Dehydrated Human Amnion-Chorion Membrane (Placenta) Reinforcement of Esophagectomy Anastomosis.

An anastomotic leak is a potentially fatal complication after esophagectomy. This report describes the use of a dehydrated human amnion-chorion membrane (dHACM) placenta allograft patch for reinforcement of an esophageal anastomosis. The anastomotic technique was a modified Orringer procedure through a right thoracotomy (Ivor Lewis procedure). The anastomosis was reinforced with dHACM placenta allograft. Use of the allograft prevented anastomotic leaks and loss of gastrointestinal integrity. Early results are promising.

WITHDRAWN: Dehydrated Human Amnion/Chorion Membrane (Placenta) Reduces Anastomotic Leaks after Esophagectomy.

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Creation of gastric conduit free-graft with intraoperative perfusion imaging during pancreaticoduodenectomy in a patient post esophagectomy.

As surgery becomes more successful for complicated malignancies, patients survive longer and can unfortunately develop subsequent malignancies. Surgical resection in these settings can be treacherous and manipulations of the patient's anatomy need to be closely considered before embarking on major operations. We report a case of a patient who survived esophageal resection for locally advanced esophageal cancer only to develop a new pancreatic head malignancy. Careful upfront planning allowed for a successful resection with an uncomplicated recovery. She underwent open pancreaticoduodenectomy, and to maintain perfusion to the gastric conduit a microvascular anastomosis of the gastroepiploic pedicle was performed to the middle colic vessels. Intraoperative fluorescent imaging was used to evaluate the anastomosis as well as gastric and duodenal perfusion during the case.

Retrospective comparison of robot-assisted minimally invasive versus open pancreaticoduodenectomy for periampullary neoplasms.

BACKGROUND: As with other open procedures now routinely performed using laparoscopy, minimally invasive pancreaticoduodenectomy (MIPD) may result in decreased pain, fewer wound complications, and accelerated recovery. However, when used for periampullary cancers, it is also important to assess if MIPD offers comparable oncologic outcomes. METHODS: Technical and perioperative outcomes were compared between patients with a preoperative diagnosis of periampullary neoplasm offered MIPD or open pancreaticoduodenectomy (OPD) from November 2009 to July 2011. RESULTS: Fifty-six consecutive MIPD and OPD (28 each) procedures were analyzed. Comparing MIPD to OPD, significant differences included longer median procedure time (431 vs 410 min, p = .04) and fewer median lymph nodes harvested (15 vs. 20, p = .04). R0 resection rate tended to be lower (63 vs. 88%, p = .07) as well as surgical site infections (18 vs. 43 %, p = .08). Clinically significant pancreatic fistula rate was the same between groups (21%). Other outcomes such as narcotic pain medication use, length of stay, and 30-day readmission rates were also similar. CONCLUSIONS: MIPD is feasible with comparable technical success and outcomes to OPD. However, there is a learning curve to the procedure and further experience and prospective study will be required to better establish the oncologic efficacy of MIPD to open resection.

Splenic vein turndown repair in superior mesenteric vein trauma: a reasonable alternative.

OBJECTIVE: To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions. DESIGN OF STUDY: Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study. RESULTS: Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma. CONCLUSION: There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.

Analysis of respiratory complications after minimally invasive esophagectomy: preliminary observation of persistent aspiration risk.

Minimally invasive (MI) esophageal resection (ER) has the theoretical advantage of reduced postoperative complications compared with standard ER. However, the impact of MIER on rates and severity of pulmonary complications is unclear. Four patients underwent laparoscopic gastroesophageal mobilization and resection followed by gastric pull-up and cervical esophageal anastomosis (MIER). Videofluoroscopic swallowing studies (VFSS) assessed pharyngolaryngeal function postoperatively. All postoperative complications were documented. Each MIER was completed successfully without intraoperative complications. Mean operative time was 4.3 +/- 2 h. Postoperatively, VFSS detected laryngeal penetration, vocal cord paralysis, and/or aspiration in three patients, two of whom experienced severe respiratory complications. MIER patients are susceptible to aspiration, likely due to transient denervation of the pharynx and laryngeal structures. Following MIER, aggressive pulmonary toilet and aspiration precautions are emphasized to reduce pulmonary complications. Furthermore, serial evaluation of deglutition is encouraged to guide the safe and appropriate resumption of oral feeding.

Laparoscopic hepatic resection using saline-enhanced electrocautery permits short hospital stays.

Laparoscopic hepatic resection has been reported to yield lower morbidity and shorter hospital stays than open resection. However, few studies have evaluated patient and technical factors associated with short hospital stays. We conducted a retrospective review of patients undergoing laparoscopic hepatic resection at our institution from May 2002 to February 2004. Patient and operative factors were analyzed with respect to time to discharge. Seventeen patients underwent 10 wedge resections and seven segmentectomies or bisegmentectomies. There were no mortalities, conversions to open procedure, clinically evident bile leaks, or transfusion requirements. Eleven patients were discharged within 24 hours. When compared with those discharged later than 24 hours, there were fewer patients with advanced ASA classification (0 versus 3 in ASA class 3, p < 0.05). With appropriate patient selection, laparoscopic hepatic resections may be safely performed, result in short hospital stays, and are facilitated by technologies such as saline-enhanced electrocautery and endoscopic ultrasound. Information reflected in advanced ASA class may predict patients unlikely to be discharged within 24 hours.

Case report: serial percutaneous cholangioscopy with laser ablation for the management of locally recurrent biliary intraductal papillary mucinous tumor.

We present a case of serial cholangioscopic laser fulguration of a biliary recurrence of pancreatic intraductal papillary mucinous tumor in a 76-year-old man. Through established percutaneous biliary drain tracts, the aseptic use of a standard 6.9 F ureteroscope and holmium laser fiber facilitated visual ablation within the biliary tree. Quarterly cholangioscopic laser ablation provided safe and effective local control without biliary infectious complications. This case appears to be the first treatment of recurrent intrabiliary intraductal papillary mucinous tumor by serial antegrade choledocoscopy and laser photocoagulation. Effective local control appears possible with minimal morbidity. Standard ureteroscopic equipment facilitates safe and efficient percutaneous antegrade choledocoscopy.