Pseudoaneurysm of the Gastroduodenal Artery: A Rare Complication of Bile Duct Surgery

Pseudoaneurysm of the gastroduodenal artery (GDA) is an exceptional complication of common bile duct (CBD) resection. We present the case of a 60-year-old woman with a history of cholecystectomy. The patient was admitted to our hospital for surgical management of the cystic dilatation of the CBD. The patient presented on postoperative day 21 with hemodynamic instability related to a pseudoaneurysm of the GDA. An urgent open surgery was performed with dissection and ligation of the GDA.

The Dilemma of the Level of the Inferior Mesenteric Artery Ligation in the Treatment of Diverticular Disease: A Systematic Review of the Literature

Background and aim: Although sigmoidectomy is a well-standardized procedure for diverticular disease, there are still unclear areas related to the varying morphology and vascular supply of the sigmoid colon. The level of vascular ligation could affect the functional outcomes of patients operated on for diverticular disease. The aim of this review is to primarily evaluate sexual, urinary and defecatory function outcomes, as well as postoperative results, in patients who underwent surgery for diverticular disease, with or without inferior mesenteric artery (IMA) preservation. Materials and methods: The MEDLINE/PubMed, WOS and Scopus databases were interrogated. Comparative studies including patients who underwent sigmoidectomy for diverticular diseases were considered. Bowel function, genitourinary function, anastomotic leak, operation time, conversion to open surgery, anastomotic bleeding, bowel obstruction were the main items of interest. Results: Twelve studies were included in the review, three randomized and nine comparative studies. Bowel and genitourinary function are not differently affected by the level of vascular ligation. The site of ligation of IMA did not influence the rate of functional complications, anastomotic leak and bleeding. Of note, the preservation of IMA is associated with a higher conversion rate and longer operative time. Conclusions: Despite the heterogeneity of patient groups, and although the findings should be interpreted with caution, functional and clinical outcomes after sigmoidectomy for diverticular disease do not seem to be affected by the level of vascular ligation as long as the IMA is ligated far from its origin.

Uterine necrosis, infection, and subinvolution: complications observed after combined application of modified B-Lynch suture and vascular ligation

Compression sutures are primarily used to treat atonic postpartum hemorrhage. We herein describe three cases of selective arterial ligation combined with B-Lynch or modified B-Lynch suture for the treatment of intractable postpartum hemorrhage unresponsive to available conservative interventions. Three pregnant women underwent a cesarean section for a macrosomic fetus, fetal distress, and oligohydramnios, respectively. All three women developed intractable postpartum hemorrhage due to uterine atony with no chance of embolization therapy. B-Lynch or modified B-Lynch suture and additional selective arterial ligation were performed using braided absorbable suture. The first woman developed postoperative hematometra and infection without response to drainage and antibiotic therapy. Although laparoscopic exploration was performed to loosen the suture line and drain the hematometra and pyometra, the necrosis and infection could not be controlled. Subtotal hysterectomy was therefore conducted, and the necrotic uterine adnexa was removed. The other two women developed subinvolution of the uterus resulting in prolonged menstruation and amenorrhea, although the uterus was preserved and the bleeding was controlled. Modified B-Lynch suture combined with vascular ligation is an invaluable technique for women with severe intractable postpartum hemorrhage. However, it can lead to serious complications such as uterine necrosis, infection, and subinvolution.

Low Tie Compared to High Tie Vascular Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery Decreases Postoperative Complications Without Affecting Overall Survival

BACKGROUND/AIM

The aim of this study was to determine the clinical impact of low tie ligation (LT) of the inferior mesenteric artery (IMA) below the left colic artery versus high tie ligation (HT) at the origin of the IMA in patients undergoing rectal cancer surgery.

PATIENTS AND METHODS

Between January 2005 and December 2017, all consecutive patients who underwent rectal resection for non-metastatic cancer were retrospectively included. Patients who had LT were compared to those who had HT.

RESULTS

Overall, 200 patients were identified (101 HT and 99 LT). Postoperative 30-day mortality rate was nil in both groups. There were significantly higher severe postoperative complications in HT versus LT patients (Clavien-Dindo III-IV) (18.8% vs. 9.1%, p=0.048). Median follow-up was 38.5 months and overall survival at 5 years was 91.5% and there was no difference between the two groups (90.1% vs. 92.9%; HT vs. LT p=0.640).

CONCLUSION

LT ligation of IMA significantly decreased the severe postoperative complication rate without affecting recurrence-free or overall survival.