[Biliodigestive anastomosis: indications, complications and interdisciplinary management]

An unusual case of severe gastrointestinal bleeding

We present the case of a 58-year-old female with a history of a bleeding duodenal peptic ulcer. Endoscopic hemostasis was unsuccessful; therefore, a transcatheter arterial embolization of a culprit vessel was performed. She was admitted to the hospital two months later because of obstruction of the common bile duct with cholangitis. Attempts to endoscopically place a biliary stent failed. The treating medical team opted for a surgical choledocho-jejunostomy. After 20 months, she presented with a melena and a severe anemia. Diagnostic work-up revealed portal vein thrombosis with portal cavernoma and bleeding choledocho-jejunostomy varices. The case presents and discusses rare complications of duodenal ulcer disease, as well as possible causes and treatment options.

Interventional treatment of biliodigestive anastomosis leaks with a modified percutaneous transhepatic cholangiodrainage

INTRODUCTION

Biliodigestive leaks are typically caused by an insufficiency at the surgical anastomosis. Biliodigestive anastomosis (BDA) insufficiencies can lead to bilomas, abscesses and vascular erosion in chronic conditions.

MATERIAL AND METHODS

We performed a retrospective analysis of the medical and radiological records of all patients with biliodigestive insufficiency who received interventional treatment between July 2015 and February 2021. Nine patients (three with unilateral drainage and six with bilateral drainage) were treated with a modified percutaneous transhepatic cholangiodrainage (PTCD). Clinical success was considered after complete resolution of the peribiliary collections, absence of bile within the surgical drains, radiological patency of the BDA (contrast medium flowing properly through the BDA and no signs of leakage) and haemodynamic stability of the patient without signs of sepsis.

RESULTS

Clinical success was achieved in all nine patients. No patients required revision surgery to repair their BDA. The mean indwelling drainage time was 34.8±16.5 days. The mean number of interventional procedures performed per patient was 6.6±2.0.

CONCLUSION

Patients who present with BDA insufficiency may benefit from interventional radiological techniques. Our modified PTCD resolved the BDA leak in all nine cases and should be considered as a valuable option for the treatment of patients with this complication. Our technique demonstrated to be feasible and effective.

Leakage of Hepaticojejunal Anastomosis: Reoperation

BACKGROUND

Leakage of a hepaticojejunal anastomosis is a rare event with potential major morbidity. Surgeons must be aware of the technical armamentarium and pitfalls in revisional surgery for hepaticojejunal anastomosis leakage.

METHODS

Review of the available literature and discussion of technical details based on experience and expert opinion.

RESULTS

Early bile leaks as well as failed interventional therapy are indications for reoperation. Almost all reports only mention rates of leakage as a secondary endpoint but do not report details of treatment and outcome. Few authors have compared outcome after reoperation versus interventional approaches in observational studies, with the latter resulting in lower morbidity. The complex and individual situation of the complication makes evidence-based argumentation difficult; this is why personal expert opinions have to be taken into account in this review. The technical aspects and pitfalls of revisional surgery are outlined but represent anecdotal evidence as comparative studies are lacking.

CONCLUSION

Bile leak after bilioenteric anastomosis is a rare condition that requires differentiated workup and therapy. Early leaks usually result from technical problems and are amenable to repair by reoperation. Reoperation technique can only be discussed on a low evidence level.

Surgical management for non-functional pancreatic neuroendocrine neoplasms with synchronous liver metastasis: A consensus from the Chinese Study Group for Neuroendocrine Tumors (CSNET)

Pancreatic neuroendocrine neoplasms (p-NENs) are slowly growing tumors with frequent liver metastasis. There is a variety of approaches to treat non-functional p-NENs with synchronous liver metastasis (LM) which complicates the determination of optimal treatment. Based on updated literature review, we discussed the treatment strategy determinants for p-NEN with LM. According to the resectability of primary tumor, the WHO 2010 grade classification and the radiological type of liver metastasis, the CSNET group reached agreements on a number of issues, including the following. Prior to treatment, biopsy is required to confirm pathology. Liver biopsy is important for more accurate grading of tumor and percutaneous core needle biopsy is more available than EUS-FNA. In patients with unresectable primary, surgical resection for liver-metastatic lesions should be avoided. Curative surgery is recommended for G1/G2 p-NET with type I LM and R1 resection also seems to improve overall survival rate. Cytoreductive surgery is recommended for G1/G2 p-NET with type II LM in select patients, and should meet stated requirements. Surgical resection for G1/G2 p-NET with type III LM and p-NEC with LM should be avoided, and insufficient evidence exists to guide the surgical treatment of G3 p-NET with LM. Liver transplantation may be an option in highly select patients. In addition, the optimal time for surgical approach is still required for more evidence.