Tag: BVA

Introduction:

Early laparoscopic cholecystectomy is the golden standard treatment for acute cholecystitis [1]. The exact learning curve definition for laparoscopic cholecystectomy was not clearly defined because of the high variability of surgical scenario, but 25 procedures might be sufficient to acquire technical competency in laparoscopic cholecystectomy [2-3].

Persistent intraoperative bleeding can be a challenging complication, particularly when unexpected sources are involved.

Case Presentation:

We present a case of a 60-year-old male patient admitted with severe right upper quadrant pain, fever, and leukocytosis. No comorbidities. No previous abdominal surgeries. Acute cholecystitis was confirmed through clinical evaluation and imaging studies. An urgent laparoscopic cholecystectomy was planned at night. An empirical antibiotic therapy was administered early at admission.

Intraoperatively, extensive adhesions due to severe inflammation complicated the dissection process and obtaining the Critical View of Safety (CVS). Despite careful handling, the procedure was abruptly complicated by persistent and severe arterial bleeding. Maintaining composure, checking the normal anatomy to recognise the source of the bleeding and the biliary tree, in order to avoid injuries to the biliary duct or to the right hepatic artery, the surgical team employed laparoscopic techniques to achieve hemostasis without negative outcomes or conversion to laparotomy.These included gauze compression, suction and irrigation to clear the field, followed by careful clipping and ligation of the aberrant cystic artery. No postoperative complications occurred. The abdominal drain was removed at PO day 3 and the patient was discharged to home. At 1-month follow-up, the patient was fully recovered, without complications.

Discussion:

Iatrogenic bile duct injury still occurs in 0.2% to 0.8% of cases following cholecystectomy. In addition vascular damage can occur in approximately 12% to 61% of iatrogenic bile duct injury cases [4-6]. Uncontrolled bleeding from the cystic artery and its branches is a serious problem that may increase the risk of intraoperative injury to vital vascular and biliary structures. Anatomic variations of the cystic artery are frequent and can differ in origin, position and number[6-8]. The cystic artery variations were classified into three groups according to the position: (group 1) Calot’s triangle, (group 2) outside Calot’s triangle, and (group 3) compound type[8-11]. This case illustrates the critical importance of being prepared for unexpected anatomical cystic artery variations during laparoscopic cholecystectomy, especially in the setting of severe inflammation. When the anatomy of the Calot’triangle is not clear, and in case of persistent arterial bleeding of unknown origin, the use of ICG cholangiography is useful to avoid injuries to the biliary tract and to the right hepatic artery [12-14]. Prompt conversion to the open approach is always a safe option to consider.

Conclusion:

Persistent intraoperative bleeding during laparoscopic cholecystectomy for acute cholecystitis is a serious complication. Intraoperative vigilance and anatomy knowledge are essential to manage difficult laparoscopic cholecystectomy. The use of ICG fluorescence cholangiography/angiography is a valid tool to avoid injuries to the biliary duct or to the right hepatic artery. Prompt conversion to the open approach is always a safe option to consider.

References

1. Pisano, M., Allievi, N., Gurusamy, K. et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 15, 61 (2020). https://doi.org/10.1186/s13017-020-00336-x
2. Lombardi, P.M., Mazzola, M., Veronesi, V. et al. Learning curve of laparoscopic cholecystectomy: a risk-adjusted cumulative summation (RA-CUSUM) analysis of six general surgery residents. Surg Endosc 37, 8133–8143 (2023). https://doi.org/10.1007/s00464-023-10345-x
3. Reitano E, de’Angelis N, Schembari E, Carrà MC, Francone E, Gentilli S, La Greca G. Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review. ANZ J Surg. 2021 Sep;91(9):E554-E560. doi: 10.1111/ans.17021. Epub 2021 Jun 28. PMID: 34180567; PMCID: PMC8518700.
4. Thomas B. Hugh, Michael D. Kelly, Bei Li,Laparoscopic anatomy of the cystic artery. The American Journal of Surgery,Volume 163, Issue 6,1992,Pages 593-595,ISSN 0002-9610,https://doi.org/10.1016/0002-9610(92)90564-8.
5. Fateh, O., Wasi, M.S.I. & Bukhari, S.A. Anaotmical variability in the position of cystic artery during laparoscopic visualization. BMC Surg 21, 263 (2021). https://doi.org/10.1186/s12893-021-01270-8
6. Dandekar, Usha, Dandekar, Kundankumar, Cystic Artery: Morphological Study and Surgical Significance, Anatomy Research International, 2016, 7201858, 6 pages, 2016. https://doi.org/10.1155/2016/7201858
7. Ding YM, Wang B, Wang WX, Wang P, Yan JS.New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy. World J Gastroenterol 2007; 13(42): 5629-5634 [PMID: 17948938 DOI: 10.3748/wjg.v13.i42.5629]
8. Pesce A, Fabbri N, Feo CV. Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication. World J Gastrointest Surg. 2023 Mar 27;15(3):338-345. doi: 10.4240/wjgs.v15.i3.338. PMID: 37032796; PMCID: PMC10080601.
9. Lopez-Lopez V, Kuemmerli C, Cutillas J, Maupoey J, López-Andujar R, Ramos E, Mils K, Valdivieso A, Valero AP, Martinez PA, Paterna S, Serrablo A, Reese T, Oldhafer K, Brusadin R, Conesa AL, Valladares LD, Loinaz C, Garcés-Albir M, Sabater L, Mocchegiani F, Vivarelli M, Pérez SA, Flores B, Lucena JL, Sánchez-Cabús S, Calero A, Minguillon A, Ramia JM, Alcazar C, Aguilo J, Ruiperez-Valiente JA, Grochola LF, Clavien PA, Petrowsky H, Robles-Campos R. Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama. Surgery. 2022 Oct;172(4):1067-1075. doi: 10.1016/j.surg.2022.06.020. Epub 2022 Aug 12. PMID: 35965144.
10. Andall RG, Matusz P, du Plessis M, Ward R, Tubbs RS, Loukas M. The clinical anatomy of cystic artery variations: a review of over 9800 cases. Surg Radiol Anat. 2016 Jul;38(5):529-39. doi: 10.1007/s00276-015-1600-y. Epub 2015 Dec 23. PMID: 26698600.
11. De Simone, B., Abu-Zidan, F.M., Saeidi, S. et al. Knowledge, attitudes and practices of using Indocyanine Green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)—WSES project. Updates Surg (2024). https://doi.org/10.1007/s13304-024-01853-z%5D.
12. Di Maggio F, Hossain N, De Zanna A, Husain D, Bonomo L. Near-Infrared Fluorescence Cholangiography can be a Useful Adjunct during Emergency Cholecystectomies. Surg Innov. 2022 Aug;29(4):526-531. doi: 10.1177/1553350620958562. Epub 2020 Sep 16. PMID: 32936054.
13. Stolz MP, Foxhall EN, Gibson BH, Gill S, McNamee MM. Improving the Safety of Laparoscopic Cholecystectomy with Indocyanine Green Dye Using Critical View of Safety Plus. Am Surg. 2023 Jul;89(7):3136-3139. doi: 10.1177/00031348231161659. Epub 2023 Mar 1. PMID: 36857190.;
14. D’Acapito F, Cucchetti A, Solaini L, Serenari M, Framarini M, Ercolani G. Fluorescence Cholangiography Using Indocyanine Green Improves the Identification of Biliary Structures During Laparoscopic Cholecystectomy. World J Surg. 2023 Mar;47(3):666-673. doi: 10.1007/s00268-022-06854-w. Epub 2022 Dec 2. PMID: 36459198.

Summary

We present the case of a 64-year-old woman underwent elective cholecystectomy for stones. Her clinical history included episodes of acute cholecystitis, dyspepsia, obesity. The US described a small gallbladder with thickened and poorly distended walls, as from scelo-atrophic gallbladder. During surgery, we performed a difficult Critical View of Safety because of unexpected small organ size, about 2,5 cm, and its intra-hepatic position. After an antegrade cholecystectomy, a carefully and slow dissection needed to recognize the cystic duct and artery and to complete surgery safely. In this video we want to highlight the difficulties related to an usual simple surgery, the risks of complications and the possible strategies to avoid them. 

Summary

Aim: Iatrogenic colonoscopy perforation is a rare complication, rate ranges from 0.005-0.085%. Perforations can be diagnosed by the endoscopist in 50% of the cases. Different therapeutic options could be found such as endoscopic repair, surgical management or conservative treatment. The aim of this video is to discuss a possible repair after a midrectal perforation during an endoscopy exploration.

Methods: We describe the case of a patient with an early-detection of a large rectal perforation during an screening colonoscopy with urgent laparoscopic repair.

Results: A 41-year-old woman suffered a rectal perforation during a screening colonoscopy due to family history. A large defect is detected during endoscopy with access to the abdominal cavity, so urgent exploratory laparoscopy is indicated immediately.

An exploratory laparoscopy was performed, showing perforation of 50% of the circumference at the level of the high intraperitoneal rectum of about 6-7 cm in extension with peritonitis in the pelvis. Given the findings, a anterior high resection of the rectum was performed with correct viability of the tissue detected by indocyanine green. Since the tissues looked good and it was a colon that had received mechanical preparation, the possibility of anastomosis was considered. A mechanical circular colorectal anastomosis was performed with a 31mm EEA and a pelvic drainage was placed.

The patient’s postoperative evolution was correct, and she was discharged on the 4th postoperative day with a control abdominal CT scan without signs of anastomotic dehiscence

Conclusion: According to the main clinical guidelines, therapeutic management in these situations should be adjusted to the patient’s baseline situation and the early or late diagnosis of the perforation, as well as its extension, the practitioner’s expertise and availability of surgical instruments in order to reduce morbidity and mortality in these situations emergency situations.

Introduction

Chagas disease, caused by the parasite Trypanosoma cruzi, is a major cause of secondary esophageal achalasia in endemic areas of Central and South America. It has clinical consequences in the heart and digestive tract. The most important changes in the digestive tract occur in the esophagus and colon. Chagas esophageal disease, also known as megaesophagus, is a severe manifestation of Chagas disease. The parasite is primarily transmitted through the feces of triatomine bugs, commonly known as “kissing bugs,” which bite humans and deposit the parasite near the bite wound. Esophageal achalasia results from the destruction of the esophageal intramural nerve plexus, leading to impaired lower esophageal sphincter (LES) relaxation and esophageal aperistalsis. As a result, patients experience severe dysphagia, regurgitation of food, chest pain, and weight loss. The esophagus becomes dilated and elongated, forming what is known as a megaesophagus. Diagnosis of Chagas esophageal disease involves a combination of clinical evaluation, serological tests to detect antibodies against Trypanosoma cruzi, and imaging studies such as barium swallow radiographs and esophageal manometry. Treatment options for Chagas esophageal disease are primarily aimed at relieving symptoms and improving the patient’s quality of life. Pharmacological treatments include the use of nitrates and calcium channel blockers to relax the LES. Surgical treatment options for achalasia, including laparoscopic Heller’s myotomy (LHM) and pneumatic dilation (PD), are commonly used. LHM involves cutting the muscle fibers at the LES to facilitate food passage and is often combined with fundoplication to reduce the risk of post-procedural gastroesophageal reflux disease (GERD). This surgical technique is considered the gold standard. While both PD and LHM are effective in the long-term control of achalasia symptoms, LHM has been associated with a significantly lower risk of esophageal perforation. Pneumatic dilation, which involves inserting and inflating a balloon at the LES, carries a higher risk of perforation, reported in up to 5.1% of cases compared to 0.9% for LHM. While both LHM and PD effectively alleviate achalasia symptoms, GERD remains a notable post-surgical complication. LHM with fundoplication reduces this risk significantly, with post-procedural GERD rates ranging from 9% to 23%, depending on the type of fundoplication used. In contrast, PD, though effective, has a slightly higher risk of GERD, with up to 31.5% of patients developing reflux in the absence of fundoplication. More recently, peroral endoscopic myotomy (POEM) has emerged as a minimally invasive option, particularly beneficial for patients with type III achalasia. POEM offers success rates over 90% in the short term, but GERD remains a frequent complication due to the lack of anti-reflux measures.

Aim

Reporting a case of a patient with chronic chagasic achalasia, which was complicated by esophageal perforation after Heller’s myotomy and was successfully managed by laparoscopic esophageal suturing.

Methods

A 59-year-old patient from Chile was admitted with progressive dysphagia, vomiting and megaesophagus. The endoscopy showed a dilated esophagus with stenosis of the distal third and retained food. A barium swallow study and high-resolution esophageal manometry confirmed esophageal dilatation and achalasia. The patient underwent an elective laparoscopic Heller myotomy with Dor fundoplication. On postoperative day 2, he developed severe intermittent chest and abdominal pain and high drain fluid amylase concentration (49.000 U/L). A CT scan demonstrated small pneumomediastinum, small bilateral pleural effusion, and suspicion of oral contrast leakage. The patient underwent an urgent diagnostic laparoscopy that revealed a 4cm esophageal longitudinal perforation at the posterolateral wall, after the Dor fundoplication reversal. A 36-Fr orogastric tube was inserted across the GE Junction into the stomach and primary repair was performed with interrupted 3–0 Vicryl-plus stitches. Then, an omental patch was sutured over the perforation area. A feeding jejunostomy was inserted for postoperative nutritional support, and a nasogastric tube was inserted to the stomach. Drains were placed intrabdominal and posterior mediastinal. The patient was discharged home in good condition 12 days post op.

Conclusions

Although surgical treatments like LHM, PD, and POEM effectively manage esophageal achalasia in Chagas disease, the choice of procedure must weigh the risk of complications like esophageal perforation and GERD. Laparoscopic Heller myotomy and fundoplication is considered as treatment of choice for idiopathic and chagasic achalasia. Laparoscopic intervention with primary repair of perforated esophagus may be challenging, but it can be a good and life-saving choice instead of esophagectomy.

References

1. Dantas RO. Management of Esophageal Dysphagia in Chagas Disease. 2021 Jun;36(3):517-522.
2. Kirchhoff LV. American trypanosomiasis (Chagas’ disease). Gastroenterol Clin North Am. 1996 Sep;25(3):517-33.
3. Dantas RO. Influence Of Esophageal Motility Impairment On Upper And Lower Esophageal Sphincter Pressure In Chagas Disease. Arq Gastroenterol. 2024 Jun 17;61:e23174.
4. Costa LCDS, Braga JGR, Tercioti Junior V, et all. Surgical treatment of relapsed megaesophagus. Rev Col Bras Cir. 2020 Jun 8;47:e20202444.
5. Bonifácio P, de Moura DTH, Bernardo WM, et all. Pneumatic dilation versus laparoscopic Heller’s myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus. 2019 Feb 1;32(2)