EUS-Guided Choledocho-duodenostomy Using Lumen Apposing Stent Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Trial (DRA-MBO Trial).

BACKGROUND & AIMS: Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of metal stents in unresectable malignant distal biliary obstruction (MDBO) and the results were conflicting. The aim of the current study was to compare the outcomes of the procedures in a large-scale study. METHODS: This was a multicenter international randomized controlled study. Consecutive patients admitted for obstructive jaundice due to unresectable MDBO were recruited. Patients were randomly allocated to receive EUS-guided choledocho-duodenostomy (ECDS) or ERCP for drainage. The primary outcome was the 1-year stent patency rate. Other outcomes included technical success, clinical success, adverse events, time to stent dysfunction, reintervention rates, and overall survival. RESULTS: Between January 2017 and February 2021, 155 patients were recruited (ECDS 79, ERCP 76). There were no significant differences in 1-year stent patency rates (ECDS 91.1% vs ERCP 88.1%, P = .52). The ECDS group had significantly higher technical success (ECDS 96.2% vs ERCP 76.3%, P < .001), whereas clinical success was similar (ECDS 93.7% vs ERCP 90.8%, P = .559). The median (interquartile range) procedural time was significantly shorter in the ECDS group (ECDS 10 [5.75-18] vs ERCP 25 [14-40] minutes, P < .001). The rate of 30-day adverse events (P = 1) and 30-day mortality (P = .53) were similar. CONCLUSION: Both procedures could be options for primary biliary drainage in unresectable MDBO. ECDS was associated with higher technical success and shorter procedural time then ERCP. Primary ECDS may be preferred when difficult ERCPs are anticipated. This study was registered to Clinicaltrials.gov NCT03000855.

Accessibility of Percutaneous Biopsy in Retrocolic-Placed Pancreatic Grafts With a Duodeno-Duodenostomy.

Duodeno-duodenostomy (DD) has been proposed as a more physiological alternative to conventional duodeno-jejunostomy (DJ) for pancreas transplantation. Accessibility of percutaneous biopsies in these grafts has not yet been assessed. We conducted a retrospective study including all pancreatic percutaneous graft biopsies requested between November 2009 and July 2021. Whenever possible, biopsies were performed under ultrasound (US) guidance or computed tomography (CT) guidance when the US approach failed. Patients were classified into two groups according to surgical technique (DJ and DD). Accessibility, success for histological diagnosis and complications were compared. Biopsy was performed in 93/136 (68.4%) patients in the DJ group and 116/132 (87.9%) of the DD group (p = 0.0001). The graft was not accessible for biopsy mainly due to intestinal loop interposition (n = 29 DJ, n = 10 DD). Adequate sample for histological diagnosis was obtained in 86/93 (92.5%) of the DJ group and 102/116 (87.9%) of the DD group (p = 0.2777). One minor complication was noted in the DD group. The retrocolic position of the DD pancreatic graft does not limit access to percutaneous biopsy. This is a safe technique with a high histological diagnostic success rate.

Endoscopic ultrasound-guided hepaticoduodenostomy versus percutaneous drainage for right intrahepatic duct dilatation in malignant hilar obstruction.

BACKGROUND AND AIM: Endoscopic ultrasound (EUS)-guided biliary drainage is being increasingly performed as an alternative to percutaneous transhepatic biliary drainage (PTBD) to treat malignant hilar obstruction (MHO) after failed endoscopic retrograde cholangiopancreatography (ERCP). However, no study has compared EUS-guided hepaticoduodenostomy (EUS-HDS) with PTBD for right intrahepatic duct (IHD) obstruction after failed ERCP in patients with unresectable MHO. METHODS: We retrospectively reviewed the data of consecutive patients with right IHD obstruction developed by unresectable MHO who underwent EUS-HDS or PTBD after a previous placement of a stent in the left and/or right IHD between March 2018 and October 2021. Technical success, clinical success, stent or tube-related adverse events, frequency of reintervention, and stent patency were evaluated. RESULTS: A total of 42 patients (18 EUS-HDS, 24 PTBD) were analyzed. Both groups did not show significant differences in technical success (EUS-HDS, 94% vs PTBD, 100%; P = 0.429), clinical success (83% vs 83%; P = 0.999), early adverse events (24% vs 46%; P = 0.144), and stent or tube-related late adverse events (29% vs 54%; P = 0.116). During follow-up, the EUS-HDS group had a longer median duration of patency (131 days vs 58.5 days; P = 0.041), and lower mean frequency of reinterventions per patient (0.35 vs 1.92; P = 0.030) than the PTBD group. CONCLUSIONS: EUS-HDS showed comparable efficacy and safety to PTBD for drainage of the right biliary system and produced longer duration of patency and lower frequency of reinterventions in patients with unresectable MHO.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe.

INTRODUCTION: Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. METHODS: Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. RESULTS: The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. CONCLUSIONS: Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Tube Duodenostomy to Treat Large Duodenal Perforation: Our Experience and Literature Review.

Background: Duodenal perforation is a life-threatening condition and ideal approaches for the management of duodenal perforations are nowadays unclear, so numerous variables must be considered. Peptic ulcer disease is the most common disease determining a duodenal perforation, however, there may be other less common causes. Methods: We retrospectively analyzed all the patients who presented at our Division of General Surgery for a Duodenal Perforation, from September 2018 to December 2019. We focused on patients requiring a tube duodenostomy. Five patients were included in this study. Results: Five patients suffering from a duodenal perforation were analyzed and their data collected. All patients were treated with tube duodenostomy, pyloric exclusion and omega loop gastro-enteroanastomosis. The duodenostomy was removed four weeks after surgery. All patients suffered postsurgical complications ranging from wound infection to pneumonitis; the incidence of severe complications was greater in the older patients. We did not record any deaths four months after the operation. Conclusions: The tube duodenostomy is an old and dated procedure but simple to implement, which may require an increase in post-operative hospitalization, but which subsists as an effective and safe way to treat patients in critical conditions.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision.

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

ERCP-related perforation: an analysis of operative outcomes in a large series over 12 years.

BACKGROUND: Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). METHODS: The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. RESULTS: Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). CONCLUSION: Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.

Endoscopic Drainage of Pancreatic Fluid Collections.

Endoscopy has emerged as a mainstay in the management of pancreatic fluid collections (PFCs), representing an important advance in clinical medicine that has significantly improved the risk-benefit ratio of treating this complex patient population. While endoscopic pseudocyst drainage has generally supplanted surgical and percutaneous approaches, the optimal strategy for walled-off necrosis remains variable and multi-disciplinary despite an emerging trend from randomized trials favoring endoscopy. Although several issues pertaining to endoscopic drainage appear to have been settled - such as the use of endoscopic ultrasound - other pressing questions - including the optimal prosthesis and debridement strategy - remain unanswered, and rigorous investigation is needed. This review aims to provide an evidence-based but practical appraisal of the endoscopic drainage of PFCs through the perspective of the author, with an emphasis on relevant clinical and endoscopic considerations and important research questions.

Pancreas transplantation: Advantages of a retroperitoneal graft position. / Trasplante de páncreas: ventajas de la posición retroperitoneal del injerto.

INTRODUCTION: In the 50 years since the first pancreas transplant performed at the University of Minnesota, the surgical techniques employed have undergone many modifications. Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the «native¼ pancreas. We herein present our experience of a modified technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy. METHODS: All pancreas transplantations performed between May 2016 and January 2017 were prospectively entered into our transplant database and retrospectively analyzed. RESULTS: A total of 10 transplants were performed using the retroperitoneal technique (6 men: median age of 41 years [IQR 36-54]). Median cold ischemia times was 10,30h [IQR 5,30-12,10]. The preservation solution used was Celsior (n=7), IGL-1 (n=2), and UW (n=1). No complications related to the new surgical technique were identified. In one patient, transplantectomy at 12h was performed due to graft thrombosis, probably related to ischemic conditions from a donor with prolonged cardio-respiratory arrest. Another procedure was aborted without completing the graft implant due to an intraoperative immediate arterial thrombosis in a patient with severe iliac atheromatosis. No primary pancreas non-function occurred in the remaining 8patients. The median hospital stay was 13,50 days [IQR 10-27]. CONCLUSIONS: Retroperitoneal graft placement appears feasible with easy access for dissection the vascular site; comfortable technical vascular reconstruction; and a decreased risk of intestinal obstruction by separation of the small bowel from the pancreas graft.

Failed primary repair of blunt duodenal injury managed by tube duodenostomy, gastrojejunostomy and a feeding jejunostomy: a case report.

BACKGROUND: The worldwide increase in road traffic crashes and use of firearms has increased the incidence of duodenal injuries. Upper gastrointestinal radiological studies and computed tomography (CT) in resource settings may lead to the diagnosis of blunt duodenal injury. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. Although the majority of duodenal injuries may be managed by simple repair, high-risk duodenal injuries are followed by a high incidence of suture line dehiscence and should be treated by duodenal diversion. CASE PRESENTATION: We report a case of a failed primary repair of a blunt injury to the second part of the duodenum (D2) in a 24-year-old African man. This was successfully managed by a tube duodenostomy, a bypass gastrojejunostomy and a feeding jejunostomy in a low resource setting. CONCLUSIONS: Detailed knowledge of the available operative choices in duodenal injury and their correct application is important. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilised. The technique of tube duodenostomy can be successfully applied to cases of large defects in the second part of the duodenum (D2), failed previous repair attempts and with defects caused by different aetiology. It may remain especially useful as a damage-control procedure in patients with multiple injuries, significant comorbidities and/or haemodynamic instability.

Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -a Survey on Opinion and Experience Among IPEG Members.

PURPOSE: Laparoscopic resection of choledochal cyst (CC) has become a popular approach. As the discussion about optimal treatment and technical strategies continues, we aimed to investigate perspectives of IPEG members. METHODS: An online survey was conducted in 2023 on behalf of the IPEG Research Committee. IPEG members were asked to complete an anonymous questionnaire that included 36 items on the management of CC. RESULT: 148 members responded to the survey (North America:49/Asia:44/Europe:23/South America:21/Others:11) and 116 completed all questions. Most surgeons (92.5%) operate on less than 5 cases annually. Diagnostic tools of choice were Magnetic Resonance Imaging (MRI, 95.9%) and ultrasonography (US, 74.5%). Regarding fusiform-type CC, operative indications were cyst size greater than 10 mm (68.9%), typical symptoms (78.5%), or anomalous pancreatico-biliary junction (63.8%). In unilateral intrahepatic biliary cysts (type IVa) cases, 81.3% of respondents do not perform a simultaneous liver resection with the initial cyst resection. While 22.0% resect the CC at diagnosis, even if asymptomatic, a larger group of surgeons (41%; 49/118) wait until the infant reaches six months. Intraoperative cholangiography and choledochoscopy are performed routinely by 38.9% and 13.7%, respectively. The majority (52.5%) ligates the common bile duct stump just below the CC. Laparoscopic reconstructions are performed by retrocolic hepatico-jejunostomy (48.3%) or hepatico-duodenostomy (45.8%) at similar rates, but when done open, 71.2% of respondents prefer retrocolic hepatico-jejunostomy. For the laparoscopic anastomosis, interrupted sutures with intracorporeal knot tying were most often utilized (48.3%). CONCLUSION: Inidividual pediatric surgeons treat a small number of patients with CC each year. Laparosopic and open reconstruction techniques vary, likely due to technical challenges. LEVEL OF EVIDENCE: III.

Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction.

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

Feeding via duodenostomy can reduce intestinal obstruction after radical resection of esophageal cancer better than jejunostomy.

Background: Enteral nutrition (EN) is superior to parenteral nutrition (PN) in improving the nutritional status of esophageal cancer (EC) patients and accelerating postoperative recovery. Therefore, feeding via jejunostomy (FJ) is currently placed during esophagectomy to maintain the postoperative nutrition supply. However, FJ have some serve complications. The aim of this study was to explore the value of feeding via duodenostomy (FD) in reducing the complications associated with FJ. Methods: In this retrospective cohort study, the clinical data of 154 patients with EC who underwent surgical treatment in our center from January 1, 2020, to June 30, 2020 were collected. A concurrent, nonrandomized control group of 154 patients underwent thoraco-laparoscopic esophagectomy (TLE) was enrolled consisting of 82 males and 72 females. These patients were randomly divided into two groups according to the different ostomy method applied, including 80 cases in the FD group and 74 cases in the FJ group. The ostomy-related complications during the 180-day follow-up and indicators including perioperative nutritional markers, length of stay (LoS), and operative time were recorded. Results: After 1 week, the albumin level in the FD group was noninferior to that in the FJ group (36.8 vs. 36.3 g/L; P=0.792), and the prealbumin level also showed no significant difference (178 vs. 176 g/L; P=0.347). Four weeks later, there was significant difference in levels of albumin (42 vs. 41 g/L; P=0.018) but no significant difference prealbumin (225 vs. 222.89 g/L; P=0.493). The LoS was similar between the 2 groups (7 vs. 7.21 days; P=0.697). In terms of the time of stoma creation, it was significantly longer in the FD group than in the FJ group (20 vs. 12 minutes; P<0.001); however, it did not bring a significant impact on the overall procedure length (240 vs. 230.69 minutes; P=0.057). The incidence of postoperative complications (e.g., intestinal obstruction) was significantly lower in the FD group than in the FJ group (P=0.017). Conclusions: The method of FD is safe, effective and acceptable. It is worthwhile to use in clinic practice.

Infantile choledochal cyst presenting with an epigastric bilioma: An iceberg phenomenon.

INTRODUCTION: Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation, can account for 1.8-7% of cases. In an infant with non-specific abdominal complaints and a vaguely palpable upper abdominal mass, a perforated CC may be overlooked, leading to a delayed or misdiagnosis and a detrimental outcome. CASE PRESENTATION: We describe a 10-month-old girl who presented to the office with upper abdominal pain and associated fullness for two weeks. An abdominal ultrasonogram revealed perihepatic collections and an evident dilatation of the common bile duct. The bile aspirated from the collections prompted pigtail drainage as an emergency. Magnetic resonance cholangiopancreatography later revealed a spontaneously perforated CC with residual bilioma. Elective resection after six weeks, followed by bilio-enteric reconstruction, resulted in an uneventful recovery. CLINICAL DISCUSSION: Biliary peritonitis and localized biliomas are rare forms among the wide range of findings that can accompany CC. Satisfactory outcomes can be achieved with a two-stage procedure that entails biliary drainage with sepsis control, followed by resection of the CC and bilio-enteric reconstruction a few weeks later. CONCLUSION: It is important to be aware of the spectrum of findings that CC may present. We discussed our experience successfully treating a perforated type IVa CC.

Triple Tube Drainage for the Treatment of Complex Duodenal Injury: A Case Report and Literature Update.

Duodenal trauma resulting in perforation is rare and management can be challenging due to injuries in other organs and vascular structures. Primary repair is the preferred option and is technically feasible even in cases with large defects. In more complex injuries with pancreaticobiliary tract involvement, damage control techniques and staged procedures may be required. Triple tube drainage with tube gastrostomy, tube duodenostomy, and feeding jejunostomy can benefit the adequate decompression of the duodenum and protect the primary repair suture line. We report the case of a 35-year-old male patient with perforation in the second part of the duodenum following a gunshot injury, who was managed with primary repair and triple tube drainage.

T-tube Duodenostomy for the Difficult Duodenum.

Tube duodenostomy has been described as a useful technique in the management of difficult duodenum arising from a variety of pathologies. In addition, the use of a t-tube for the duodenostomy presents a resourceful option in the event of Malecot or other such catheter unavailability. The aim of our study is to describe the technique and outcomes associated with this approach. During a six-month period in 2020, t-tube duodenostomies were performed in three patients for duodenal stump perforation: the first case involved a patient with Roux-en-Y esophagojejunostomy anatomy; the second involved duodenal stump closure security following Billroth II gastrectomy for peptic ulcer disease; and the third involved decompression following primary closure of duodenal perforation. All duodenostomies were performed with a t-tube that was trimmed with the back wall divided and then secured via the Witzel approach. The t-tube duodenostomies were performed during the index operations of all patients. No patient required additional operations. There was no mortality. All patients were closely monitored postoperatively with duodenostomies kept in place for six weeks. One patient developed a small leak after a trial of tube clamping, which was managed with continued tube drainage and antibiotics prior to definitive removal. The mean length of stay was 20.3 days with two patients being discharged to rehab. T-tube duodenostomy is a simple technique that helps avoid the blowout of the vulnerable duodenal stump in situations of biliopancreatic limb pathology, ulcerative disease, or injury.

Endoscopic ultrasound guided biliary interventions.

Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5-10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP. This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.

Situs Inversus Totalis in Association With Duodenal Atresia.

Situs inversus totalis is the mirror image transposition of the abdominal-thoracic viscera. Approximately one in every 5,000 to 20,000 live births has situs inversus totalis. Most commonly, it is found incidentally and is asymptomatic. A number of malformations, including cardiac, splenic, and gastrointestinal, have been associated with this condition. Coexistence with duodenal atresia is extremely rare, reported in fewer than 30 cases worldwide and one case in Saudi Arabia. We report a preterm neonate who presented with bilious vomiting. Diagnosis of situs inversus totalis with duodenal atresia type III was established and other anomalies were ruled out. The patient was managed surgically by duodenal-duodenostomy and Ladd's procedure. The report emphasizes the importance of identifying this condition and recognizing the "mirror anatomy" before carrying out an operation. Once the diagnosis is confirmed, surgical intervention must be performed as soon as possible to prevent complications.

Annular pancreas mimicking hypertrophic pyloric stenosis in a female infant.

Annular pancreas is a rare congenital intestinal obstruction to be found in infants. It is characterized by nonbilious vomiting, abdominal distention, and feeding intolerance that share similar symptoms with other intestinal obstructions. We reported a case of 11-month-old female infant with a history of nonbilious vomiting after coughing as much as 6 times per day 1 day before admission. The patient had an incorrect provisional diagnosis of hypertrophic pyloric stenosis based on ultrasound. Later on, an upper gastrointestinal series showed dilatation of the second part of the duodenum which was successfully treated by a duodenostomy during laparotomy procedure. It is suggested that treating an intestinal obstruction needs a further investigation when the symptoms were continuously repeated.