METHODS: This is an observational single-center study using a prospectively collected database. All consecutive patients who underwent an EUS-GE using the freehand technique due to malignant GOO were included. Patients with previous gastric surgery, a wire-guided EUS-GE technique, or those presenting without GOO were excluded. The primary outcome was the clinical success, defined as a solid oral intake at 1 week after the procedure (GOO Score, GOOSS ≥ 2). The secondary outcomes were technical success and adverse event (AE) rates. The impact on nutritional parameters was also assessed. RESULTS: Forty-five patients underwent an EUS-GE for all indications. Finally, 28 patients (mean age: 63 ± 17.2 years, 57.1% male) with (n = 13, 46.4%) and without (n = 15, 53.6%) a previous ES were included. The technical success was achieved in 25 cases (89.3%), with no differences between the two groups (92.3% vs. 86.7%, p = 1). The median limb diameter and procedure time were 27 mm (range:15-48) and 37 min. Overall, clinical success was achieved in 22 cases (88%), with three failures due to AEs (n = 2) or peritoneal carcinomatosis (n = 1). The diet progression was quicker in patients with a previous ES (GOOSS at 48 h, 2 vs. 1, p = 0.023), but the GOOSS at 1 week (p = 0.299), albumin gain (p = 0.366), and BMI gain (0.257) were comparable in the two groups. The AE rate was 7.1%. CONCLUSIONS: EUS-GE achieves a high technical and clinical success in patients with GOO regardless of the presence of a previous ES. Patients with previous ES may have a quicker progression of their diet, but the GOOSS and nutritional status in the long term at 1 week or 1 month are comparable. Primary EUS-GE might require fewer procedures and less discontinuation of chemotherapy to achieve a comparable result.

Gastrointestinal tumors in transplantation: Two case reports and review of literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. As most of them harbor a KIT mutation (75%), selective kinase inhibitors are the therapeutic option and show a sustained objective response among patients with metastatic or unresectable GISTs. A well-known higher risk of neoplasm has been described among renal transplant recipients (RTRs). Nevertheless, only few cases of GIST onset among transplant patients have been reported in the literature. CASE SUMMARY: Here, we describe 2 cases of gastric GIST occurring during the follow-up of RTRs. We also review the existing literature concerning GIST occurrence in transplant patients. In total and in association with our 2 cases, 16 patients have been reported. The median age was 59.5 years and 69% were male. With a median tumor size of 45 mm, no patient displayed metastatic dissemination at diagnosis. Time from transplantation to diagnosis was highly variable between 5 mo and 21 years. Histopathological data mostly revealed high risk of progression (43%). Death increased to 29% during follow-up. Surgical treatment was systematically performed when the tumor was operable (94%). The use of adjuvant therapy was uncommon (19%). CONCLUSION: GISTs represent rare but potentially severe malignant complication among transplant patients.

Hybrid retroperitoneal necrosectomy using a triple-port approach under endoscopic guidance.

Complex walled-off necrosis with a retroperitoneal component represent a therapeutic challenge. Although mini-invasive approaches have been described, hybrid procedures combining surgical, endoscopic and radiological techniques have slightly been evaluated. A 58 years-old male presented with a 20-cm infected multilocular walled-off necrosis. First, endoscopic-ultrasound guided cystogastrostomy using a lumen-apposing metal stent with further necrosectomy was performed, but the access to distal retroperitoneal collection was average.

Arterial vascularization of the right colon with implications for surgery.

PURPOSE: During right-sided colectomies, surgeons encounter major anatomical variations at the level of the right colon, leading to morbidity. Due to the confusion surrounding the colonic arterial vessels emerging from the superior mesenteric artery (SMA) to vascularize the right part of the colon, this review aimed to describe the arterial vessels found in the mesocolic structures of the ascending colon, the hepatic flexure and the right transverse colon. METHODS: A review of the literature was performed using the MEDLINE database. Only human studies were included. All dissection, angiographic, arterial cast and corrosion studies were analyzed. RESULTS: This review demonstrates that the right colon, the hepatic flexure and the right transverse colon are vascularized by three significant arteries emerging from the SMA and forming one peripheral paracolic arc: (1) the ileocolic artery (ICA), the most constant vessel (99.8%) with low variability; (2) the right colic artery (RCA), the most inconstant vessel (2/3 of cases) with high variability in its origin; and (3) the middle colic artery (MCA), a constant vessel (95%) with variation in its origin and its number. The marginal artery is almost constant (100%) and represents the only peripheral arterial arc at the level of the right side of the colon. CONCLUSIONS: Three arteries emerging from the superior mesenteric artery exist: the ICA, the RCA and the MCA. The ICA and the MCA are the most constant. Knowledge of this vascular anatomy is essential for performing right-sided colectomies.

Anastomotic Location Predicts Anastomotic Leakage After Elective Colonic Resection for Cancer.

BACKGROUND: Anastomotic leakage (AL) is a potential feared complication after colorectal resection, which is associated with an increased risk of postoperative mortality and frequently requires additional surgery. The aim of this study was to assess major independent risk factors for AL after elective colonic resection for cancer, including anastomotic location. METHODS: Among 1940 consecutive patients referred to our institution for colorectal adenocarcinoma, 1025 patients had elective colonic resection with intraperitoneal anastomosis without diverting stoma. Risk factors were assessed among preoperative, operative, and histological data. RESULTS: Clinical AL was observed in 36 patients (3.5%) with 24 patients requiring revisional surgery (67%). In multivariate analysis, endoscopic impassable tumor and colo-colic or ileo-colic anastomosis were independent risk factors for AL. The occurrence of AL was associated with poor overall (43.1 months vs. 146.4 months; p < 0.001) and disease-free survival (40.5 months vs. 137.3 months; p = 0.003). CONCLUSION: Anastomotic leakage occurs more frequently after colo-colic and ileo-colic anastomosis than after intraperitoneal colorectal anastomosis. The right colectomy appears to be at higher risk of AL, with a greater risk of surgical intervention than after an elective left colectomy. Ileo-colic anastomosis should be avoided in cases of suboptimal conditions.

Visceral Obesity and Open Passive Drainage Increase the Risk of Pancreatic Fistula Following Distal Pancreatectomy.

BACKGROUND: The predictive risk factors of clinically relevant pancreatic fistula (CR-PF) following distal pancreatectomy (DP) remain to be identified. METHODS: This is a retrospective cohort analysis of a single-institution database of patients undergoing DP, taking into account usual demographic, operative, and pathologic variables and visceral fat area (VFA), total muscle area (TMA), and surface muscle index (SMI) measured on preoperative CT scan. The primary end point was CR-PF. All variables associated with a p value < 0.05 on univariate analysis were included in a logistic regression model for multivariate analysis. RESULTS: From 2012 to 2016, 208 patients operated by 4 pancreatic surgeons underwent DP including 32 (15%) who developed CR-PF. Risk factors of CR-PF on univariate analysis were: BMI ≥ 25 kg/m2 (p = 0.050), VFA ≥ 92 cm2 (p = 0.006), laparotomy (p = 0.023), main pancreatic duct dilatation (p = 0.035), open passive drainage (versus closed suction drainage) (p = 0.001), and blood loss ≥ 225 ml (p = 0.001). Sarcopenia did not influence the risk of CR-PF (p = 0.076). On multivariate analysis, VFA ≥ 92 cm2 (OR 3.14; IC 95% (1.18-8.31), p = 0.022), blood loss ≥ 225 ml (OR: 2.72; IC 95% (1.06-6.96), p = 0.037), and open passive drainage (OR 3.72; IC 95% (1.40-9.87) p = 0.008) were three independent predictive factors of CR-PF. A CR-PF risk score was developed, predicting a 0% risk of CR-PF when no risk factors were present and a 39% risk when the 3 risk factors were present. CONCLUSIONS: Visceral obesity, blood loss ≥ 225 ml and open passive drainage significantly increase the risk of CR-PF following DP.

Reconstruction of Bile Duct Injury and Defect with the Round Ligament.

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction.

Pancreaticobiliary Maljunctions in European Patients with Bile Duct Cysts: Results of the Multicenter Study of the French Surgical Association (AFC).

BACKGROUND: Pancreaticobiliary maljunctions (PBMs) are congenital anomalies of the junction between pancreatic and bile ducts, frequently associated with bile duct cyst (BDC). BDC is congenital biliary tree diseases that are characterized by distinctive dilatation types of the extra- and/or intrahepatic bile ducts. Todani's types I and IVa, in which dilatation involves principally the main bile duct, are the most frequent. PBM induces pancreatic juice reflux into the biliary tract that is supposed to be one of the main factors of biliary cancer degeneration, although the diagnostic criteria of PBM that can be either morphological and/or functional are not well defined especially in Western series. OBJECTIVE: The aim of this study was to assess the relative prevalence of PBM in BDC in a large European multicenter study, to analyze the characteristics of PBM and try to propose diagnostic criteria of PBMs based on morphological and/or functional criteria and define the positive, negative predictive values, sensibility and specificity of either criteria. RESULTS: From 1975 to 2012, 263 patients with BDC were analyzed. Among them, 190 (72.2 %) were considered to present PBM. Types I and IVa had a similar rate of PBM association. According to the "AFC classification," 57.2 % had a C-P type, 34.5 % a P-C type and 8.3 % a complex type ("anse-de-seau"). The median length of the common channel in patients with PBM was 15.8 ± 6.8 mm (range 5-40 mm). The median intrabiliary amylase and lipase levels were 65,249 and 172,104 UI/L, respectively. For the diagnostic of PBM, a common channel length of more than 8 mm and an intrabiliary amylase level superior to 8000 UI/L were associated with a predictive positive value and a specificity of more than 90 %. Synchronous biliary cancer had an incidence of 8.7 % in all patients with BDC and PBM 11.1 % in adults. Compared to type IV, the type I BDC was associated with statistically more cancer patients in the presence of PBM. CONCLUSIONS: Characteristics of PBM associated with BDC in Western population are quite close to reported Eastern series. The results suggest considering both the intrabiliary value of amylase >8000 UI/L and a length of a common channel >8 mm as appropriate values for positive diagnosis of PBM.

Impact of previous cyst-enterostomy on patients' outcome following resection of bile duct cysts.

AIM: To analyze the impact of previous cyst-enterostomy of patients underwent congenital bile duct cysts (BDC) resection. METHODS: A multicenter European retrospective study between 1974 and 2011 were conducted by the French Surgical Association. Only Todani subtypes I and IVb were included. Diagnostic imaging studies and operative and pathology reports underwent central revision. Patients with and without a previous history of cyst-enterostomy (CE) were compared. RESULTS: Among 243 patients with Todani types I and IVb BDC, 16 had undergone previous CE (6.5%). Patients with a prior history of CE experienced a greater incidence of preoperative cholangitis (75% vs 22.9%, P < 0.0001), had more complicated presentations (75% vs 40.5%, P = 0.007), and were more likely to have synchronous biliary cancer (31.3% vs 6.2%, P = 0.004) than patients without a prior CE. Overall morbidity (75% vs 33.5%; P < 0.0008), severe complications (43.8% vs 11.9%; P = 0.0026) and reoperation rates (37.5% vs 8.8%; P = 0.0032) were also significantly greater in patients with previous CE, and their Mayo Risk Score, during a median follow-up of 37.5 mo (range: 4-372 mo) indicated significantly more patients with fair and poor results (46.1% vs 15.6%; P = 0.0136). CONCLUSION: This is the large series to show that previous CE is associated with poorer short- and long-term results after Todani types I and IVb BDC resection.

Congenital bile duct cyst (BDC) is a more indolent disease in children compared to adults, except for Todani type IV-A BDC: results of the European multicenter study of the French Surgical Association.

AIM: To compare clinical presentation, operative management and short- and long-term outcomes of congenital bile duct cysts (BDC) in adults with children. METHODS: Retrospective multi-institutional Association Francaise de Chirurgie study of Todani types I+IVB and IVA BDC. RESULTS: During the 37-year period to 2011, 33 centers included 314 patients (98 children; 216 adults). The adult population included more high-risk patients, with more active, more frequent prior treatment (47.7% vs 11.2%; p < 0.0001), more complicated presentation (50.5% vs 35.7%; p = 0.015), more synchronous biliary cancer (11.6% vs 0%; p = 0.0118) and more major surgery (23.6% vs 2%; p < 0.0001), but this latter feature was only true for type I+IVB BDC. Compared to children, the postoperative morbidity (48.1% vs 20.4%; p < 0.0001), the need for repeat procedures and the status at follow-up were worse in adults (27% vs 8.8%; p = 0.0009). However, severe postoperative morbidity and fair or poor status at follow-up were not statistically different for type IVA BDC, irrespective of patients' age. Synchronous cancer, prior HBP surgery and Todani type IVA BDC were independent predictive factors of poor or fair long-term outcome. CONCLUSION: BDC is a more indolent disease in children compared to adults, except for Todani type IV-A BDC.

Todani Type II Congenital Bile Duct Cyst: European Multicenter Study of the French Surgical Association and Literature Review.

OBJECTIVE: The purpose of the study was to analyze clinical presentation, surgical management, and long-term outcome of patients suffering from biliary diverticulum, namely Todani type II congenital bile duct cyst (BDC). BACKGROUND: The disease incidence ranges between 0.8% and 5% of all reported BDC cases with a lack of information about clinical presentation, management, and outcome. METHODS: A multicenter European retrospective study was conducted by the French Surgical Association. The patients' medical records were included in a Web site database. Diagnostic imaging studies, operative and pathology reports underwent central revision. RESULTS: Among 350 patients with congenital BDC, 19 type II were identified (5.4%), 17 in adults (89.5%) and 2 in children. The biliary diverticulum was located at the upper, middle, and lower part of the extrahepatic biliary tree in 11, 4, and 4 patients (58%, 21%, and 21%, respectively). Complicated presentation occurred in 6 patients (31.6%), including one case of synchronous carcinoma. Surgical techniques included diverticulum excision in all patients. Associated resection of the extrahepatic biliary tree was required in 11 cases (58%) and could be predicted by the presence of complicated clinical presentation. There was no mortality. Long-term outcome was excellent in 89.5% of patients (median follow-uptime: 52 months). CONCLUSIONS: According to the present largest Western series of Todani type II BDC, the type of clinical presentation rather than BDC location, was able to guide the extent of biliary resection. Excellent long-term outcome can be achieved in expert centers.