Left colon interposition for esophageal reconstruction after perforation by metal blades ingestion: a case report.

Esophageal reconstruction with colonic or jejunal segment is a second choice treatment when the stomach is injured or not adequate for use. These reconstructions, whether pedicled or as free jejunal graft, are technically demanding and they are associated with high rate of morbidity and mortality. Complications are mainly due to insufficient blood supply and therefore anastomotic leak or stricture and graft necrosis. We describe the case of a 51-year-old psychiatric man with diagnosis of esophageal perforation after ingestion of metallic razor blades for suicide intent. The patient was treated at an outside hospital with endoscopic removal of the blades and apposition of endoscopic clips, be cause of esophageal mucosal perforation. Nevertheless, he developed a septic status caused by mediastinitis. The patient underwent several interventions to solve the sepsis and after complete recovery he was referred to our Department for esophageal reconstruction. During surgery we found that the stomach was unavailable for reconstruction, therefore a left colonic interposition pedicled on the left colic vessels was performed through the retrosternal route. During the postoperative course the patient developed acute respiratory failure and suppuration of the cervical wound. The postoperative course was complicated because of the poor compliance of the patient due to his psychiatric disorder. He was discharged in postoperative day (POD) 42 in good clinical conditions, on oral-only diet. Colonic interposition through the retrosternal route after esophagectomy is a technically demanding procedure, associated with high morbidity and mortality, but it is a feasible option when the stomach is not available for reconstruction.

A novel reconstructive strategy for pancreaticoduodenectomy following Roux-en-Y distal gastrectomy.

The rate of pancreaticoduodenectomy (PD) performed for both benign and malignant periampullary diseases has increased. In addition, Roux-en-Y reconstruction after distal gastrectomy for cancer or ulcer is still widely used. Therefore, a surgeon may be confronted with a partially- gastrectomized patient who needs a PD. This is a very challenging circumstance for surgeons because of adhesions, bloodstream, anatomical changes and length of the remnant intestine. In our experience, we performed two pancreaticoduodenectomies after distal gastrectomy in patients with periampullary tumors. We preserve gastrojejunal anastomosis and perform an end-to-side pancreaticojejunostomy (PJ) on the afferent limb of gastrojejunal anastomosis and a termino-lateral hepaticojejunal anastomosis on an independent transmesocolic Roux-en-Y limb. In literature, few cases of PD after distal gastrectomy are reported and most of them consider only PD after Billroth II reconstruction. Many authors have demonstrated pancreaticogastrostomy (PG) is superior to PJ in terms of lower risk of pancreatic and biliary fistula, but it is not possible to anastomose pancreas stump with gastric wall in patients who have been undergone distal gastrectomy. For this reason, we retrospectively review our experience about PD following distal gastrectomy and suggest a novel standardized technique which allow surgeons to benefit from same advantages of a typical PG also in this group of patients.

Complicated duodenal-jejunal diverticulosis: case report.

BACKGROUND: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur. CASE REPORT: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump. CONCLUSION: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.