Post-surgical leaks and fistulas are the most feared complication of bariatric surgery.They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to tre...Post-surgical leaks and fistulas are the most feared complication of bariatric surgery.They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat.These two related conditions must be distinguished and characterized to guide the appropriate treatment.Leak is defined as a transmural defect with communication between the intra and extraluminal compartments,while fistula is defined as an abnormal communication between two epithelialized surfaces.Traditionally,surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates.However,with the development of novel devices and techniques,endoscopic therapy plays an increasingly essential role in managing these conditions.Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas.Several endoscopic techniques are available with different mechanisms of action,including direct closure,covering/diverting or draining.The treatment should be individualized by considering the characteristics of both the patient and the defect.Although there is a lack of high-quality studies to provide standardized treatment algorithms,this narrative review aims to provide a summary of the current scientific evidence and,based on this data and our extensive experience,make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.展开更多
Unanticipated sabotage of two underwater pipelines in the Baltic Sea(Nord Stream 1 and 2)happened on 26September 2022.Massive quantities of natural gas,primarily methane,were released into the atmosphere,which lasted ...Unanticipated sabotage of two underwater pipelines in the Baltic Sea(Nord Stream 1 and 2)happened on 26September 2022.Massive quantities of natural gas,primarily methane,were released into the atmosphere,which lasted for about one week.As a more powerful greenhouse gas than CO_(2),the potential climatic impact of methane is a global concern.Using multiple methods and datasets,a recent study reported a relatively accurate magnitude of the leaked methane at 0.22±0.03 million tons(Mt),which was lower than the initial estimate in the immediate aftermath of the event.Under an energy conservation framework used in IPCC AR6,we derived a negligible increase in global surface air temperature of 1.8×10^(-5)℃ in a 20-year time horizon caused by the methane leaks with an upper limit of 0.25 Mt.Although the resultant warming from this methane leak incident was minor,future carbon release from additional Earth system feedbacks,such as thawing permafrost,and its impact on the methane mitigation pathways of the Paris Agreement,warrants investigation.展开更多
AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n=12) and bile leaks...AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n=12) and bile leaks (n=5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL (Conmed, Utica, New York, United States) stents and three had Wallflex (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall blad-der fossa. Rate of complications such as migration, and instent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement. RESULTS: All 17 patients underwent successful FC- SEMS placement and removal. Etiologies of BBS included: cholecystectomies (n=8), cholelithiasis (n=2), hepatic artery compression (n=1), pancreatitis (n=2), and Whipple procedure (n=1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n=7), common hepatic duct (n=1), hepaticojejunal anastomosis (n=2), right intrahepatic duct (n=1), and choledochoduo-denal anastomatic junction (n=1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n=2), stent clogging (n=1), cholangitis (n=1), and sepsis with hepatic abscess (n=1). CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.展开更多
The modern field of Forensic Engineering evaluates the origin, cause, and duration of failed building components. As many failed components are subject to insurance claims and legal probes, a scientific methodology fo...The modern field of Forensic Engineering evaluates the origin, cause, and duration of failed building components. As many failed components are subject to insurance claims and legal probes, a scientific methodology for evaluating such events is inherently valuable. Due to the potential for widespread interior finish damage, failed plumbing supply components are commonly encountered during forensic evaluations. Plumbing pipes?themselves and properly soldered fittings rarely fail. Consequently, many failures correspond to mechanical fittings which form connections from pipes to plumbing fixtures.?The results of this study provide a scientific methodology to evaluate the duration of connection leaks by quantifying the extent of corrosion, patina, and accumulated deposits on various components?by creating and evaluating slow plumbing supply component connection leaks.展开更多
<strong>Background:</strong> To present the experience of management of leaks following laparoscopic sleeve gastrectomy for morbid obesity in Show-Chwan memorial Hospital. <strong>Patients and Method...<strong>Background:</strong> To present the experience of management of leaks following laparoscopic sleeve gastrectomy for morbid obesity in Show-Chwan memorial Hospital. <strong>Patients and Methods:</strong> Laparoscopic sleeve gastrectomy is considered one of the surgical options for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. The first laparoscopic sleeve gastrectomy was performed in January 2010 at Show-Chwan Memorial Hospital. Between January 2010 and October 2016, 300 patients underwent laparoscopic sleeve gastrectomy for morbid obesity. There were 218 women and 82 men with a mean age of 35.4 years. Preoperative mean body weight was 90.7 kg and mean body mass index (BMI) was 37.3 kg/m2. <strong>Results:</strong> Mean operative time was 85 minutes. Mean hospital stay was 3.5 days. There were no deaths. There were 5 complications (1.67%): leakage of gastroesophageal junction. One patient was conservative treatment. Two patients were successfully treated by self-expandable metallic stents and the other two patients were treated with esophageal stent also, but failed and further treated with fibrin (Histoacryl) injection to the leak site to try to seal the fistula. In six months follow-up, mean BMI decreased from 37.3 to 29.2 kg/m2, and mean excess weight loss reached 42.8%. <strong>Conclusions:</strong> Laparoscopic sleeve gastrectomy is a beneficial operation in terms of excessive weight loss, with acceptably complications. The leaks were located in gastroesophageal junction mostly, and could be resolved with esophageal stent. For the patients failed in esophageal stents, we try Histoacryl injection to improve it.展开更多
According to data from the China E-commerce Complaint and Rights Safeguard Public Service Platform,information leaks are no more in the top 10 complaint issues,showing that e-commerce companies have made improvements ...According to data from the China E-commerce Complaint and Rights Safeguard Public Service Platform,information leaks are no more in the top 10 complaint issues,showing that e-commerce companies have made improvements to the protection of user information.However,as online purchasing further develops,how to prevent user information leaks and stealing of account information is展开更多
Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated ...Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size,location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment.However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.展开更多
Gastrointestinal leaks and fistulae are serious, potentially life threateningconditions that may occur with a wide variety of clinical presentations. Leaks aremostly related to post-operative anastomotic defects and a...Gastrointestinal leaks and fistulae are serious, potentially life threateningconditions that may occur with a wide variety of clinical presentations. Leaks aremostly related to post-operative anastomotic defects and are responsible for animportant share of surgical morbidity and mortality. Chronic leaks and longstanding post-operative collections may evolve in a fistula between twoepithelialized structures. Endoscopy has earned a pivotal role in the managementof gastrointestinal defects both as first line and as rescue treatment. Endotherapyis a minimally invasive, effective approach with lower morbidity and mortalitycompared to revisional surgery. Clips and luminal stents are the pioneer ofgastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closuredevices and techniques, such as endoscopic internal drainage, suturing systemand vacuum therapy, has broadened the indications of endoscopy for themanagement of GI wall defect. Although several endoscopic options are currentlyused, a standardized evidence-based algorithm for management of GI defect isnot available. Successful management of gastrointestinal leaks and fistulaerequires a tailored and multidisciplinary approach based on clinical presentation,defect features (size, location and onset time), local expertise and the availabilityof devices. In this review, we analyze different endoscopic approaches, which weselected on the basis of the available literature and our own experience. Then, weevaluate the overall efficacy and procedural-specific strengths and weaknesses ofeach approach.展开更多
BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their...BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8%(95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy(HE), respectively, and doubled(20%) after totally minimally invasive esophagectomy(TMIE)(P = 0.016). No other predictive factors were found. The 30-and 90-d overall mortality rates were 1.4% and 3.2%,respectively; the 30-and 90-d leak-related mortality rates were 5.1% and 10.2%,respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%,respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%). Removal of the gastric tube with stoma formation was necessary in 8(13.6%) cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However, the general and specific(leak-related) mortality rates were low. Early treatment(surgical or endoscopic) of severe leaks is mandatory to limit related mortality.展开更多
BACKGROUND:Endoscopic retrograde cholangiopan- creatography(ERCP)with placement of a biliary stent or nasobiliary(NB)drain is the procedure of choice for treatment of post-cholecystectomy bile duct leaks.The aim of th...BACKGROUND:Endoscopic retrograde cholangiopan- creatography(ERCP)with placement of a biliary stent or nasobiliary(NB)drain is the procedure of choice for treatment of post-cholecystectomy bile duct leaks.The aim of this study was to compare the effect of NB drainage versus internal biliary stenting on rates of leak closure, time elapsed until drain or stent removal,length of hospital stay and number of required endoscopic procedures. METHODS:Charts were reviewed on 20 patients who underwent laparoscopic cholecystectomy complicated by Luschka or cystic duct leak.Ten patients were treated with NB drains connected to low intermittent suction and repeat NB cholangiograms were performed until leak closure was observed.Ten patients were treated with internal biliary stents.Biliary sphincterotomies were performed for stone extraction or a presumed papillary stenosis.Large bilomas were drained percutaneously prior to stenting. RESULTS:In all 20 patients,a cholangiogram and successful placement of a NB drain or internal stent was achieved.Four patients(20%)were found to have bile duct stones,which were extracted following a sphincterotomy. Sixteen patients required percutaneous drains to evacuate large bilomas prior to biliary instrumentation.Fifteen cystic duct leaks and 5 Luschka duct leaks were reviewed. There were no complications related to ERCP.Closure of the leak was documented within 2 to 11 days(mean 4.7±0.9 days)in patients receiving a NB drain.The drains were removed non-endoscopically following leak closure. The internal stent group required stenting for 14 to 53 days(mean 29.1±4.4 days).The stent was then removed endoscopically after documentation of leak closure.Bile leaks following laparoscopic cholecystectomy closed rapidly after NB drainage and did not require repeat endoscopy for removal of the NB drain,resulting in fewer ERCPs required for treatment of biliary leaks.Internal biliary stents were in place longer owing to the nature of this intermittent endoscopic approach but an accurate comparison of time to leak closure could not be determined. Leak closure resulted once the bile flow was re-established, regardless of the technique,but removal of the NB drains was performed earlier than removal of the biliary stents. The number of ERCPs required per patient was 1.0±0 in the NB group and 2.2±0.1(range 2-3)in the internal stent group.The length of hospitalization was 8.7±3.3 days for the NB group and 7.5±2.3 days for the internal stent group.Biliary stent placement resulted in an insignificant decrease in hospitalization at the expense of generating twice as many endoscopic procedures. CONCLUSIONS:Our data suggest that NB drainage may be advantageous in patients requiring a prolonged hospital admission or in patients in whom repeat endoscopy is undesirable.Internal biliary stenting appears preferable when early discharge is anticipated or when expertise in placement and management of NB drains is lacking.展开更多
Between April 2013 and October 2015, 6 patients developed periampul ary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with pr...Between April 2013 and October 2015, 6 patients developed periampul ary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experiencedstent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.展开更多
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may...Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.展开更多
The reliability of industrial installation requires minimum leakage of pressurized sealed joints during operation. At the design stage, the leakage behavior of the gasket must be one of the most important parameter in...The reliability of industrial installation requires minimum leakage of pressurized sealed joints during operation. At the design stage, the leakage behavior of the gasket must be one of the most important parameter in the gasket selection. The objective of the work presented in this paper is to develop an analytical leak rate prediction methodology used in gasketed joints. A pseudo analytical-experimental innovative approach was used to estimate the characteristics of the porous structure for the purpose of predicting accurate leak rate through gaskets with different fluids under conditions similar to those of operation. The analytical model assumes the flow to be continuum but employs a slip boundary condition on the leak path wall to determine the porosity parameters of the gasket. The analytical model results are validated and confronted against experimental data which were conducted under various conditions of fluid media, pressure, gasket stress and temperature. Two experimental test rigs fully automate that accurately reproduces the real leakage behavior of the gasketed joint have been developed to analyze the mechanical and thermal effects on the gasket flow regime. The gas leaks were measured with multi-gas mass spectrometers while liquid leaks were measure using a sophisticated detection system based on the pressure rise method.展开更多
BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a ...BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.展开更多
BACKGROUND Intraoperative methylene blue testing(IMBT),air leak testing,or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer.Totally laparosc...BACKGROUND Intraoperative methylene blue testing(IMBT),air leak testing,or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer.Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades.However,reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.AIM To explore the effects of IMBT on the incidence of postoperative anastomotic leaks(PALs)and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.METHODS From January 2017 to December 2019,patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed.According to whether or not they experienced an IMBT,the patients were divided into an IMBT group and a control group.If the IMBT was positive,an intraoperative suture was required to reinforce the anastomosis.The difference in the incidence of PALs was compared,and the risk factors were investigated.RESULTS This study consisted of 513 patients,211 in the IMBT group and 302 in the control group.Positive IMBT was shown in seven patients(3.3%)in the IMBT group,and no PAL occurred in these patients after suture reinforcement.Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index(BMI)>25 kg/m2(hazard ratio[HR]=8.357,P=0.009),operation time>4 h(HR=55.881,P=0.002),and insufficient surgical experience(HR=15.286,P=0.010).Moreover,15 patients(2.9%)developed PALs in 513 patients,and the rates of PALs were significantly lower in the IMBT group than in the control group[2 of 211 patients(0.9%)vs 13 of 302 patients(4.3%),P=0.0026].Further analysis demonstrated that preoperative complications(HR=13.128,P=0.017),totally laparoscopic total gastrectomy(HR=9.075,P=0.043),and neoadjuvant chemotherapy(HR=7.150,P=0.008)were independent risk factors for PALs.CONCLUSION IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy,thus preventing technical defect-related anastomotic leaks.Preoperative complications,totally laparoscopic total gastrectomy,and neoadjuvant chemotherapy are independent risk factors for PALs.展开更多
Objectives: The aim of this study was to assess the safety and efficacy of percutaneous CT-guided drainage of gastric leaks post sleeve gastrectomy. Methods: For this single-center retrospective study, we reviewed the...Objectives: The aim of this study was to assess the safety and efficacy of percutaneous CT-guided drainage of gastric leaks post sleeve gastrectomy. Methods: For this single-center retrospective study, we reviewed the clinical data of 78 patients (44 men and 34 women with an average age of 34.6 ±10.5 years and a body mass index (BMI) of 45 kg/m2 ±3.2) that underwent percutaneous CT-guided drainage of gastric leaks due to sleeve gastrectomy from September 2011 to September 2018. The outcome measurements were technical and clinical success, complications, and the need for revisional surgery. Results: The technical success rate of drain insertion was 97.5% (76/78 patients). All of the patients (76/76 patients) exhibited early clinical and laboratory improvement, and no emergency surgery was required. However, six patients underwent revisional surgery after 3 - 5 months for non-healing gastric leaks/fistulas. One patient had a major complication of active bleeding due to arterial injury;this was managed by transcatheter coil embolization. All patients underwent endoluminal stent placement and received antimicrobial therapy and nutritional support. Conclusion: Percutaneous CT-guided drainage of gastric leaks after sleeve gastrectomy is a safe, effective, and minimally invasive alternative to surgery. This technique is in line with other conservative measures (endoluminal stent placement, antimicrobial therapy, and nutritional support), which heal most gastric leaks due to sleeve gastrectomy and prevent the need for revisional surgery.展开更多
<strong>Background:</strong> Coincidental pleural effusion has been observed by computed tomography (CT) scans in individual patients with gastric leaks after laparoscopic sleeve gastrectomy;however, the f...<strong>Background:</strong> Coincidental pleural effusion has been observed by computed tomography (CT) scans in individual patients with gastric leaks after laparoscopic sleeve gastrectomy;however, the frequency of this phenomenon has not been investigated in cohort studies. <strong>Objectives:</strong> This study aimed to assess the diagnostic accuracy of left pleural effusion as an indicator of gastric leaks after laparoscopic sleeve gastrectomy. <strong>Setting:</strong> University hospital and bariatric surgery center of excellence. <strong>Methods:</strong> This single-center retrospective analysis included consecutive patients who had undergone laparoscopic sleeve gastrectomy followed by CT scans to investigate suspected gastric leaks from September 2011 to September 2018. The sensitivity, specificity, Youden’s index, and predictive values were estimated using a 2 × 2 cross-tabulation. <strong>Results:</strong> The study involved assessing the CT scans of 148 patients;80 patients (44 men and 36 women, mean age: 34 years, mean body mass index {BMI}: 46 kg/m<sup>2</sup>) had positive findings of gastric leaks after laparoscopic sleeve gastrectomy, such as contrast leak, gas leak, and peri-gastric collection (either singly or in combination). The CT findings were negative for gastric leaks in 68 patients (38 men and 30 women, mean age: 33 years, mean BMI: 45 kg/m<sup>2</sup>). Pleural effusion manifested as a fluid density in the dependent portion of pleural cavity on CT. The sensitivity of left pleural effusion to predict gastric leaks after laparoscopic sleeve gastrectomy was 73.8%, and the specificity was 91.2%. The positive and negative predictive values were 90.8% and 74.7%, respectively, and the Youden’s index was 64.9%. <strong>Conclusion:</strong> Left pleural effusion exhibits good diagnostic accuracy for gastric leaks after laparoscopic sleeve gastrectomy. Notably, the specificity (91.2%) was very high.展开更多
Coronavirus disease 2019(COVID-19)continues to create havoc and may present with myriad complications involving many organ systems.However,the respiratory system bears the maximum brunt of the disease and continues to...Coronavirus disease 2019(COVID-19)continues to create havoc and may present with myriad complications involving many organ systems.However,the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected.There is a high incidence of air leaks in patients with COVID-19,leading to acute worsening of clinical condition.The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and underlying lung disease.The exact pathophysiology of air leaks with COVID-19 remains unclear,but multiple factors may play a role in their development.A significant proportion of air leaks may be asymptomatic;hence,a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality.These air leaks may even develop weeks to months after the disease onset,leading to acute deterioration in the post-COVID period.Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.展开更多
Importance:The safety and efficacy of the bath-plug technique for the closure of cerebrospinal fluid(CSF)leaks in children remain unknown.Objective:We undertook this study to ascertain whether the bath-plug technique ...Importance:The safety and efficacy of the bath-plug technique for the closure of cerebrospinal fluid(CSF)leaks in children remain unknown.Objective:We undertook this study to ascertain whether the bath-plug technique was safe and effective for the repair of CSF leaks.Methods:We retrospectively reviewed patients who underwent endoscopic repair of CSF leaks with the fat graft as a plug-in at Beijing Children’s Hospital from March 2016 to May 2020.Demographic data,medical history,defect sites and sizes,interventions,and clinical outcomes were analyzed.One representative clinical case was additionally selected to highlight the procedure and the healing process.Results:A total of 18 pediatric patients were included in this study.The group was composed of 11 boys and seven girls,aged from 5 to 123 months.The etiologies included congenital CSF leaks(n=9)and head trauma(n=9).Among all patients,12 fistulas(66.7%)were located at the cribriform plate area,two(11.1%)at the roof of the ethmoid sinuses,two(11.1%)in the sphenoid sinus,and two(11.1%)at the frontal sinus.The maximum diameters of fistulas ranged from 5 to 20 mm,with a median value of 8 mm.Encephaloceles were identified in 14(77.8%)patients.No hydrocephalus was recognized.All CSF leaks were successfully repaired with a bath-plug technique.Follow-up ranged from 50 to 70 months.No surgical complications were encountered in any patient.Interpretation:Bath-plug technique is safe and reliable for the endoscopic management of CSF leaks in children.Meticulous peri-operative preparations are important for pediatric patients.展开更多
Objectives:Anastomotic leakage(AL)stands out as a prevalent and severe complication following gastric cancer surgery.It frequently precipitates additional serious complications,significantly influencing the overall su...Objectives:Anastomotic leakage(AL)stands out as a prevalent and severe complication following gastric cancer surgery.It frequently precipitates additional serious complications,significantly influencing the overall survival time of patients.This study aims to enhance the risk-assessment strategy for AL following gastrectomy for gastric cancer.Methods:This study included a derivation cohort and validation cohort.The derivation cohort included patients who underwent radical gastrectomy at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine,from January 1,2015 to December 31,2020.An evidence-based predictor questionnaire was crafted through extensive literature review and panel discussions.Based on the questionnaire,inpatient data were collected to form a model-derivation cohort.This cohort underwent both univariate and multivariate analyses to identify factors associated with AL events,and a logistic regression model with stepwise regression was developed.A 5-fold cross-validation ensured model reliability.The validation cohort included patients from August 1,2021 to December 31,2021 at the same hospital.Using the same imputation method,we organized the validation-queue data.We then employed the risk-prediction model constructed in the earlier phase of the study to predict the risk of AL in the subjects included in the validation queue.We compared the predictions with the actual occurrence,and evaluated the external validation performance of the model using model-evaluation indicators such as the area under the receiver operating characteristic curve(AUROC),Brier score,and calibration curve.Results:The derivation cohort included 1377 patients,and the validation cohort included 131 patients.The independent predictors of AL after radical gastrectomy included age65 y,preoperative albumin<35 g/L,resection extent,operative time240 min,and intraoperative blood loss90 mL.The predictive model exhibited a solid AUROC of 0.750(95%CI:0.694e0.806;p<0.001)with a Brier score of 0.049.The 5-fold cross-validation confirmed these findings with a calibrated C-index of 0.749 and an average Brier score of 0.052.External validation showed an AUROC of 0.723(95%CI:0.564e0.882;p?0.006)and a Brier score of 0.055,confirming reliability in different clinical settings.Conclusions:We successfully developed a risk-prediction model for AL following radical gastrectomy.This tool will aid healthcare professionals in anticipating AL,potentially reducing unnecessary interventions.展开更多
文摘Post-surgical leaks and fistulas are the most feared complication of bariatric surgery.They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat.These two related conditions must be distinguished and characterized to guide the appropriate treatment.Leak is defined as a transmural defect with communication between the intra and extraluminal compartments,while fistula is defined as an abnormal communication between two epithelialized surfaces.Traditionally,surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates.However,with the development of novel devices and techniques,endoscopic therapy plays an increasingly essential role in managing these conditions.Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas.Several endoscopic techniques are available with different mechanisms of action,including direct closure,covering/diverting or draining.The treatment should be individualized by considering the characteristics of both the patient and the defect.Although there is a lack of high-quality studies to provide standardized treatment algorithms,this narrative review aims to provide a summary of the current scientific evidence and,based on this data and our extensive experience,make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.
基金supported by the National Key Research and Development Program(Grant No.2017YFA0603503)the National Natural Science Foundation of China(Grant No.41605057)。
文摘Unanticipated sabotage of two underwater pipelines in the Baltic Sea(Nord Stream 1 and 2)happened on 26September 2022.Massive quantities of natural gas,primarily methane,were released into the atmosphere,which lasted for about one week.As a more powerful greenhouse gas than CO_(2),the potential climatic impact of methane is a global concern.Using multiple methods and datasets,a recent study reported a relatively accurate magnitude of the leaked methane at 0.22±0.03 million tons(Mt),which was lower than the initial estimate in the immediate aftermath of the event.Under an energy conservation framework used in IPCC AR6,we derived a negligible increase in global surface air temperature of 1.8×10^(-5)℃ in a 20-year time horizon caused by the methane leaks with an upper limit of 0.25 Mt.Although the resultant warming from this methane leak incident was minor,future carbon release from additional Earth system feedbacks,such as thawing permafrost,and its impact on the methane mitigation pathways of the Paris Agreement,warrants investigation.
文摘AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n=12) and bile leaks (n=5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL (Conmed, Utica, New York, United States) stents and three had Wallflex (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall blad-der fossa. Rate of complications such as migration, and instent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement. RESULTS: All 17 patients underwent successful FC- SEMS placement and removal. Etiologies of BBS included: cholecystectomies (n=8), cholelithiasis (n=2), hepatic artery compression (n=1), pancreatitis (n=2), and Whipple procedure (n=1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n=7), common hepatic duct (n=1), hepaticojejunal anastomosis (n=2), right intrahepatic duct (n=1), and choledochoduo-denal anastomatic junction (n=1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n=2), stent clogging (n=1), cholangitis (n=1), and sepsis with hepatic abscess (n=1). CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.
文摘The modern field of Forensic Engineering evaluates the origin, cause, and duration of failed building components. As many failed components are subject to insurance claims and legal probes, a scientific methodology for evaluating such events is inherently valuable. Due to the potential for widespread interior finish damage, failed plumbing supply components are commonly encountered during forensic evaluations. Plumbing pipes?themselves and properly soldered fittings rarely fail. Consequently, many failures correspond to mechanical fittings which form connections from pipes to plumbing fixtures.?The results of this study provide a scientific methodology to evaluate the duration of connection leaks by quantifying the extent of corrosion, patina, and accumulated deposits on various components?by creating and evaluating slow plumbing supply component connection leaks.
文摘<strong>Background:</strong> To present the experience of management of leaks following laparoscopic sleeve gastrectomy for morbid obesity in Show-Chwan memorial Hospital. <strong>Patients and Methods:</strong> Laparoscopic sleeve gastrectomy is considered one of the surgical options for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. The first laparoscopic sleeve gastrectomy was performed in January 2010 at Show-Chwan Memorial Hospital. Between January 2010 and October 2016, 300 patients underwent laparoscopic sleeve gastrectomy for morbid obesity. There were 218 women and 82 men with a mean age of 35.4 years. Preoperative mean body weight was 90.7 kg and mean body mass index (BMI) was 37.3 kg/m2. <strong>Results:</strong> Mean operative time was 85 minutes. Mean hospital stay was 3.5 days. There were no deaths. There were 5 complications (1.67%): leakage of gastroesophageal junction. One patient was conservative treatment. Two patients were successfully treated by self-expandable metallic stents and the other two patients were treated with esophageal stent also, but failed and further treated with fibrin (Histoacryl) injection to the leak site to try to seal the fistula. In six months follow-up, mean BMI decreased from 37.3 to 29.2 kg/m2, and mean excess weight loss reached 42.8%. <strong>Conclusions:</strong> Laparoscopic sleeve gastrectomy is a beneficial operation in terms of excessive weight loss, with acceptably complications. The leaks were located in gastroesophageal junction mostly, and could be resolved with esophageal stent. For the patients failed in esophageal stents, we try Histoacryl injection to improve it.
文摘According to data from the China E-commerce Complaint and Rights Safeguard Public Service Platform,information leaks are no more in the top 10 complaint issues,showing that e-commerce companies have made improvements to the protection of user information.However,as online purchasing further develops,how to prevent user information leaks and stealing of account information is
文摘Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size,location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment.However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.
文摘Gastrointestinal leaks and fistulae are serious, potentially life threateningconditions that may occur with a wide variety of clinical presentations. Leaks aremostly related to post-operative anastomotic defects and are responsible for animportant share of surgical morbidity and mortality. Chronic leaks and longstanding post-operative collections may evolve in a fistula between twoepithelialized structures. Endoscopy has earned a pivotal role in the managementof gastrointestinal defects both as first line and as rescue treatment. Endotherapyis a minimally invasive, effective approach with lower morbidity and mortalitycompared to revisional surgery. Clips and luminal stents are the pioneer ofgastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closuredevices and techniques, such as endoscopic internal drainage, suturing systemand vacuum therapy, has broadened the indications of endoscopy for themanagement of GI wall defect. Although several endoscopic options are currentlyused, a standardized evidence-based algorithm for management of GI defect isnot available. Successful management of gastrointestinal leaks and fistulaerequires a tailored and multidisciplinary approach based on clinical presentation,defect features (size, location and onset time), local expertise and the availabilityof devices. In this review, we analyze different endoscopic approaches, which weselected on the basis of the available literature and our own experience. Then, weevaluate the overall efficacy and procedural-specific strengths and weaknesses ofeach approach.
文摘BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8%(95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy(HE), respectively, and doubled(20%) after totally minimally invasive esophagectomy(TMIE)(P = 0.016). No other predictive factors were found. The 30-and 90-d overall mortality rates were 1.4% and 3.2%,respectively; the 30-and 90-d leak-related mortality rates were 5.1% and 10.2%,respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%,respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%). Removal of the gastric tube with stoma formation was necessary in 8(13.6%) cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However, the general and specific(leak-related) mortality rates were low. Early treatment(surgical or endoscopic) of severe leaks is mandatory to limit related mortality.
文摘BACKGROUND:Endoscopic retrograde cholangiopan- creatography(ERCP)with placement of a biliary stent or nasobiliary(NB)drain is the procedure of choice for treatment of post-cholecystectomy bile duct leaks.The aim of this study was to compare the effect of NB drainage versus internal biliary stenting on rates of leak closure, time elapsed until drain or stent removal,length of hospital stay and number of required endoscopic procedures. METHODS:Charts were reviewed on 20 patients who underwent laparoscopic cholecystectomy complicated by Luschka or cystic duct leak.Ten patients were treated with NB drains connected to low intermittent suction and repeat NB cholangiograms were performed until leak closure was observed.Ten patients were treated with internal biliary stents.Biliary sphincterotomies were performed for stone extraction or a presumed papillary stenosis.Large bilomas were drained percutaneously prior to stenting. RESULTS:In all 20 patients,a cholangiogram and successful placement of a NB drain or internal stent was achieved.Four patients(20%)were found to have bile duct stones,which were extracted following a sphincterotomy. Sixteen patients required percutaneous drains to evacuate large bilomas prior to biliary instrumentation.Fifteen cystic duct leaks and 5 Luschka duct leaks were reviewed. There were no complications related to ERCP.Closure of the leak was documented within 2 to 11 days(mean 4.7±0.9 days)in patients receiving a NB drain.The drains were removed non-endoscopically following leak closure. The internal stent group required stenting for 14 to 53 days(mean 29.1±4.4 days).The stent was then removed endoscopically after documentation of leak closure.Bile leaks following laparoscopic cholecystectomy closed rapidly after NB drainage and did not require repeat endoscopy for removal of the NB drain,resulting in fewer ERCPs required for treatment of biliary leaks.Internal biliary stents were in place longer owing to the nature of this intermittent endoscopic approach but an accurate comparison of time to leak closure could not be determined. Leak closure resulted once the bile flow was re-established, regardless of the technique,but removal of the NB drains was performed earlier than removal of the biliary stents. The number of ERCPs required per patient was 1.0±0 in the NB group and 2.2±0.1(range 2-3)in the internal stent group.The length of hospitalization was 8.7±3.3 days for the NB group and 7.5±2.3 days for the internal stent group.Biliary stent placement resulted in an insignificant decrease in hospitalization at the expense of generating twice as many endoscopic procedures. CONCLUSIONS:Our data suggest that NB drainage may be advantageous in patients requiring a prolonged hospital admission or in patients in whom repeat endoscopy is undesirable.Internal biliary stenting appears preferable when early discharge is anticipated or when expertise in placement and management of NB drains is lacking.
文摘Between April 2013 and October 2015, 6 patients developed periampul ary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experiencedstent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.
文摘Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
文摘The reliability of industrial installation requires minimum leakage of pressurized sealed joints during operation. At the design stage, the leakage behavior of the gasket must be one of the most important parameter in the gasket selection. The objective of the work presented in this paper is to develop an analytical leak rate prediction methodology used in gasketed joints. A pseudo analytical-experimental innovative approach was used to estimate the characteristics of the porous structure for the purpose of predicting accurate leak rate through gaskets with different fluids under conditions similar to those of operation. The analytical model assumes the flow to be continuum but employs a slip boundary condition on the leak path wall to determine the porosity parameters of the gasket. The analytical model results are validated and confronted against experimental data which were conducted under various conditions of fluid media, pressure, gasket stress and temperature. Two experimental test rigs fully automate that accurately reproduces the real leakage behavior of the gasketed joint have been developed to analyze the mechanical and thermal effects on the gasket flow regime. The gas leaks were measured with multi-gas mass spectrometers while liquid leaks were measure using a sophisticated detection system based on the pressure rise method.
文摘BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.
文摘BACKGROUND Intraoperative methylene blue testing(IMBT),air leak testing,or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer.Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades.However,reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.AIM To explore the effects of IMBT on the incidence of postoperative anastomotic leaks(PALs)and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.METHODS From January 2017 to December 2019,patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed.According to whether or not they experienced an IMBT,the patients were divided into an IMBT group and a control group.If the IMBT was positive,an intraoperative suture was required to reinforce the anastomosis.The difference in the incidence of PALs was compared,and the risk factors were investigated.RESULTS This study consisted of 513 patients,211 in the IMBT group and 302 in the control group.Positive IMBT was shown in seven patients(3.3%)in the IMBT group,and no PAL occurred in these patients after suture reinforcement.Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index(BMI)>25 kg/m2(hazard ratio[HR]=8.357,P=0.009),operation time>4 h(HR=55.881,P=0.002),and insufficient surgical experience(HR=15.286,P=0.010).Moreover,15 patients(2.9%)developed PALs in 513 patients,and the rates of PALs were significantly lower in the IMBT group than in the control group[2 of 211 patients(0.9%)vs 13 of 302 patients(4.3%),P=0.0026].Further analysis demonstrated that preoperative complications(HR=13.128,P=0.017),totally laparoscopic total gastrectomy(HR=9.075,P=0.043),and neoadjuvant chemotherapy(HR=7.150,P=0.008)were independent risk factors for PALs.CONCLUSION IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy,thus preventing technical defect-related anastomotic leaks.Preoperative complications,totally laparoscopic total gastrectomy,and neoadjuvant chemotherapy are independent risk factors for PALs.
文摘Objectives: The aim of this study was to assess the safety and efficacy of percutaneous CT-guided drainage of gastric leaks post sleeve gastrectomy. Methods: For this single-center retrospective study, we reviewed the clinical data of 78 patients (44 men and 34 women with an average age of 34.6 ±10.5 years and a body mass index (BMI) of 45 kg/m2 ±3.2) that underwent percutaneous CT-guided drainage of gastric leaks due to sleeve gastrectomy from September 2011 to September 2018. The outcome measurements were technical and clinical success, complications, and the need for revisional surgery. Results: The technical success rate of drain insertion was 97.5% (76/78 patients). All of the patients (76/76 patients) exhibited early clinical and laboratory improvement, and no emergency surgery was required. However, six patients underwent revisional surgery after 3 - 5 months for non-healing gastric leaks/fistulas. One patient had a major complication of active bleeding due to arterial injury;this was managed by transcatheter coil embolization. All patients underwent endoluminal stent placement and received antimicrobial therapy and nutritional support. Conclusion: Percutaneous CT-guided drainage of gastric leaks after sleeve gastrectomy is a safe, effective, and minimally invasive alternative to surgery. This technique is in line with other conservative measures (endoluminal stent placement, antimicrobial therapy, and nutritional support), which heal most gastric leaks due to sleeve gastrectomy and prevent the need for revisional surgery.
文摘<strong>Background:</strong> Coincidental pleural effusion has been observed by computed tomography (CT) scans in individual patients with gastric leaks after laparoscopic sleeve gastrectomy;however, the frequency of this phenomenon has not been investigated in cohort studies. <strong>Objectives:</strong> This study aimed to assess the diagnostic accuracy of left pleural effusion as an indicator of gastric leaks after laparoscopic sleeve gastrectomy. <strong>Setting:</strong> University hospital and bariatric surgery center of excellence. <strong>Methods:</strong> This single-center retrospective analysis included consecutive patients who had undergone laparoscopic sleeve gastrectomy followed by CT scans to investigate suspected gastric leaks from September 2011 to September 2018. The sensitivity, specificity, Youden’s index, and predictive values were estimated using a 2 × 2 cross-tabulation. <strong>Results:</strong> The study involved assessing the CT scans of 148 patients;80 patients (44 men and 36 women, mean age: 34 years, mean body mass index {BMI}: 46 kg/m<sup>2</sup>) had positive findings of gastric leaks after laparoscopic sleeve gastrectomy, such as contrast leak, gas leak, and peri-gastric collection (either singly or in combination). The CT findings were negative for gastric leaks in 68 patients (38 men and 30 women, mean age: 33 years, mean BMI: 45 kg/m<sup>2</sup>). Pleural effusion manifested as a fluid density in the dependent portion of pleural cavity on CT. The sensitivity of left pleural effusion to predict gastric leaks after laparoscopic sleeve gastrectomy was 73.8%, and the specificity was 91.2%. The positive and negative predictive values were 90.8% and 74.7%, respectively, and the Youden’s index was 64.9%. <strong>Conclusion:</strong> Left pleural effusion exhibits good diagnostic accuracy for gastric leaks after laparoscopic sleeve gastrectomy. Notably, the specificity (91.2%) was very high.
文摘Coronavirus disease 2019(COVID-19)continues to create havoc and may present with myriad complications involving many organ systems.However,the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected.There is a high incidence of air leaks in patients with COVID-19,leading to acute worsening of clinical condition.The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and underlying lung disease.The exact pathophysiology of air leaks with COVID-19 remains unclear,but multiple factors may play a role in their development.A significant proportion of air leaks may be asymptomatic;hence,a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality.These air leaks may even develop weeks to months after the disease onset,leading to acute deterioration in the post-COVID period.Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.
基金National Clinical Research Center for Respiratory Diseases(HXZX-20210501)
文摘Importance:The safety and efficacy of the bath-plug technique for the closure of cerebrospinal fluid(CSF)leaks in children remain unknown.Objective:We undertook this study to ascertain whether the bath-plug technique was safe and effective for the repair of CSF leaks.Methods:We retrospectively reviewed patients who underwent endoscopic repair of CSF leaks with the fat graft as a plug-in at Beijing Children’s Hospital from March 2016 to May 2020.Demographic data,medical history,defect sites and sizes,interventions,and clinical outcomes were analyzed.One representative clinical case was additionally selected to highlight the procedure and the healing process.Results:A total of 18 pediatric patients were included in this study.The group was composed of 11 boys and seven girls,aged from 5 to 123 months.The etiologies included congenital CSF leaks(n=9)and head trauma(n=9).Among all patients,12 fistulas(66.7%)were located at the cribriform plate area,two(11.1%)at the roof of the ethmoid sinuses,two(11.1%)in the sphenoid sinus,and two(11.1%)at the frontal sinus.The maximum diameters of fistulas ranged from 5 to 20 mm,with a median value of 8 mm.Encephaloceles were identified in 14(77.8%)patients.No hydrocephalus was recognized.All CSF leaks were successfully repaired with a bath-plug technique.Follow-up ranged from 50 to 70 months.No surgical complications were encountered in any patient.Interpretation:Bath-plug technique is safe and reliable for the endoscopic management of CSF leaks in children.Meticulous peri-operative preparations are important for pediatric patients.
基金This workwas supported by the Medical and Health Science and Technology Project of Zhejiang Province(No.2021KY180).
文摘Objectives:Anastomotic leakage(AL)stands out as a prevalent and severe complication following gastric cancer surgery.It frequently precipitates additional serious complications,significantly influencing the overall survival time of patients.This study aims to enhance the risk-assessment strategy for AL following gastrectomy for gastric cancer.Methods:This study included a derivation cohort and validation cohort.The derivation cohort included patients who underwent radical gastrectomy at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine,from January 1,2015 to December 31,2020.An evidence-based predictor questionnaire was crafted through extensive literature review and panel discussions.Based on the questionnaire,inpatient data were collected to form a model-derivation cohort.This cohort underwent both univariate and multivariate analyses to identify factors associated with AL events,and a logistic regression model with stepwise regression was developed.A 5-fold cross-validation ensured model reliability.The validation cohort included patients from August 1,2021 to December 31,2021 at the same hospital.Using the same imputation method,we organized the validation-queue data.We then employed the risk-prediction model constructed in the earlier phase of the study to predict the risk of AL in the subjects included in the validation queue.We compared the predictions with the actual occurrence,and evaluated the external validation performance of the model using model-evaluation indicators such as the area under the receiver operating characteristic curve(AUROC),Brier score,and calibration curve.Results:The derivation cohort included 1377 patients,and the validation cohort included 131 patients.The independent predictors of AL after radical gastrectomy included age65 y,preoperative albumin<35 g/L,resection extent,operative time240 min,and intraoperative blood loss90 mL.The predictive model exhibited a solid AUROC of 0.750(95%CI:0.694e0.806;p<0.001)with a Brier score of 0.049.The 5-fold cross-validation confirmed these findings with a calibrated C-index of 0.749 and an average Brier score of 0.052.External validation showed an AUROC of 0.723(95%CI:0.564e0.882;p?0.006)and a Brier score of 0.055,confirming reliability in different clinical settings.Conclusions:We successfully developed a risk-prediction model for AL following radical gastrectomy.This tool will aid healthcare professionals in anticipating AL,potentially reducing unnecessary interventions.
