BACKGROUND With the increasing use of laparoscopic techniques in living-donor kidney transplantation,limitations in donor vessel length,particularly of the right renal vein,pose significant challenges for vascular ana...BACKGROUND With the increasing use of laparoscopic techniques in living-donor kidney transplantation,limitations in donor vessel length,particularly of the right renal vein,pose significant challenges for vascular anastomosis to the recipient’s external iliac vein.These anatomical constraints can complicate graft implantation and increase the risk of postoperative complications.CASE SUMMARY To address the issue of short right renal veins,several surgical strategies have been proposed.In this report,we describe our experience with three cases in which venous extension was successfully achieved using a venous cuff interposition technique during back-table reconstruction.This approach was used to facilitate secure vascular anastomosis and improve graft positioning in anatomically complex transplant scenarios.CONCLUSION Venous cuff interposition represents an effective technique for managing short renal veins in living-donor kidney transplantation.It provides additional length and flexibility,easing anastomotic tension and supporting successful transplantation.展开更多
BACKGROUND Kidney transplantation is increasingly more common due to the ongoing shortage of deceased donors.However,anatomical challenges,such as a short renal artery,can complicate surgical procedures and increase c...BACKGROUND Kidney transplantation is increasingly more common due to the ongoing shortage of deceased donors.However,anatomical challenges,such as a short renal artery,can complicate surgical procedures and increase complication risk,including thrombosis and anastomotic stenosis.To address these issues and optimize graft outcomes,innovative surgical techniques are essential.CASE SUMMARY We present a case of kidney transplantation complicated by a short donor renal artery.To address the discrepancy between arterial length and diameter mismatch,the recipient’s inferior epigastric artery was used as a cuff interposition for arterial reconstruction.Following standard laparoscopic donor nephrectomy,vascular reconstruction was performed on the back table.The use of the inferior epigastric artery as a cuff allowed for successful elongation and size matching of the donor renal artery,enabling a tension-free anastomosis to the recipient’s external iliac artery.Postoperative Doppler ultrasound and angiography confirmed excellent graft perfusion.The patient experienced an uneventful recovery with immediate graft function and maintained stable renal function at 6 months post-transplant.To our knowledge,this is the first reported use of the inferior epigastric artery as a cuff interposition in renal artery reconstruction,offering a novel and effective technique for managing short renal arteries in kidney transplantation.CONCLUSION Interposition of the epigastric artery offers an innovative technique for managing short donor renal arteries,reducing the risk of early thrombosis and long-term complications as size mismatch and intimal hyperplasia.展开更多
Hallux rigidus is a degenerative disease of the first metatarsalphalangeal(MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of...Hallux rigidus is a degenerative disease of the first metatarsalphalangeal(MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1^(st) MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intraarticular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient's goal and expectations, and surgeon's experience with the technique.展开更多
AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).
BACKGROUND: Congestion of the right anterior segment may lead to graft dysfunction in right-lobe living donor liver transplantation (LDLT) without a middle hepatic vein (MHV) trunk. Selective reconstruction of MHV tri...BACKGROUND: Congestion of the right anterior segment may lead to graft dysfunction in right-lobe living donor liver transplantation (LDLT) without a middle hepatic vein (MHV) trunk. Selective reconstruction of MHV tributaries with the interposition of vascular grafts has been introduced to overcome this problem. However, there is still no consensus on the definite criteria of MHV reconstruction. METHODS: LDLT patients were reviewed to evaluate the effects of MHV reconstruction. From March 2005 to September 2008 in our transplantation center, 120 consecutive LDLTs were performed using a right-lobe graft without a MHV. Excluding 11 patients, among the remainder, 73 (67%) had reconstructed MHV tributaries, and the others 36 (33%) did not. The values of liver functional index and liver graft regeneration ratio were compared between the two groups. RESULTS: There was a prolonged period of liver functional recovery in patients with small-for-size grafts and a graft-recipient weight ratio (GRWR) <1.0%, and without MHV reconstruction. The ratio of liver regeneration 1 month postoperatively in reconstruction cases was 81%, versus 78% in patients without reconstruction (P=0.352), but among small-for-size grafts, there was a significant difference between the two groups (95% vs. 80%). CONCLUSION: Our study shows that reconstruction of MHV tributaries is not necessary in all patients, but is beneficial for patients with GRWR <1.0%. (Hepatobiliary Pancrent Dis Int 2010; 9: 135-138)展开更多
BACKGROUND The life-threatening complications following pancreatoduodenectomy(PD),intraabdominal hemorrhage,and postoperative infection,are associated with leaks from the anastomosis of pancreaticoduodenectomy.Althoug...BACKGROUND The life-threatening complications following pancreatoduodenectomy(PD),intraabdominal hemorrhage,and postoperative infection,are associated with leaks from the anastomosis of pancreaticoduodenectomy.Although several methods have attempted to reduce the postoperative pancreatic fistula(POPF)rate after PD,few have been considered effective.The safety and short-term clinical benefits of omental interposition remain controversial.AIM To investigate the safety and feasibility of omental interposition to reduce the POPF rate and related complications in pancreaticoduodenectomy.METHODS In total,196 consecutive patients underwent PD performed by the same surgical team.The patients were divided into two groups:An omental interposition group(127,64.8%)and a non-omental interposition group(69,35.2%).Propensity scorematched(PSM)analyses were performed to compare the severe complication rates and mortality between the two groups.RESULTS Following PSM,the clinically relevant POPF(CR-POPF,10.1%vs 24.6%;P=0.025)and delayed postpancreatectomy hemorrhage(1.4%vs 11.6%;P=0.016)rates were significantly lower in the omental interposition group.The omental interposition technique was associated with a shorter time to resume food intake(7 d vs 8 d;P=0.048)and shorter hospitalization period(16 d vs 21 d;P=0.031).Multivariate analyses showed that a high body mass index,nonapplication of omental interposition,and a main pancreatic duct diameter<3 mm were independent risk factors for CR-POPF.CONCLUSION The application of omental interposition is an effective and safe approach to reduce the CR-POPF rate and related complications after PD.展开更多
Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve.However,no comparative study of th...Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve.However,no comparative study of these two procedures has yet been reported.In this two-site,twoarm,retrospective case review study,32 patients were included.Of these,17 patients(eight men and nine women,mean age 42.1 years)underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute,School of Medicine,Shanghai Jiao Tong University,China,and 15 patients(six men and nine women,mean age 40.6 years)underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People's Hospital,China.More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair(15/15 vs.12/17).The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft.These findings suggest that masseter nerve transfer results in strong oral commissure excursion,avoiding obvious synkinesis,while an interposition nerve graft provides better resting symmetry.This study was approved by the Institutional Ethics Committee,Shanghai Ninth People's Hospital,China(approval No.SH9 H-2019-T332-1)on December 12,2019.展开更多
We present a case of 50 year old male patient with coexistence of Pneumothorax and Chilaiditi sign.Chilaiditi sign is an incidental radiographic finding of a usually asymptomatic condition in which a part of intestine...We present a case of 50 year old male patient with coexistence of Pneumothorax and Chilaiditi sign.Chilaiditi sign is an incidental radiographic finding of a usually asymptomatic condition in which a part of intestine is located between the liver and diaphragm;however,the term"Chilaiditi syndrome"is used for symptomatic hepatodiaphragmatic interposition.The patient had no symptoms of abdominal pain,constipation,diarrhea,or emesis.Incidentally,Chilaiditi sign was diagnosed on chest radiography.Pneumothorax is defined as air in the pleural space.Pneumothoraces are classified as spontaneous or traumatic.Spontaneous pneumothorax is labelled as primary when no underlying lung disease is present,or secondary,when it is associated with pre-existing lung disease.Our case is the rare in the literature indicating the coexistence of Chilaiditi sign and pneumothorax.展开更多
The colon is an alternative graft organ for esophageal reconstruction.The present study reviewed our experience with the colon interposition for esophageal replacement following corrosive ingestion,to evaluate the out...The colon is an alternative graft organ for esophageal reconstruction.The present study reviewed our experience with the colon interposition for esophageal replacement following corrosive ingestion,to evaluate the outcomes of colon interposition based on our surgical experience. The clinical data of 119 patients who underwent colon interposition for esophageal replacement from January 2005 to March 2017 were retrospectively analyzed. The routes of the colon interposition were retrosternal in 119 (100%). The median operative time was 390 min (range: 290-610 min) and the median blood loss was 615 mL (range:270-2500 mL). Of these 119 patients, the cervical anastomosis was performed at the hypopharynx (n=20,16.8%), the larynx (n=3,2.5%), and the cervical esophagus (n=96, 80.7%). Five patients experienced cervical anastomotic leakage (4 cases for esophagus-colon, and one for hypopharynx-colon).One patient experienced wound infection of the abdominal wall. Three patients had injury of recurrent laryngeal nerve and hoarseness. Three patients had stress ulcer with bleeding and treated with octreotide. Two patients suffered from incomplete intestinal obstruction. The postoperative follow-up was made for 12 months in all patients and all of them were alive. In conclusion, The colon is well-suited for esophageal reconstruction. The selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed. We must therefore make every effort to reduce the number of postoperative complications, and improve the quality of life for patients.展开更多
Herein we describe an early colonic carcinoma which developed in a colonic interposition 14 years after surgery for esophageal cancer, which was successfully treated by endoscopic submucosal dissection (ESD). An 80-ye...Herein we describe an early colonic carcinoma which developed in a colonic interposition 14 years after surgery for esophageal cancer, which was successfully treated by endoscopic submucosal dissection (ESD). An 80-year-old man underwent colonic interposition between the upper esophagus and stomach after surgery for an early esophageal squamous cell carcinoma in 1994. He received a surveillance endoscopy, and a laterally-spreading tumor of granular type, approximately 20 mm in size, was identified in the colonic interposition. An endoscopic biopsy revealed moderately differentiated adenocarcinoma histologically, however, we diagnosed the lesion as an intramucosal carcinoma based on the endoscopic findings. The lesion was safely and completely removed en bloc by ESD using a bipolar knife. Histologically, the lesion was an intramucosal moderately differentiated adenocarcinoma in a tubular adenoma.展开更多
Thermal injuries of the esophagus are rare causes of benign esophageal stricture, and all published cases were successfully treated with conservative management. A 28-year-old Japanese man with a thermal esophageal in...Thermal injuries of the esophagus are rare causes of benign esophageal stricture, and all published cases were successfully treated with conservative management. A 28-year-old Japanese man with a thermal esophageal injury caused by drinking a cup of hot coffee six months earlier was referred to our hospital. The hot coffee was consumed in a single gulp at a party. Although the patient had been treated conservatively at another hospital, his symptoms of dysphagia gradually worsened after discharge. An upper gastrointestinal endoscopy and computed tomography revealed a pinhole like area of stricture located 19 cm distally from the incisors to the esophagogastric junction, as well as circumferential stenosis with notable wall thickness at the same site. The patient underwent a thoracoscopic esophageal resection with reconstruction using ileocolon interposition. The pathological findings revealed wall thickening along the entire length of the esophagus, with massive fibrosis extending to the muscularis propria and adventitia at almost all levels. Treatment with balloon dilation for long areas of stricture is generally difficult, and stent placement in patients with benign esophageal stricture, particularly young patients, is not yet widely accepted due to the incidence of late adverse events. Considering the curability and qualityof-life associated with a long expected prognosis, we determined that surgery was the best treatment option for this young patient. In this case, we decided to perform an esophagectomy and reconstruction with ileocolon interposition in order to preserve the reservoir function of the stomach and to avoid any problems related to the reflux of gastric contents. In conclusion, resection of the esophagus is a treatment option in patients with benign esophageal injury, especially in cases involving young patients with refractory esophageal stricture. In addition, ileocolon interposition may help to improve the quality-of-life of patients.展开更多
Select group of patients with concurrent esophagealand gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with signi...Select group of patients with concurrent esophagealand gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with significant complications and have up to 18% ischemic conduit necrosis. Following corrosive intake, up to 30% of such patients have stricturing at the pyloro-duodenal canal area only and rest of the stomach is available for rather less complex and better perfused gastrointestinal reconstruction. Here we describe an alternative technique where we utilize stomach following distal gastric resection along with Roux-en-Y reconstruction instead of colonic or jejunal interposition. This neo-conduit is potentially superior in terms of perfusion, lower risk of gastro-esophageal anastomotic leakage and technical ease as opposed to colonic and jejunal counterparts. We have utilized the said technique in three patients with acceptable postoperative outcome. In addition this technique offers a feasible reconstruction plan in patients where colon is not available for reconstruction due to concomitant pathology. Utility of this technique may also merit consideration for gastroesophageal junction tumors.展开更多
Symptomatic hepato-diaphragmatic interposition of a bowel loop or Chilaiditi's syndrome is a peculiar anatomical condition most often found by chance. Its described symptoms range from intermittent, mild abdominal...Symptomatic hepato-diaphragmatic interposition of a bowel loop or Chilaiditi's syndrome is a peculiar anatomical condition most often found by chance. Its described symptoms range from intermittent, mild abdominal pain and dyspepsia to acute intestinal obstruction. We report a case of hepato-diaphragmatic migration of the hepatic flexure of the colon associated to an unusual, heretofore unreported, angina-like pain exclusively evoked by the left lateral decubitus. To maximize the chance of observing anatomical changes in different postures, computed tomography of the chest and abdomen was performed after air insufflation into the colon. While frank herniation into the chest was excluded, the scan showed that the hepatic flexure-with the interposition of the diaphragm-came in contact with the right side of the heart in the left lateral, but not in the supine, decubitus. This finding was reproduced by echocardiography which also showed virtually unaltered hemodynamics after the change of posture. ECG, left and right ventricular global and regional function as well as cardiac injury markers also remained unchanged during the maneuver, indicating that the pain evoked by the latter was unlikely due to myocardial ischemia. This case suggests that Chilaiditi's syndrome should be included among the possible, although rare,causes of unexplained angina-like symptoms.展开更多
BACKGROUND: Bilio-intestinal drainage is routinely per- formed by Roux-en-Y reconstruction after resection of the central bile duct. Alternatively reconstruction can be achieved by cholangio-duodenal interposition of ...BACKGROUND: Bilio-intestinal drainage is routinely per- formed by Roux-en-Y reconstruction after resection of the central bile duct. Alternatively reconstruction can be achieved by cholangio-duodenal interposition of an isolated jejunal segment (CDJI). This method offers the benefit of potential endoscopic control and intervention during fol- low-up. Critics of CDJI assume a higher rate of postopera- tive cholangitis compared to the Roux-en-Y construction. METHODS: Seventy-six patients with malignant tumors (n = 56) or benign strictures and choledochal cysts (n =20) were treated between 1989 and 2002 by cholangio-duodenal interposition of an isolated jejunal segment (measuring 15- 25 cm) after central bile duct resection. In 22 patients endoscopic control was first performed postoperatively dur- ing hospitalization. In 12 patients bilio-intestinal anastomo- sis could be inspected endoscopically. In the remaining patients the anastomosis could not be visualized endoscopi- cally because of kinking of the jejunal segment, but in all patients it could be evaluated by endoscopic retrograde cholangiography (ERC). RESULTS: During follow-up, 25 (33%) patients died from extrahepatic tumor recurrence. Three patients receiving CDJI after severe iatrogenic bile duct injury developed anas- tomotic strictures. Two of these patients were treated by endoscopic pigtail drainage, and one was treated by percu- taneous drainage. Two patients who had received CDJI af- ter choledochal cyst resection developed cholestasis post- operatively because of sludge formation (1 patient) and an intrahepatic concrement (1), which could be solved endo- scopically. One patient after resection of a Klatskin tumor developed an anastomotic stricture which could not be vi- sualized endoscopically, making percutaneous drainage necessary. The rate of postoperative cholangitis after CDJI in our patients was comparable to that after the Roux-en-Y reconstruction.CONCLUSION: Interposition of an isolated jejunal seg- ment for reconstruction after bile duct resection should be performed in patients with a high risk of postoperative ste- nosis. To benefit endoscopic follow-up the jejunal segment should be shorter than 20 cm.展开更多
BACKGROUND Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair.We propose using a synthetic polypropylene mesh to increase the tensile strength of rota...BACKGROUND Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair.We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs.We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair.AIM To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model.METHODS A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear.We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair.In seven specimens,the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens.Five specimens with an intact tendon were tested.The specimens underwent cyclic loading to determine the ultimate failure load and gap formation.RESULTS The mean gap formation after 3000 cycles was 1.67 mm in the continuous group,and 4.16 mm in the mattress group(P=0.001).The mean ultimate failure load was significantly higher at 549.2 N in the continuous group,426.4 N in the mattress group and 370 N in the intact group(P=0.003).CONCLUSION The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.展开更多
BACKGROUND The incidence of gastric cancer has significantly increased in recent years.Surgical resection is the main treatment,but the method of digestive tract reconstruction after gastric cancer surgery remains con...BACKGROUND The incidence of gastric cancer has significantly increased in recent years.Surgical resection is the main treatment,but the method of digestive tract reconstruction after gastric cancer surgery remains controversial.In the current study,we sought to explore a reasonable method of digestive tract reconstruction and improve the quality of life and nutritional status of patients after surgery.To this end,we statistically analyzed the clinical results of patients with gastric cancer who underwent jejunal interposition double-tract reconstruction(DTR)and esophageal jejunum Roux-en-Y reconstruction(RY).AIM To explore the application effect of DTR in total laparoscopic radical total gastrectomy(TLTG)and evaluate its safety and efficacy.METHODS We collected the relevant data of 77 patients who underwent TLTG at the Fourth Hospital of Hebei Medical University from October 2021 to January 2023.Among them,35 cases were treated with DTR,and the remaining 42 cases were treated with traditional RY.After 1:1 propensity score matching,the cases were grouped into 31 cases per group,with evenly distributed data.The clinical characteristics and short-and long-term clinical outcomes of the two groups were statistically analyzed.RESULTS The two groups showed no significant differences in basic data,intraoperative blood loss,number of lymph node dissections,first defecation time after operation,postoperative hospital stay,postoperative complications,and laboratory examination results on the 1st,3rd,and 5th days after operation.The operation time of the DTR group was longer than that of the RY group[(307.58±65.14)min vs(272.45±62.09)min,P=0.016],but the first intake of liquid food in the DTR group was shorter than that in the RY group[(4.45±1.18)d vs(6.0±5.18)d,P=0.028].The incidence of reflux heartburn(Visick grade)and postoperative gallbladder disease in the DTR group was lower than that in the RY group(P=0.033 and P=0.038).Although there was no significant difference in body weight,hemoglobin,prealbumin,and albumin between the two groups at 1,3 and 6 months after surgery,the diet of patients in the DTR group was better than that in the RY group(P=0.031).CONCLUSION The clinical effect of DTR in TLTG is better than that of RY,indicating that it is a more valuable digestive tract reconstruction method in laparoscopic gastric cancer surgery.展开更多
Esophageal reconstruction can be challenging when stomach and colon are not anatomically intact and their use as esophageal substitutes is therefore limited. Innovative individual approaches are then necessary to rest...Esophageal reconstruction can be challenging when stomach and colon are not anatomically intact and their use as esophageal substitutes is therefore limited. Innovative individual approaches are then necessary to restore the intestinal passage. We describe a technique in which a short stump of the right hemicolon and 25 cm of ileum on a long, non-supercharged, fully mobilized ileocolic arterial pedicle were used for esophageal reconstruction to the neck. In this case, a 65 year-old male patient had accidentally indigested hydrochloric acid which caused necrosis of his upper digestive tract. An emergency esophagectomy, gastrectomy, duodenectomy, pancreatectomy and splenectomy had been performed in an outside hospital. A cervical esophagostomy and a biliodigestive anastomosis had been created and a jejunal catheter for enteral feeding had been placed. After the patient had recovered, a reconstruction of his food passage via the left and transverse colon failed for technical reasons due to an intraoperative necrotic demarcation of the colon. Our team then faced the situation that only a short stump of the right hemi-colon was left in situ when the patient was referred to our center. After intensified nutritional therapy, we reconstructed this patient's food passage with the right hemicolonapproach described herein. After treatment of a postoperative pneumonia, the patient was discharged from hospital on the 26 th postoperative day in a good clinical condition on an oral-only diet. In conclusion, individual approaches for long-segment reconstruction of the esophagus can be technically feasible in experienced hands. They do not always require arterial supercharging or free intestinal transplantation.展开更多
Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay treatment for bile duct disease. The procedure is difficult per se, especially when a side-viewing duodenoscope is used, and when the p...Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay treatment for bile duct disease. The procedure is difficult per se, especially when a side-viewing duodenoscope is used, and when the patient has altered anatomical features, such as colonic interposition. Currently, there is no consensus on the standard approach for therapeutic ERCP in patients with total esophagectomy and colonic interposition. We describe a novel treatment design that involves the use of a side-viewing duodenoscope to perform therapeutic ERCP in patients with total esophagectomy and colonic interposition. A gastroscope was initially introduced into the interposed colon and a radio-opaque standard guidewire was advanced to a distance beyond the papilla of Vater, before the gastroscope was withdrawn. A sideviewing duodenoscope was then introduced along the guidewire under fluoroscopic guidance. After cannulation into the papilla of Vater, endoscopic retrograde chol-angiography (ERC) revealed a filling defect (maximum diameter: 15 cm) at the distal portion of the common bile duct (CBD). This defect was determined to be a stone, which was successfully retrieved by a Dormia basket after complete sphincterotomy. With this treatment design, it is possible to perform therapeutic ERCP in patients with colonic interposition, thereby precluding the need for percutaneous drainage or surgery.展开更多
BACKGROUND:Obstructive jaundice is a common condition in advanced digestive cancer.Palliative procedures can improve quality of life and allow patients to attempt a systemic treatment.Bilioenteric anastomosis is still...BACKGROUND:Obstructive jaundice is a common condition in advanced digestive cancer.Palliative procedures can improve quality of life and allow patients to attempt a systemic treatment.Bilioenteric anastomosis is still the procedure of choice for patients in many centers.When a surgical bypass is not possible,biliary drainage can be done by placing endoscopic or transparietal stents,which are less durable methods even when an expandable stent is employed. METHODS:A 47-year-old male with an excellent clinical status and a previous cholecystectomy and an exploratory laparotomy for advanced gastric cancer was referred with obstructive jaundice.A preoperative CT scan showed a dilated bile duct and a small mass at the distal hepatic hilum.No other signs of metastasis were found.A surgical bilioenteric anastomosis was indicated.At surgery,a distal choledochal obstruction and a mesenteric retraction by a lymph node mass prevented the jejunum to ascend for a bilioenteric anastomosis. Surgically,an alternative bilioenteric bypass was performed by means of an ileal loop interposition between the bile duct and the jejunum. RESULT:The recovery of the patient was uneventful and his bilirubin levels normalized after one week.The patient was then referred for systemic chemotherapy. CONCLUSIONS:This alternative biliary bypass can be safely and easily performed,and may be a good alternative for patients already referred for surgery because of a better life expectancy and when the jejunum is not an alternative.展开更多
文摘BACKGROUND With the increasing use of laparoscopic techniques in living-donor kidney transplantation,limitations in donor vessel length,particularly of the right renal vein,pose significant challenges for vascular anastomosis to the recipient’s external iliac vein.These anatomical constraints can complicate graft implantation and increase the risk of postoperative complications.CASE SUMMARY To address the issue of short right renal veins,several surgical strategies have been proposed.In this report,we describe our experience with three cases in which venous extension was successfully achieved using a venous cuff interposition technique during back-table reconstruction.This approach was used to facilitate secure vascular anastomosis and improve graft positioning in anatomically complex transplant scenarios.CONCLUSION Venous cuff interposition represents an effective technique for managing short renal veins in living-donor kidney transplantation.It provides additional length and flexibility,easing anastomotic tension and supporting successful transplantation.
文摘BACKGROUND Kidney transplantation is increasingly more common due to the ongoing shortage of deceased donors.However,anatomical challenges,such as a short renal artery,can complicate surgical procedures and increase complication risk,including thrombosis and anastomotic stenosis.To address these issues and optimize graft outcomes,innovative surgical techniques are essential.CASE SUMMARY We present a case of kidney transplantation complicated by a short donor renal artery.To address the discrepancy between arterial length and diameter mismatch,the recipient’s inferior epigastric artery was used as a cuff interposition for arterial reconstruction.Following standard laparoscopic donor nephrectomy,vascular reconstruction was performed on the back table.The use of the inferior epigastric artery as a cuff allowed for successful elongation and size matching of the donor renal artery,enabling a tension-free anastomosis to the recipient’s external iliac artery.Postoperative Doppler ultrasound and angiography confirmed excellent graft perfusion.The patient experienced an uneventful recovery with immediate graft function and maintained stable renal function at 6 months post-transplant.To our knowledge,this is the first reported use of the inferior epigastric artery as a cuff interposition in renal artery reconstruction,offering a novel and effective technique for managing short renal arteries in kidney transplantation.CONCLUSION Interposition of the epigastric artery offers an innovative technique for managing short donor renal arteries,reducing the risk of early thrombosis and long-term complications as size mismatch and intimal hyperplasia.
文摘Hallux rigidus is a degenerative disease of the first metatarsalphalangeal(MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1^(st) MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intraarticular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient's goal and expectations, and surgeon's experience with the technique.
文摘AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).
文摘BACKGROUND: Congestion of the right anterior segment may lead to graft dysfunction in right-lobe living donor liver transplantation (LDLT) without a middle hepatic vein (MHV) trunk. Selective reconstruction of MHV tributaries with the interposition of vascular grafts has been introduced to overcome this problem. However, there is still no consensus on the definite criteria of MHV reconstruction. METHODS: LDLT patients were reviewed to evaluate the effects of MHV reconstruction. From March 2005 to September 2008 in our transplantation center, 120 consecutive LDLTs were performed using a right-lobe graft without a MHV. Excluding 11 patients, among the remainder, 73 (67%) had reconstructed MHV tributaries, and the others 36 (33%) did not. The values of liver functional index and liver graft regeneration ratio were compared between the two groups. RESULTS: There was a prolonged period of liver functional recovery in patients with small-for-size grafts and a graft-recipient weight ratio (GRWR) <1.0%, and without MHV reconstruction. The ratio of liver regeneration 1 month postoperatively in reconstruction cases was 81%, versus 78% in patients without reconstruction (P=0.352), but among small-for-size grafts, there was a significant difference between the two groups (95% vs. 80%). CONCLUSION: Our study shows that reconstruction of MHV tributaries is not necessary in all patients, but is beneficial for patients with GRWR <1.0%. (Hepatobiliary Pancrent Dis Int 2010; 9: 135-138)
基金Supported by the Shanghai Science and Technology Commission of Shanghai Municipality,No.20Y11908600the Shanghai Shenkang Hospital Development Center,No.SHDC2020CR5008Shanghai Municipal Health Commission,No.20194Y0195。
文摘BACKGROUND The life-threatening complications following pancreatoduodenectomy(PD),intraabdominal hemorrhage,and postoperative infection,are associated with leaks from the anastomosis of pancreaticoduodenectomy.Although several methods have attempted to reduce the postoperative pancreatic fistula(POPF)rate after PD,few have been considered effective.The safety and short-term clinical benefits of omental interposition remain controversial.AIM To investigate the safety and feasibility of omental interposition to reduce the POPF rate and related complications in pancreaticoduodenectomy.METHODS In total,196 consecutive patients underwent PD performed by the same surgical team.The patients were divided into two groups:An omental interposition group(127,64.8%)and a non-omental interposition group(69,35.2%).Propensity scorematched(PSM)analyses were performed to compare the severe complication rates and mortality between the two groups.RESULTS Following PSM,the clinically relevant POPF(CR-POPF,10.1%vs 24.6%;P=0.025)and delayed postpancreatectomy hemorrhage(1.4%vs 11.6%;P=0.016)rates were significantly lower in the omental interposition group.The omental interposition technique was associated with a shorter time to resume food intake(7 d vs 8 d;P=0.048)and shorter hospitalization period(16 d vs 21 d;P=0.031).Multivariate analyses showed that a high body mass index,nonapplication of omental interposition,and a main pancreatic duct diameter<3 mm were independent risk factors for CR-POPF.CONCLUSION The application of omental interposition is an effective and safe approach to reduce the CR-POPF rate and related complications after PD.
基金supported by Shanghai Municipal Commission of Health and Family Planning Program,China,No.201504253(to WW)Special Fund for Science and Technology Innovation by Shanghai Jiao Tong University,China,No.YG2016MS10(to WW)the National Natural Science Foundation of China,Nos.81570906(to HW)and 81371086(to ZYW)。
文摘Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve.However,no comparative study of these two procedures has yet been reported.In this two-site,twoarm,retrospective case review study,32 patients were included.Of these,17 patients(eight men and nine women,mean age 42.1 years)underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute,School of Medicine,Shanghai Jiao Tong University,China,and 15 patients(six men and nine women,mean age 40.6 years)underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People's Hospital,China.More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair(15/15 vs.12/17).The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft.These findings suggest that masseter nerve transfer results in strong oral commissure excursion,avoiding obvious synkinesis,while an interposition nerve graft provides better resting symmetry.This study was approved by the Institutional Ethics Committee,Shanghai Ninth People's Hospital,China(approval No.SH9 H-2019-T332-1)on December 12,2019.
文摘We present a case of 50 year old male patient with coexistence of Pneumothorax and Chilaiditi sign.Chilaiditi sign is an incidental radiographic finding of a usually asymptomatic condition in which a part of intestine is located between the liver and diaphragm;however,the term"Chilaiditi syndrome"is used for symptomatic hepatodiaphragmatic interposition.The patient had no symptoms of abdominal pain,constipation,diarrhea,or emesis.Incidentally,Chilaiditi sign was diagnosed on chest radiography.Pneumothorax is defined as air in the pleural space.Pneumothoraces are classified as spontaneous or traumatic.Spontaneous pneumothorax is labelled as primary when no underlying lung disease is present,or secondary,when it is associated with pre-existing lung disease.Our case is the rare in the literature indicating the coexistence of Chilaiditi sign and pneumothorax.
文摘The colon is an alternative graft organ for esophageal reconstruction.The present study reviewed our experience with the colon interposition for esophageal replacement following corrosive ingestion,to evaluate the outcomes of colon interposition based on our surgical experience. The clinical data of 119 patients who underwent colon interposition for esophageal replacement from January 2005 to March 2017 were retrospectively analyzed. The routes of the colon interposition were retrosternal in 119 (100%). The median operative time was 390 min (range: 290-610 min) and the median blood loss was 615 mL (range:270-2500 mL). Of these 119 patients, the cervical anastomosis was performed at the hypopharynx (n=20,16.8%), the larynx (n=3,2.5%), and the cervical esophagus (n=96, 80.7%). Five patients experienced cervical anastomotic leakage (4 cases for esophagus-colon, and one for hypopharynx-colon).One patient experienced wound infection of the abdominal wall. Three patients had injury of recurrent laryngeal nerve and hoarseness. Three patients had stress ulcer with bleeding and treated with octreotide. Two patients suffered from incomplete intestinal obstruction. The postoperative follow-up was made for 12 months in all patients and all of them were alive. In conclusion, The colon is well-suited for esophageal reconstruction. The selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed. We must therefore make every effort to reduce the number of postoperative complications, and improve the quality of life for patients.
文摘Herein we describe an early colonic carcinoma which developed in a colonic interposition 14 years after surgery for esophageal cancer, which was successfully treated by endoscopic submucosal dissection (ESD). An 80-year-old man underwent colonic interposition between the upper esophagus and stomach after surgery for an early esophageal squamous cell carcinoma in 1994. He received a surveillance endoscopy, and a laterally-spreading tumor of granular type, approximately 20 mm in size, was identified in the colonic interposition. An endoscopic biopsy revealed moderately differentiated adenocarcinoma histologically, however, we diagnosed the lesion as an intramucosal carcinoma based on the endoscopic findings. The lesion was safely and completely removed en bloc by ESD using a bipolar knife. Histologically, the lesion was an intramucosal moderately differentiated adenocarcinoma in a tubular adenoma.
文摘Thermal injuries of the esophagus are rare causes of benign esophageal stricture, and all published cases were successfully treated with conservative management. A 28-year-old Japanese man with a thermal esophageal injury caused by drinking a cup of hot coffee six months earlier was referred to our hospital. The hot coffee was consumed in a single gulp at a party. Although the patient had been treated conservatively at another hospital, his symptoms of dysphagia gradually worsened after discharge. An upper gastrointestinal endoscopy and computed tomography revealed a pinhole like area of stricture located 19 cm distally from the incisors to the esophagogastric junction, as well as circumferential stenosis with notable wall thickness at the same site. The patient underwent a thoracoscopic esophageal resection with reconstruction using ileocolon interposition. The pathological findings revealed wall thickening along the entire length of the esophagus, with massive fibrosis extending to the muscularis propria and adventitia at almost all levels. Treatment with balloon dilation for long areas of stricture is generally difficult, and stent placement in patients with benign esophageal stricture, particularly young patients, is not yet widely accepted due to the incidence of late adverse events. Considering the curability and qualityof-life associated with a long expected prognosis, we determined that surgery was the best treatment option for this young patient. In this case, we decided to perform an esophagectomy and reconstruction with ileocolon interposition in order to preserve the reservoir function of the stomach and to avoid any problems related to the reflux of gastric contents. In conclusion, resection of the esophagus is a treatment option in patients with benign esophageal injury, especially in cases involving young patients with refractory esophageal stricture. In addition, ileocolon interposition may help to improve the quality-of-life of patients.
文摘Select group of patients with concurrent esophagealand gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with significant complications and have up to 18% ischemic conduit necrosis. Following corrosive intake, up to 30% of such patients have stricturing at the pyloro-duodenal canal area only and rest of the stomach is available for rather less complex and better perfused gastrointestinal reconstruction. Here we describe an alternative technique where we utilize stomach following distal gastric resection along with Roux-en-Y reconstruction instead of colonic or jejunal interposition. This neo-conduit is potentially superior in terms of perfusion, lower risk of gastro-esophageal anastomotic leakage and technical ease as opposed to colonic and jejunal counterparts. We have utilized the said technique in three patients with acceptable postoperative outcome. In addition this technique offers a feasible reconstruction plan in patients where colon is not available for reconstruction due to concomitant pathology. Utility of this technique may also merit consideration for gastroesophageal junction tumors.
文摘Symptomatic hepato-diaphragmatic interposition of a bowel loop or Chilaiditi's syndrome is a peculiar anatomical condition most often found by chance. Its described symptoms range from intermittent, mild abdominal pain and dyspepsia to acute intestinal obstruction. We report a case of hepato-diaphragmatic migration of the hepatic flexure of the colon associated to an unusual, heretofore unreported, angina-like pain exclusively evoked by the left lateral decubitus. To maximize the chance of observing anatomical changes in different postures, computed tomography of the chest and abdomen was performed after air insufflation into the colon. While frank herniation into the chest was excluded, the scan showed that the hepatic flexure-with the interposition of the diaphragm-came in contact with the right side of the heart in the left lateral, but not in the supine, decubitus. This finding was reproduced by echocardiography which also showed virtually unaltered hemodynamics after the change of posture. ECG, left and right ventricular global and regional function as well as cardiac injury markers also remained unchanged during the maneuver, indicating that the pain evoked by the latter was unlikely due to myocardial ischemia. This case suggests that Chilaiditi's syndrome should be included among the possible, although rare,causes of unexplained angina-like symptoms.
文摘BACKGROUND: Bilio-intestinal drainage is routinely per- formed by Roux-en-Y reconstruction after resection of the central bile duct. Alternatively reconstruction can be achieved by cholangio-duodenal interposition of an isolated jejunal segment (CDJI). This method offers the benefit of potential endoscopic control and intervention during fol- low-up. Critics of CDJI assume a higher rate of postopera- tive cholangitis compared to the Roux-en-Y construction. METHODS: Seventy-six patients with malignant tumors (n = 56) or benign strictures and choledochal cysts (n =20) were treated between 1989 and 2002 by cholangio-duodenal interposition of an isolated jejunal segment (measuring 15- 25 cm) after central bile duct resection. In 22 patients endoscopic control was first performed postoperatively dur- ing hospitalization. In 12 patients bilio-intestinal anastomo- sis could be inspected endoscopically. In the remaining patients the anastomosis could not be visualized endoscopi- cally because of kinking of the jejunal segment, but in all patients it could be evaluated by endoscopic retrograde cholangiography (ERC). RESULTS: During follow-up, 25 (33%) patients died from extrahepatic tumor recurrence. Three patients receiving CDJI after severe iatrogenic bile duct injury developed anas- tomotic strictures. Two of these patients were treated by endoscopic pigtail drainage, and one was treated by percu- taneous drainage. Two patients who had received CDJI af- ter choledochal cyst resection developed cholestasis post- operatively because of sludge formation (1 patient) and an intrahepatic concrement (1), which could be solved endo- scopically. One patient after resection of a Klatskin tumor developed an anastomotic stricture which could not be vi- sualized endoscopically, making percutaneous drainage necessary. The rate of postoperative cholangitis after CDJI in our patients was comparable to that after the Roux-en-Y reconstruction.CONCLUSION: Interposition of an isolated jejunal seg- ment for reconstruction after bile duct resection should be performed in patients with a high risk of postoperative ste- nosis. To benefit endoscopic follow-up the jejunal segment should be shorter than 20 cm.
文摘BACKGROUND Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair.We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs.We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair.AIM To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model.METHODS A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear.We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair.In seven specimens,the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens.Five specimens with an intact tendon were tested.The specimens underwent cyclic loading to determine the ultimate failure load and gap formation.RESULTS The mean gap formation after 3000 cycles was 1.67 mm in the continuous group,and 4.16 mm in the mattress group(P=0.001).The mean ultimate failure load was significantly higher at 549.2 N in the continuous group,426.4 N in the mattress group and 370 N in the intact group(P=0.003).CONCLUSION The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.
基金Supported by 2024 Government-funded Clinical Medicine Talent Project,No.ZF2024122.
文摘BACKGROUND The incidence of gastric cancer has significantly increased in recent years.Surgical resection is the main treatment,but the method of digestive tract reconstruction after gastric cancer surgery remains controversial.In the current study,we sought to explore a reasonable method of digestive tract reconstruction and improve the quality of life and nutritional status of patients after surgery.To this end,we statistically analyzed the clinical results of patients with gastric cancer who underwent jejunal interposition double-tract reconstruction(DTR)and esophageal jejunum Roux-en-Y reconstruction(RY).AIM To explore the application effect of DTR in total laparoscopic radical total gastrectomy(TLTG)and evaluate its safety and efficacy.METHODS We collected the relevant data of 77 patients who underwent TLTG at the Fourth Hospital of Hebei Medical University from October 2021 to January 2023.Among them,35 cases were treated with DTR,and the remaining 42 cases were treated with traditional RY.After 1:1 propensity score matching,the cases were grouped into 31 cases per group,with evenly distributed data.The clinical characteristics and short-and long-term clinical outcomes of the two groups were statistically analyzed.RESULTS The two groups showed no significant differences in basic data,intraoperative blood loss,number of lymph node dissections,first defecation time after operation,postoperative hospital stay,postoperative complications,and laboratory examination results on the 1st,3rd,and 5th days after operation.The operation time of the DTR group was longer than that of the RY group[(307.58±65.14)min vs(272.45±62.09)min,P=0.016],but the first intake of liquid food in the DTR group was shorter than that in the RY group[(4.45±1.18)d vs(6.0±5.18)d,P=0.028].The incidence of reflux heartburn(Visick grade)and postoperative gallbladder disease in the DTR group was lower than that in the RY group(P=0.033 and P=0.038).Although there was no significant difference in body weight,hemoglobin,prealbumin,and albumin between the two groups at 1,3 and 6 months after surgery,the diet of patients in the DTR group was better than that in the RY group(P=0.031).CONCLUSION The clinical effect of DTR in TLTG is better than that of RY,indicating that it is a more valuable digestive tract reconstruction method in laparoscopic gastric cancer surgery.
文摘Esophageal reconstruction can be challenging when stomach and colon are not anatomically intact and their use as esophageal substitutes is therefore limited. Innovative individual approaches are then necessary to restore the intestinal passage. We describe a technique in which a short stump of the right hemicolon and 25 cm of ileum on a long, non-supercharged, fully mobilized ileocolic arterial pedicle were used for esophageal reconstruction to the neck. In this case, a 65 year-old male patient had accidentally indigested hydrochloric acid which caused necrosis of his upper digestive tract. An emergency esophagectomy, gastrectomy, duodenectomy, pancreatectomy and splenectomy had been performed in an outside hospital. A cervical esophagostomy and a biliodigestive anastomosis had been created and a jejunal catheter for enteral feeding had been placed. After the patient had recovered, a reconstruction of his food passage via the left and transverse colon failed for technical reasons due to an intraoperative necrotic demarcation of the colon. Our team then faced the situation that only a short stump of the right hemi-colon was left in situ when the patient was referred to our center. After intensified nutritional therapy, we reconstructed this patient's food passage with the right hemicolonapproach described herein. After treatment of a postoperative pneumonia, the patient was discharged from hospital on the 26 th postoperative day in a good clinical condition on an oral-only diet. In conclusion, individual approaches for long-segment reconstruction of the esophagus can be technically feasible in experienced hands. They do not always require arterial supercharging or free intestinal transplantation.
文摘Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay treatment for bile duct disease. The procedure is difficult per se, especially when a side-viewing duodenoscope is used, and when the patient has altered anatomical features, such as colonic interposition. Currently, there is no consensus on the standard approach for therapeutic ERCP in patients with total esophagectomy and colonic interposition. We describe a novel treatment design that involves the use of a side-viewing duodenoscope to perform therapeutic ERCP in patients with total esophagectomy and colonic interposition. A gastroscope was initially introduced into the interposed colon and a radio-opaque standard guidewire was advanced to a distance beyond the papilla of Vater, before the gastroscope was withdrawn. A sideviewing duodenoscope was then introduced along the guidewire under fluoroscopic guidance. After cannulation into the papilla of Vater, endoscopic retrograde chol-angiography (ERC) revealed a filling defect (maximum diameter: 15 cm) at the distal portion of the common bile duct (CBD). This defect was determined to be a stone, which was successfully retrieved by a Dormia basket after complete sphincterotomy. With this treatment design, it is possible to perform therapeutic ERCP in patients with colonic interposition, thereby precluding the need for percutaneous drainage or surgery.
文摘BACKGROUND:Obstructive jaundice is a common condition in advanced digestive cancer.Palliative procedures can improve quality of life and allow patients to attempt a systemic treatment.Bilioenteric anastomosis is still the procedure of choice for patients in many centers.When a surgical bypass is not possible,biliary drainage can be done by placing endoscopic or transparietal stents,which are less durable methods even when an expandable stent is employed. METHODS:A 47-year-old male with an excellent clinical status and a previous cholecystectomy and an exploratory laparotomy for advanced gastric cancer was referred with obstructive jaundice.A preoperative CT scan showed a dilated bile duct and a small mass at the distal hepatic hilum.No other signs of metastasis were found.A surgical bilioenteric anastomosis was indicated.At surgery,a distal choledochal obstruction and a mesenteric retraction by a lymph node mass prevented the jejunum to ascend for a bilioenteric anastomosis. Surgically,an alternative bilioenteric bypass was performed by means of an ileal loop interposition between the bile duct and the jejunum. RESULT:The recovery of the patient was uneventful and his bilirubin levels normalized after one week.The patient was then referred for systemic chemotherapy. CONCLUSIONS:This alternative biliary bypass can be safely and easily performed,and may be a good alternative for patients already referred for surgery because of a better life expectancy and when the jejunum is not an alternative.
