Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.
A 37-year-old woman with a past medical history significant for congenital deafness and surgically repaired Tetralogy ofFallot presented with three day history of nausea, vomiting, fever, chills, dyspnea, and lower extremity weakness and physicalexamination notable for Janeway lesions. Peripheral blood and urine cultures were positive for methicillin sensitive Staphlococcusaureus. Transesophageal echocardiogram was consistent with mitral valve endocarditis. Computed tomography images of thechest, abdomen and pelvis demonstrated septic emboli to multiple organs including lungs, liver, spleen and kidneys. Salinecontrast study was negative for a patent foramen ovale, or residual ventricular septal defect. Thus, effectively ruling out left toright intracardiac shunt as the cause of pulmonary septic emboli from mitral valve endocarditis. Moreover, cardiac MRI did notshow any evidence of right sided endocarditis. Therefore, we believe the source of septic pulmonary emboli from mitral valveendocarditis to be through the bronchial arteries. The extent of septic emboli to various organs and the precise mechanism ofpulmonary emboli from left sided endocarditis in a patient with surgically altered cardiac anatomy make this case unique.
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