Management of the injured bowel: preserving bowel continuity as a gold standard.

BACKGROUND: Management of bowel traumatic injuries is a challenge. Although anastomotic or suture leak remains a feared complication, preserving bowel continuity is increasingly the preferred strategy. The aim of this study was to evaluate the outcomes of such a strategy. METHODS: All included patients underwent surgery for bowel traumatic injuries at a high volume trauma center between 2007 and 2017. Postoperative course was analyzed for abdominal complications, morbidity and mortality. RESULTS: Among 133 patients, 78% had small bowel injuries and 47% had colon injuries. 87% of small bowel injuries and 81% of colon injuries were treated with primary repair or anastomosis, with no difference in treatment according to injury site (p = 0.381). Mortality was 8%. Severe overall morbidity was 32%, and abdominal complications occurred in 32% of patients. Risk factors for severe overall morbidity were stoma creation (p = 0.036), heavy vascular expansion (p = 0.005) and a long delay before surgery (p = 0.023). Fistula rate was 2.2%; all leaks occurred after repairing small bowel wounds. CONCLUSION: Primary repair of bowel injuries should be the preferred option in trauma patient, regardless of the site-small bowel or colon-of the injury. Stoma creation is an important factor for postoperative morbidity, which should be weighed against the risk of an intestinal suture or anastomosis.

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.

Antroduodenectomy with Gastroduodenal Anastomosis: Salvage Emergency Surgery for Complicated Peptic Ulcer Disease--Results of a Double Institution Study of 35 Patients.

BACKGROUND: Endoscopic and interventional techniques are currently the mainstay of management of bleeding duodenal ulcer. As well, for patients with perforated duodenal ulcer, laparoscopic simple closure is nowadays usually performed. Although indications for emergency antroduodenectomy have declined, this procedure is still necessary as a salvage option when conservative management has failed or is not practicable. Our study aimed to evaluate indications and results of antroduodenectomy with gastroduodenal anastomosis in current practice and to examine the factors that predict operative outcomes. METHODS: All patients who underwent emergency antroduodenectomy with gastroduodenal anastomosis in two surgical care departments specialized in emergency digestive surgery were studied from 2000 to 2015. RESULTS: Thirty-five patients (27 males, 77 %) with a median age of 68 years (20-90) underwent emergency antroduodenectomy with gastroduodenal anastomosis. Indications were bleeding and perforated duodenal ulcer in 24 and 11 patients, respectively. The overall complication rate was 69 %, especially because of a high rate of medical complications (57 %). Only two patients (6 %) required reoperation for anastomotic leakage. The overall mortality rate was 40 % (n = 14). According to the univariate analysis, age >70, >3 comorbidities, ASA score >2, and postoperative medical complications were associated with an increased risk of in-hospital mortality. In the multivariate analysis, age and ASA score remained independent risk factors. No recurrence of complicated duodenal disease was observed. CONCLUSION: Antroduodenectomy with gastroduodenal anastomosis is a safe and effective long-term strategy, with a low and acceptable rate of surgical complications, for complicated duodenal ulcer not responding to conservative measures.