A modified single jejunal loop reconstruction by performing proximal gastrojejunostomy after Whipple's pancreticoduodenectomy in a low-volume hospital.

BACKGROUNDS/AIMS: It is needed to ensure bowel and biliary tract continuity after pancreaticoduodenectomies. It is possible to find a variety of reconstruction methods in literature. METHODS: We realized a modified reconstruction method by performing proximal gastrojejunostomy, on a jejunal loop after Whipple's pancreticoduodenectomy, with surgical succes in 7 patients with pancreatic head or periampullary carcinomas in a low-volume hospital 2009-2017. RESULTS: A modified jejunal loop reconstruction method, was performed in 7 patients after Whipple's pancreaticoduodenectomy. We had no perioperative mortality. Pancreatic fistula treated with medical attempts was observed following post-operative pancreatitis in a patient. No marginal ulceration was observed. Delayed gastric emptying was not observed, except for post-operative acute pancreatitis and pancreatic fistula developing in a patient. CONCLUSIONS: A modified reconstruction method by performing proximal gastrojejunostomy on a jejunal loop, can be considered as alternative reconstructive surgical procedure after pancreaticoduodenectomy.

A double row epiploicoplasty for primary closure of free perforated sigmoid diverticulitis / Epiploicoplastia de duas fileiras para fechamento primário de diverticulite perfurada livre de sigmoide

ABSTRACT Acute free perforation of the sigmoid diverticulitis is an emergency surgical intervention required condition. Although the sigmoid resection and temporary end colostomy or abdominal lavage and drainage are the most commonly used surgical methods for its treatment, the most effective surgical method has not been established yet. We applied a different surgical method for the surgical treatment of free perforation of acute sigmoid diverticulitis outside of these surgical procedures. A double row epiploicoplasty was performed for surgical treatment of free perforated sigmoid diverticulitis with surgical success in a patient who had concominant serious diseases.

RESUMO A perfuração livre aguda da diverticulite de sigmoide é um problema que exige intervenção cirúrgica de emergência. Embora a ressecção de sigmoide e a colostomia de extremidade temporária ou a lavagem e drenagem abdominal sejam os métodos cirúrgicos mais comumente utilizados para o seu tratamento, o método cirúrgico mais eficaz ainda não foi estabelecido. Aplicamos um método cirúrgico diferente para o tratamento cirúrgico de perfuração livre de diverticulite de sigmoide aguda fora desses procedimentos cirúrgicos. Uma epiploicoplastia de duas fileiras foi realizada para o tratamento cirúrgico de diverticulite perfurada livre de sigmoide com sucesso cirúrgico em um paciente com doenças graves concomitantes.

Anatomical, surgical and clinical considerations related with operative procedures performed in combined abdominal and perineal approaches for the treatment of lower rectal cancer / Considerações anatômicas, cirúrgicas e clínicas relacionadas a procedimentos operatórios realizados em abordagens abdominais e perineais combinadas para o tratamento de câncer retal baixo

ABSTRACT Background and aim: Combined abdominal and perineal (anterior or posterior) approaches used in lower rectal cancer surgery have been based on similar anatomical and surgical features. The main aim of this manuscript is to evaluate the results of combined approaches performed for lower rectal cancer and to comment on surgical and anatomical features of the operations. Methods: Anatomical, surgical and clinical details of the combined abdominal and perineal approaches performed for lower rectal cancer were evaluated by reviewing published articles about this subject in English in PubMed, EMBASE, Cochrane library and other sources. Results: Ten articles including case reports were found on combined abdominal and perineal approaches published between 2003 and 2015. There were 83 patients who had been operated by using combined approaches for lower rectal cancer surgical treatment in these series. While the circular resection margine positivity had not been reported in the cases; the mean Wexner continence score had been reported between 5 and 5.5. The most important dissatisfaction of these surgical methods has been reported as persistent perineal fistulas encountered 9.6% of the patients in average in the postoperative period. Conclusion: The APPEAR (Anterior Perineal Plane for Ultra Low Anterior Resection) procedure is the most known surgical procedure in which the combined abdominal and anterior perineal approach is used. Combined abdominal and perineal (anterior or posterior) approaches can be described as surgical procedures in which the sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques are performed.

RESUMO Experiência e objetivo: As abordagens abdominais e perineais (anterior ou posterior) combinadas, utilizadas na cirurgia para o câncer retal baixo, têm se baseado em características anatômicas e cirúrgicas similares. O objetivo principal desse estudo é avaliar os resultados de abordagens combinadas realizadas em pacientes com câncer retal baixo e também comentar as características cirúrgicas e anatômicas das operações. Métodos: Avaliamos os detalhes anatômicos, cirúrgicos e clínicos das abordagens abdominais e perineais combinadas para o câncer retal baixo por meio de uma revisão dos artigos publicados no idioma inglês sobre esse tópico em PubMed, EMBASE, Cochrane Library e outras fontes. Resultados: Encontramos 10 artigos, inclusive relatos de casos, sobre abordagens abdominais e perineais combinadas publicados entre 2003 e 2015. Nessas séries, 83 pacientes no total tinham sido operados com o uso de abordagens combinadas para o tratamento de câncer retal baixo. Embora a positividade para ressecção circular da margem não tenha sido informada nos casos, foi relatado um escore de Wexner para continência que variou de 5-5,5. A insatisfação mais importante relatada com esses métodos cirúrgicos foi a persistência de fístulas perineais, em uma média de 9,6% dos pacientes no período pós-operatório. Conclusão: APPEAR é o procedimento cirúrgico mais conhecido; com seu uso, emprega-se a abordagem abdominal/perineal anterior combinada. As abordagens abdominais e perineais (anterior ou posterior) combinadas podem ser descritas como procedimentos cirúrgicos nos quais são realizadas técnicas de dissecção extra-esfinctérica (com preservação do esfíncter) e de excisão esfinctérica segmentar proximal.

Sphincter-saving extrasphincteric rectal dissection and proximal segmental sphincteric excision techniques by using combined abdominal and transvaginal anterior perineal access in female patients who have lower rectal cancer (Transvaginal low anterior rectal resection) / Técnicas de dissecção retal extra-esfincteriana e de excisão esfincteriana segmentar proximal com preservação de esfíncter com o uso de acesso abdominal e perineal anterior transvaginal combinado em mulheres portadoras de câncer retal baixo (Ressecção anterior do reto baixa por via transvaginal)

ABSTRACT Background: Combined abdominal and transvaginal anterior perineal approaches have been used as an alternative surgical method for the surgical treatment of the lower rectal cancer. The main aim of this paper is to describe the surgical stages of the combined abdominal and transvaginal approaches performed for lower rectal cancer, especially in transvaginal anterior perineal stage. Method: We have performed sphincter-saving surgical operations by using transvaginal anterior perineal access by combining with the abdominal access in four female patients who had lower rectal cancer. Results: Sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques were performed in four female patients operated with combined abdominal and transvaginal anterior perineal approach. All patients were found to have continence. Postoperatively, one patient was converted to abdominoperineal rectal amputation due to the detected distal resection margin positivity. Conclusion: Transvaginal anterior perineal access provides the extrasphincteric rectal dissection possibility in the ischioanal fossa. Therefore, the combined abdominal and transvaginal anterior perineal approaches have been based on the different anatomical and surgical features when compared to intersphincteric dissection technique which is the most common used surgical procedure in lower rectal cancer surgery.

RESUMO Introdução: Uma combinação de abordagens abdominal e perineal anterior transvaginal tem sido empregada como método cirúrgico alternativo para o tratamento cirúrgico do câncer de reto baixo. O principal objetivo do presente artigo é a descrição dos estágios cirúrgicos das abordagens abdominal e transvaginal combinadas realizadas para câncer de reto baixo, especialmente no estágio perineal anterior transvaginal. Método: Realizamos operações cirúrgicas com preservação de esfíncter com o uso do acesso perineal anterior transvaginal, em combinação com o acesso abdominal, em quatro pacientes mulheres portadoras de câncer de reto baixo. Resultados: Realizamos técnicas de dissecção extra-esfincteriana e de excisão esfincteriana segmental proximal com preservação de esfíncter em quatro pacientes operadas com uma combinação de abordagens abdominal e perineal anterior transvaginal. Todas as pacientes estavam continentes. Em uma paciente, houve necessidade de conversão para amputação retal abdominoperineal, por ter sido detectada, no pós-operatório, positividade na margem de ressecção distal. Conclusão: O acesso perineal anterior transvaginal torna possível a dissecção retal extra-esfincteriana na fossa isquioanal. Portanto, as abordagens combinadas abdominal e perineal anterior transvaginal se baseiam em diferentes características anatômicas e cirúrgicas, em comparação com a técnica de dissecção interesfincteriana, que é o procedimento cirúrgico de uso mais comum na cirurgia para câncer de reto baixo.

Secondary gallbladder hydatidosis and nonfragmanted germinative membrane sourced obstructive jaundice caused by intrabiliary ruptured hepatic hydatid cyst (a case report): two rare complication of the intrabiliary ruptured hepatic hydatid cyst.

Intrabiliary rupture is the most frequently seen complication of the hepatic hydatid cysts. Obstructive jaundice can be seen as a complication of the intrabiliary ruptured hepatic hydatid cysts due to the migrated cystic content into bile ducts. In this study, we present two rare complications seen in a patient who has intrabiliary ruptured hepatic hydatid cyst. Obstructive jaundice and secondary gallbladder hydatidosis depending on to the intrabiliary ruptured hepatic hydatid cyst in a 58-year-old man patient were diagnosed and treated. A large choledochal nonfragmanted germinative membran was found in the choledochus as the reason of biliary obstruction. Hepatic hydatid cyst is a world-wide disease. Intrabiliary rupture must be kept in mind in the patients who has hepatic hydatid cyst and biliary tract problems.

The techniques of sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision in low rectal cancer surgery.

OBJECTIVE: To define the techniques used in lower rectal cancer surgery, by transvaginal and transperineal approach; extrasphincteric dissection, proximal segmental sphincteric excision and transsphincteric rectal resection. MATERIAL AND METHODS: Between 2007 and 2013, 7 patients (4 female, 3 male with lower rectal cancer were operated by sphincter-saving extrasphincteric disection and proksimal sphincteric excision techniques. After completion of the rectosigmoid dissection and total mesorectal excision up to the puborectal muscle level; extrasphincteric rectal dissection, transsphincteric rectal resection and ultra-low coloanal anastomosis were performed by using the transvaginal and transperineal approach in the sublevator phase of the operation. RESULTS: Seven patients were operated with sublevator access for lower rectal cancer. Bowel contiunity has been provided in all patients. One patient died due to surgical complications in the early postoperative period. One patient deceveloped anastomotic leakage and there were two patients with anastomotic stricture. Circumferential resection margin and tumoral perforation were found negative in all of the patients. Tumoral deposits at the distal resection line was observed in one patient. CONCLUSION: The techniques of sublevator rectal resection may be considered as an alternative sphincter-saving surgical method, especially in lower rectal cancer surgery.

Dog ear graft for closure of the large skin defects in meningomyelocele surgery.

The closure of large skin defects is one of the challenging problems in plastic surgery and neurosurgery. Different reconstructive surgical techniques can be used for closing large skin defects. We report a technique for closing the large skin defects after the surgical repair of meningomyeloceles.

A modified posterior pelvic exenteration technique in a woman: (a simplified method with using transvaginal way).

We represent a simplified surgical method for posterior pelvic exenteration in a woman by using the transvaginal way in addition to classic abdominal approach. A modified posterior pelvic exenteration technique was performed in a patient with bulky pelvic tumor. The transvaginal way was used for the deep perineal dissection when the abdominal dissection was arrested. An ultralow coloanal anastomosis was completed by using the transvaginal way. After the recovery period, the patient was discharged from hospital without any complication. The transvaginal access should be reminded in the circumstances of the abdominal dissection arrested in posterior pelvic exenteration operations in women.