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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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108
https://t.me/med1917
M. Poelman and C.J.J. Mulder
b
Illustration 19.1 (continued)
Operation
At laparotomy a perforation was seen in the tumor localized at the junction between
the distal duodenum and the proximal jejunum. The tumor was 4 cm, and enlarged
lymph nodes were found in the mesentery at the level of ligament of Treitz. A radical resection was performed followed by an end-to-side anastomosis between the
descending part of the duodenum and the proximal jejunum (Illustration
19.1b ).
19 Case on Distal Duodenal Perforation After Double Balloon Endoscopy (DBE)
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Pathology
Pathological examination demonstrated a B-cell lymphoma, radically resected.
Patient recovered.
Discussion
Xin et al. [ 1 ] performed a systematic review about the indications and complications
of the diagnostic double balloon endoscopy after a 10-year experience of its application. A total of 66 articles involving 12,823 procedures were included. Suspected
mid-GI bleeding (MGIB) was the most common indication (62.5 %), followed by
symptoms/signs only (7.9 %), small-bowel obstruction (5.8 %), and Crohn’s disease
(5.8 %). Infl ammatory lesions (37.6 %) and vascular lesions (65.9 %) were the most
common fi ndings, respectively. The pooled total enteroscopy rate was 44.0 % by
combined or antegrade-only approach. The pooled minor and major complication
rates were 9.1 and 0.72 %, respectively. They concluded that the detectability and
complication risk of diagnostic DBE are acceptable.
Reference
1. Xin L, Liao Z, Jiang YP, Li ZS. Indications, detectability, positive fi ndings, total enteroscopy,
and complications of diagnostic double-balloon endoscopy: a systematic review of data over
the fi rst decade of use. Gastrointest Endosc. 2011;74:563–70.
Chapter 20
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Case on Duodenal Leakage After Resection
of an Insulinoma of the Head of the Pancreas
Miguel A. Cuesta and Donald L. van der Peet
Keywords Duodenal leakage • Insulinoma • Pancreas • Laparoscopic enucleation •
Pancreatic leakage
Diagnosis and Indication for Surgery
In our focus is a 48-year-old male patient, who, after series of collapses, was diagnosed with an insulinoma of 3 cm in the head of the pancreas. The tumor was visible
on the MRI scan (Fig. 20.1 ).
Operation
The patient underwent a laparoscopic enucleation after laparoscopic ultrasonography. A distance of 3–4 mm with the pancreatic duct could be seen. After performing
a Kocher maneuver, the tumor was excised. In the pancreas opening no leakage of
pancreatic fl uid was observed, leaving a drain at the level of the pancreas.
Postoperative Course: Identifi cation and Treatment
of the Complication
Postoperatively, the patient experienced abdominal pain and the amylase level in
the drain was high (20,000 U/ml), suggesting the existence of a pancreatic leakage.
A CT scan confi rmed some leakage from the pancreas with a fl uid collection
M. A. Cuesta , M.D. () • D.L. van der Peet
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; dl.vdpeet@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_20,
© Springer International Publishing Switzerland 2014
111
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Fig. 20.1 MRI, insulinoma
in head of the pancreas
Fig. 20.2 CT scan showing
local leakage of pancreas
M.A. Cuesta and D.L. van der Peet
around the duodenum (Fig. 20.2 ) (Illustration 20.1a ). The location of the drain in
the middle of the collection was considered good. On the 10th postoperative day,
the patient became hemodynamically unstable, with decreasing Hemoglobin levels. On the performed CT more fl uids and clots were visible in the abdomen, and
20 Case on Duodenal Leakage After Resection of an Insulinoma of the Head
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Fig. 20.3 Duodenal leakage
direct to the drain
113
on the CT angiography a blush was found around the head of the pancreas, but it
could not be coiled. Liver perfusion was considered irregular. An explorative laparotomy through a subcostal incision was done. A bleeding caused by some small
vessels around the junction between pancreatic head and the common bile duct
was found and fi xed with stitches. Moreover, the aspect of the duodenal wall was
considered fragile and infl amed. The patient recovered, but on the 7th postoperative day intestinal contents came through the drain. The CT scan with contrast
showed a duodenal fi stula of the descending part of the duodenum (Fig. 20.3 ) with
adequate drainage and no intra-abdominal collections. The patient was treated by
total parenteral nutrition (TPN) and after 7 days drain production decreased and
then ceased. The patient could reinitiate oral feeding. After 3 weeks, she acquired
a feeling of gastric fullness and started vomiting. A new CT scan with oral contrast
showed an important stenosis of the descending part of the duodenum with a gastric dilatation. Nasogastric tubing and TPN was given. Deliberation by the multidisciplinary group considered two possibilities for treating the stenosis, endoscopic
dilatation or surgery.
Considering the risk of perforation, the fi rst option was adopted. After four balloon dilatations, passage (2.5 cm) was considered suffi cient; oral feeding could be
initiated and this was well tolerated (Illustration 20.1b ).
One year after operation, the patient has been doing well; her weight is optimal
and there are no signs of recurrence of the insulinoma.
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M.A. Cuesta and D.L. van der Peet
a
Insulinoma
b
Bleeding
Illustration 20.1 ( a , b ) Benign insulinomas of the pancreas should be operated laparoscopically.
Small tumors or preoperative unidentifi ed tumors will be localized by visual inspection and laparoscopic ultrasonography. After enucleation, the most frequent complication is the pancreatic fi stula. Drainage should be maintained until no production of the fi stula. If suspicion that the main
pancreatic duct (PD) is the cause of the fi stula, the PD should drained by ERCP
Clots
20 Case on Duodenal Leakage After Resection of an Insulinoma of the Head
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Discussion
In our department Berends et al. described ten patients treated laparoscopically
because of insulinoma of the pancreas [ 1 ]. There were localized all over the pan-
creas with a maximal size of 3 cm. Laparoscopic ultrasonography was used to localize properly the insulinoma during the operation. Six tumors could be excised
laparoscopically, four patients being converted to laparotomy. Five complications
were observed: two after laparoscopy (two pancreatic fi stulas, one treated by drainage and the other by drainage, ERCP, and drain in the pancreatic duct) and three
after laparotomy (pancreatic collection around the duodenum treated by percutaneous drainage, and two paralytic ileus, one of them treated by laparotomy, fi nding no
obstruction). All patients recovered from the hypoglycemia.
Reference
1. Berends FJ, Cuesta MA, Kazemier G, et al. Laparoscopic detection and resection of insulino-
mas. Surgery. 2000;128:386–91.
Chapter 21
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Case on Postoperative Intraluminal Bleeding
Following a Gastric Bypass
Jose L. Garcia Sabrido and Wenceslao Vasquez Jimenez
Keywords Intraluminal bleeding • Gastric bypass • Morbid obesity • Dyslipidemia
Diagnosis and Indication for Surgery
We regard a 34-year-old female patient, BMI 45 kg/m 2 , with a history of hypertension
and dyslipidemia, and scheduled for a laparoscopic gastric bypass. Gastroscopy did
not show abnormalities, and abdominal ultrasound showed severe hepatic steatosis.
Eight hours before surgery she received thromboembolic prophylaxis with subcutaneous 5,000 UI heparin.
Operation
The laparoscopic gastric bypass was performed with a long-loop Roux-Y technique;
the feeding loop measured 100 cm and the jejunojejunostomy was performed at
45 cm from the ligament of Treitz, antecolic, with a side-to-side anastomosis, by
means of an endoscopic linear stapler 60 mm/3.5 mm. The gastric reservoir had a
volume of approximately 30 mL and was created using two shots of an endostapler
60 mm/3.5 mm. The closure of the gastro-jejunostomy was done by a continuous
suture with Vycril 3/0 ® , followed by a serosa layer stitches with silk 3/0. Two vacuum laminate drains were placed close to the gastro-jejunostomy and gastric remnant. The procedure was evaluated as routine with no technical diffi culties.
J. L. G. Sabrido , M.D. (*) • W. V. Jimenez , M.D., Ph.D.
Department of Surgery , Gregorio Marañon Hospital , Madrid , Spain
e-mail: jlgsabrido@gmail.com, jlgsabrido@ciriii.hggm.es
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_21,
© Springer International Publishing Switzerland 2014
117
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J.L.G. Sabrido and W.V. Jimenez
Postoperative Course: Identifi cation and Treatment
of the Complication
During the intraoperative period, a nasogastric tube was placed and then withdrawn
12 h later. Postoperative analgesia included NSAID’s (Dextroprofen 50 mg) alternating with Acetaminophen 1 g, thereby achieving good pain control.
The patient had a good oral tolerance to clear fl uids in the fi rst hours after the
procedure. Twenty-four hours following the operation, the patient developed
hematemesis, tachycardia, mild hypotension, and a decreased hemoglobin (7 g/dL).
Summarily, a gastroscopy was performed showing an intraluminal bleeding at
the level of the stapled gastrojejunostomy. The bleeding was treated with diathermia
and a hemostatic clip. Following this procedure, the patient quickly recovered without further complications.
Discussion
The incidence of bleeding following gastric bypass is between 0.9 and 4.4 %, and it
seems that bleeding is more frequent after laparoscopic than open bypass [ 1 ]. In a
laparoscopic bypass, the most likely places for intraluminal bleeding are the gastrojejunostomy and the jejunojejunostomy (Illustration 21.1 ), and for intraperitoneal
bleeding, the suture line of the gastric remnant and the trocar openings (Figs. 21.1 ,
21.2 , and 21.3 ). Postoperative bleeding after gastric bypass should be diagnosed by
means of gastroscopy. If a bleeding is seen at the gastrojejunostomy, it should be
treated by diathermia or clips. If patient is steadily bleeding from other source or
hemodynamically unstable, CT angiography may be helpful to establish the cause.
Otherwise explorative laparotomy should be done [ 2 , 3 ].
Fig. 21.1 Review of the
suture line with stapler after
jejunojejunostomy
21 Case on Postoperative Intraluminal Bleeding Following a Gastric Bypass
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Fig. 21.2 Arrow showing intra-abdominal hematoma at the level of the suture line of the gastric
remnant
Fig. 21.3 Arrow showing
hematoma of the abdominal
wall associated with the
trocar entrance
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