Introduction Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. Objective The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). Methods We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. Results Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66 years. The median time to diagnosis of anastomotic leak was 10 days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). Conclusions Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.
Appendiceal intussusception is an rare diagnosis that may be found on imaging or at the time of surgery, as seen in this case of a 33-year-old female presenting with gastrointestinal symptoms. Images are presented with differential diagnosis as well as treatment options. Case reportA 33-year-old white female presented with a several months' history of left lower-quadrant pain most notable after menstrual cycles. This was associated with episodes of intermittent loose stools alternating with constipation. Past medical history was significant for hypertension, anxiety and asthma. Previous surgical history includes a tubal ligation approximately 5 years earlier. On physical examination, her general condition was good and her abdomen was soft, although some tenderness was exhibited in the right lower quadrant. Laboratory tests and a urinalysis were grossly normal with a white cell count of of 9,990/mm 3 .The patient underwent a colonoscopy as part of the workup for her abdominal pain, at which time a lesion was discovered in the lumen of the appendix (Fig 1). The lesion was suspicious for a polyp or mucocele, which was benign on superficial cold biopsy. A follow-up abdominal computed tomography (CT) scan showed dilated, thickened appendix impinging on the cecum (Fig 2). After discussion with the patient regarding the possibility of mucocele, among other diagnoses, she agreed to proceed with a laparoscopic resection. A shortened, thickened appendix and cecum were dissected free from surrounding structures and lateral attachments to the abdominal wall were freed. A laparoscopic partial cecectomy with appendectomy was performed. The specimen consisted of an appendix measuring approximately 5cm in length by 1.7cm in diameter. Final pathology was read as benign appendix with intussusception in the setting of intramural endometriosis. This was negative for dysplasia and malignancy. The patient did well postoperatively and was discharged on hospital day two, tolerating a regular diet. DiscussionAppendiceal intussusception is an uncommon diagnosis, with an estimated incidence reported by Collins as 0.01%. 1 Clinical presentation of appendiceal intussusception can vary from crampy lower abdominal pain to acute appendicitis. 2 In this case, the patient had symptoms suggestive of a
In the absence of definitive data, we sought to determine the consensus on the contribution of adhesions to pelvic pain. Impressions about the role of adhesion location, extent, and severity of pelvic pain, were surveyed among 13 gynaecological surgeons. They were asked whether adhesions covering specific organs to a varying extent would be likely to cause pain significant enough to require pain medication, or to lead a woman to alter her normal activities, and when they would recommend surgery to reduce pelvic pain. Women with dense vascular adhesions covering all of the uterus but not the bowel or adnexal structures were thought to have a 49 ± 9% likelihood of having pelvic pain; this fell to a 34 ± 7% and 18 ± 5% likelihood of pain if 60% or 20%, respectively, of the uterus was involved with adhesions. Similar observations were made for adhesions involving the posterior cul‐de‐sac and large bowel. However, adhesions involving the anterior cul‐de‐sac were thought to be less likely to cause pain. Women with total involvement of both tubes and ovaries with dense, vascular adhesions were thought to be 60 ± 9% likely to have pelvic pain; reduction in extent of adhesions to 50% or 25% reduced the prediction of pain to 38 ± 5% and 21 ± 3%, respectively. In contrast, filmy adhesions to both tubes and ovaries, were thought to cause pain in 46 ± 9%, 26 ± 5%, and 13 ± 3% of women, respectively, according to extent. Half the surgeons said they would recommend surgery for patients with pain and dense adhesions involving 15% of both tubes and ovaries; 10 recommended surgery if it was known that adhesions involved 100% of both ovaries and tubes. Surgeons were only slightly less likely to recommend surgery for pain relief for adhesions involving either both tubes or both ovaries or for pain associated with unilateral tubal and ovarian adhesions. For bilateral tube and ovary adhesions, surgery was equally likely to be recommended for relief of pain when adhesions were cohesive and dense; for adhesions which were filmy, surgery was less likely to be recommended. For dense adhesions involving 20%, 40%, 60%, and 80% of the uterine surface, surgery was recommended by 42%, 58%, 83% and 92% of surgeons, respectively. Posterior cul‐de‐sac involvement resulted in recommendation of surgery by 50%, 83%, 92%, and 100% of surgeons, respectively; however, for corresponding amounts of anterior cul‐de‐sac adhesions, surgery was recommended by only 17%, 33%, 67%, and 75% of surgeons. (1) Adhesions are frequently considered to be a cause of pelvic pain; (2) the likelihood of discomfort is related to location, extent, and to a lesser degree, the severity of adhesions, and (3) adhesiolysis is thought to provide the potential for pain relief.
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