Clipping for endoscopic perforations: initial success but late complication requiring surgery.

INTRODUCTION: This response discusses the article by Kim and colleagues entitled "endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients". Iatrogenic colonoscopic perforation, although uncommon, implies serious management problems for endoscopists and surgeons. Nonoperative treatment currently is recommended under certain conditions, and endoscopic clips can primarily close iatrogenic perforations, helping to avoid surgery. Of the 27 colonoscopic perforation cases presented in the article by Kim and colleagues, 16 were managed by endoscopic clipping closure and 11 by primary surgery. Conservative treatment failed for three patients. Only perforation size obtained statistical significance among the nine variables contrasted between the 11 cases with primary surgery and the 13 cases with successful endoscopic clipping. The results for the three patients whose endoscopic closure failed are not reported. AUTHORS' OPINION: The authors of this letter think it would have been interesting if these three patients had been included in the analysis due to the high importance of discovering factors that can predict failure of endoscopic clipping for perforations. CONCLUSIONS: To call attention to possible late complications requiring surgery even when initial conservative management of endoscopic perforation succeeds, the authors of this letter present a case of a colocutaneous (actually, sigmoid-scrotal) fistula in a patient 2 weeks after an apparently successful closure of colonoscopic perforation with an "over-the-scope" clip.

Renoportal Anastomosis and Its Complications: A Complex Case Report.

BACKGROUND: Renoportal anastomosis (RPA) is an effective technique in cases of complex portal vein thrombosis with the presence of a splenorenal shunt. The objective of this report is to describe the possible complications related to RPA. CASE REPORT: A 50-year-old man with alcohol-related and hepatitis C-related cirrhosis and 2 hepatocellular carcinomas underwent liver transplant. He presented a portal vein thrombosis Yerdel IV, a splenorenal shunt, and another shunt between the inferior mesenteric vein (IMV) and the perirectal plexus. During surgery, the flow of the left renal vein was 891 mL/min, and this rose to 1050 mL/min after IMV clamping. RPA was made through iliac vein graft interposition, and the IMV was ligated. Portal flow was 832 mL/min but drastically decreased because of mesenteric root compression. After finishing the liver transplant, a renoiliac graft percutaneous transhepatic stent was put in place. The patient presented graft dysfunction and acute kidney injury. On postoperative day +18, a second stent was put in place because of a thrombosis in the splenomesenteric confluence. The patient subsequently presented partial distal rethrombosis and a pancreaticoduodenal arteriovenous fistula, which required several embolizations. The patient developed ascites, recurrent gastrointestinal bleeding, and persistent bacterial peritonitis. Finally, a modified Sugiura procedure (without splenectomy) was performed, achieving a portal flow of 1800 mL/min. However, the patient developed sepsis and multiorgan failure, and died on postoperative day +70. CONCLUSIONS: Despite long-term patient and graft survival within accepted limits after LT, RPA is a challenging technique not exempt from complications.

Nonsplenorenal Spontaneous Portosystemic Shunts in Liver Transplant Attitude and Outcomes: A Single-Center Series.

BACKGROUND: Management of nonsplenorenal spontaneous portosystemic shunts (NSRSPSS) in liver transplant (LT) is controversial. Reports on the influence of its ligation suggest improvements in morbidity and survival. METHODS: Retrospective study of a single-center series. The objective was to analyze the outcomes and post-LT survival after the closure of NSRSPSS. RESULTS: Between January 2005 and April 2021 a total of 23 patients with NSRSPSS underwent LT. The shunt was superior mesenteric vein-vena cava in 12 (52.2%), inferior mesenteric vein-vena cava in 6 (26.1%), through the left gastric vein in 4 (17.4%), and portocava in 1 (4.3%). Seven patients presented portal vein thrombosis, with thrombectomy being performed in 5. Moreover, 21 patients had portoportal anastomosis, 1 patient required portal reconstruction at the splenomesenteric confluence, and 1 had a coronary-portal anastomosis. The NSRSPSS was closed in 22 cases (95.7%). The mean (SD) portal flow before and after the closure of NSRSPSS was 1395 (572) mL/min and 1773 (583) mL/min (104.4 [47.9] mL/min/100 g and 127.9 [4.9] mL/min/100 g, respectively). Six patients (26.1%) presented primary graft dysfunction, 13 (56.5%) acute kidney injury, and 9 (39%) ascites. Three arterial stenoses (13%), 2 biliary stenoses (8.6%), and 1 intrahepatic portal thrombosis (4.3%) occurred. Median intensive care unit and hospital stay was 5 days (range, 3-8 days) and 15 days (range, 13-21 days). After a mean follow-up of 5.18 (3.2) years, all patients except 1 are alive. CONCLUSIONS: The closure of the NSRSPSS during LT can optimize portal flow, with potential influence in morbidity and survival rates.

[Biliopancreatic diversion and simultaneous resection of a giant ulcerated fatty mass in a patient with body mass index: 75]. / Derivación biliopancreática y resección simultánea de masa adiposa ulcerada gigante en paciente con índice de masa corporal de 75.

Bariatric Surgery is currently the best treatment option for patients with Morbid Obesity and a Body Mass Index ≥ 40 kg/m2. Despite its high rate of postoperative and nutritional complications, biliopancreatic diversion (Scopinaro s procedure) has shown best results in terms of excess weight loss and improving obesity-associated diseases. This technique was performed on a 52-year-old woman (weight = 174 Kg, height = 152 cm, BMI= 75.3 kg/m2), with a classic open access due to anaesthesiologist's indication. During this procedure it was also performed a resection of a giant fatty mass on the inner side of left lower limb, which was ulcerated and infected. Postoperative period was uneventful, excepting wound dehiscence of the leg, requiring re-suturing. Six months after hospital discharge, the patient's percent excess weight loss was 36.98%. In our bariatric surgery series, with more than 400 patients since 2002, this patient was the one with the highest BMI.

Duodenal involvement by seminomatous tumors

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Derivación biliopancreática y resección simultánea de masa adiposa ulcerada gigante en paciente con Índice de Masa Corporal de 75 / Biliopancreatic diversion and simultaneous resection of a giant ulcerated fatty mass in a patient with body mass index: 75

La Cirugía Bariátrica es la mejor opción terapéutica de la obesidad mórbida con índice de masa corporal ≥ 40 kg/m2. A pesar del elevado riesgo de complicaciones post-quirúrgicas y nutricionales que presenta, la derivación biliopancreática de Scopinaro ha demostrado los mejores resultados de pérdida del exceso de peso y reducción de patologías asociadas. Esta fue la técnica realizada en una mujer de 52 años (peso = 174 kg, talla = 152 cm, IMC = 75,3 kg/m2), optando por abordaje vía abierta por indicación anestésica. En el mismo acto operatorio se resecó gran masa adiposa ulcerada y sobreinfectada en muslo izquierdo. El postoperatorio fue favorable, salvo dehiscencia de herida del muslo, que requirió resutura. Seis meses después, el porcentaje de pérdida de exceso de peso es del 36,98%. En nuestra serie de más de 400 enfermos con Cirugía Bariátrica desde el año 2002, esta paciente ha sido la de mayor IMC (AU)

Bariatric Surgery is currently the best treatment option for patients with Morbid Obesity and a Body Mass Index ≥ 40 kg/m2. Despite its high rate of postoperative and nutritional complications, biliopancreatic diversion (Scopinaro s procedure) has shown best results in terms of excess weight loss and improving obesity-associated diseases. This technique was performed on a 52-year-old woman (weight = 174 Kg, height = 152 cm, BMI= 75.3 kg/m2), with a classic open access due to anaesthesiologist's indication. During this procedure it was also performed a resection of a giant fatty mass on the inner side of left lower limb, which was ulcerated and infected. Postoperative period was uneventful, excepting wound dehiscence of the leg, requiring resuturing. Six months after hospital discharge, the patient's percent excess weight loss was 36.98%. In our bariatric surgery series, with more than 400 patients since 2002, this patient was the one with the highest BMI (AU)