» Anterior glenohumeral instability is a complex problem that requires careful attention to osseous and soft-tissue lesions in order to treat it effectively.» The arthroscopic soft-tissue Bankart repair is considered first-line treatment for patients with anterior glenohumeral instability. However, recent long-term outcome studies have shown surprisingly high failure rates, specifically in the setting of anterior glenoid bone loss.» The definition of “critical” glenoid bone loss that cannot be overcome by a soft-tissue procedure alone continues to evolve and may in fact be lower than the previously published total of 20%.» Arthroscopic reconstruction of the anterior glenoid margin can be performed with either autograft or allograft. The arthroscopic Latarjet procedure has emerged as a reliable and effective technique for autograft augmentation, while the distal aspect of the tibia appears to be a promising source of allograft.
Dear Editor:Total proctocolectomy (TP) with ileal pouch-anal anastomosis (IPAA) is currently the surgical treatment of choice for medically refractory ulcerative colitis (UC), familial adenomatous polyposis (FAP), indeterminate colitis, and selected cases of Crohn's disease (CD) [1]. In contrast to the low mortality rate after IPAA (less than 1 %), the morbidity rate occurs in 19 to 54 % of the cases [2]. Complications after this procedure can be classified as early (anastomotic leaks, pelvic sepsis, pouch bleeding) and late complications (pouchitis, pouch fistulae, small bowel obstruction, malignant transformation, and pouch failure) [2]. The most overall common complication is pouchitis. In this letter, we describe a case of a recurrent volvulus of the ileal pouch, an extremely rare complication described only once before in the literature [3]. Case reportA 36-year-old female with a history of Gardner's syndrome that required laparoscopic TP and an ileal J-pouch 9 years earlier, presented to the emergency room (ER) with generalized abdominal pain. She had no nausea, vomiting, or fever. Physical examination showed abdominal distension with no signs of peritonitis. Blood tests came out normal, but the abdominal X-ray revealed important small bowel distention and air fluid levels. Computed tomography (CT) showed distention of the distal ileum proximal to the pouch-anal anastomosis and in the pelvis a whirl image including part of the pouch and mesenteric vessels. These findings suggested volvulus of the ileal pouch. Endoscopic decompression was tried unsuccessfully. Emergency laparotomy was then performed revealing volvulation of the J-pouch and herniation through a mesenteric defect. Reduction and devolvulation followed; fortunately, the aspect of the pouch was viable so no resection was needed. Suture of the mesentery defect and pouchpexy to the retroperitoneum took place in order to prevent further volvulation. The postoperative course went without complications, and the patient was discharged few days after.Ten months later, the patient presented to the ER showing the exact same symptoms. The abdominal X-ray showed important small bowel distension. CT scan demonstrated a whirl image in the pelvis, which once more included part of the pouch and mesentery, conditioning important proximal distension of the ileum. Findings were compatible with new pouch volvulus. Again, endoscopic decompression was tried unsuccessfully and the patient underwent emergency laparotomy. At the operating room, volvulus of the J-pouch with recurrent herniation through a new mesenteric defect was confirmed. Reduction and closure of the defect were performed. This time, pouchpexy was not possible due to the gigantic size of the pouch limiting access to the retroperitoneum or other anchoring points. A rectal tube was placed to help reduce intestinal distension. Interestingly, adhesions were found neither in this operation nor in the first one. The patient had an uneventful postoperative course and was discharged a few days after surgery.Af...
Summary Enteric complications remain a major cause of morbidity in the post‐transplant period of pancreas transplantation despite improvements surgical technique. The aim of this single‐center study was to analyze retrospectively the early intestinal complications and their potential relation with vascular events. From 2000 to 2016, 337 pancreas transplants were performed with systemic venous drainage. For exocrine secretion, intestinal drainage was done with hand‐sewn anastomosis duodenojejunostomy. Twenty‐three patients (6.8%) had early intestinal complications. Median age was 39 years (male: 65.2%). Median cold ischemia time was 11 h [IQR: 9–12.4]. Intestinal complications were intestinal obstruction (n = 7); paralytic ileus (n = 5); intestinal fistula without anastomotic dehiscence (n = 3); ischemic graft duodenum (n = 3); dehiscence of duodenojejunostomy (n = 4); and anastomotic dehiscence in jejunum after pancreas transplantectomy (n = 1). Eighteen cases required relaparotomy: adhesiolysis (n = 6); repeated laparotomy without findings (n = 1); transplantectomy (n = 6); primary leak closure (n = 3); re‐positioning of the graft (n = 1); and intestinal resection (n = 1). Of the intestinal complications, 4 were associated with vascular thrombosis, resulting in two pancreatic graft losses. Enteric drainage with duodenum–jejunum anastomosis is safe and feasible, with a low rate of intra‐abdominal complications. Vascular thrombosis associated with intestinal complications presents a risk factor for the viability of pancreatic grafts, so prevention and early detection is vital.
Acetabular defects, particularly as a result of protrusion of acetabular components into the hemipelvis, may cause serious complications during revision procedures as a result of iatrogenic injury to surrounding anatomical structures. In these challenging cases, we advocate the utilisation of preoperative three dimensional imaging. MRI and CT- imaging offer superior understanding of the three-dimensional quality of bony defects and the relationship of implants to important anatomical structures. Appropriate preoperative planning may also prevent major complications during the removal of the pre-existing hardware, prior to re-implantation of implants. Potential complications include injury of nerves, blood vessels and other intrapelvic structures.In our case, a major bony defect of the acetabulum was a result of the protrusion of an implanted reinforcement ring. A preoperative, contrast-enhanced CT scan showed that the urethra was in close proximity to the hook of the reinforcement ring.The preoperative imaging aided in identifying and understanding the potential complications that could occur intraoperatively. Additionally, it delineated the intact anatomic structures prior to surgery, which could have medico-legal implications.The importance of preoperative imaging and the existing literature is discussed within this case description.
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