Isolated vascularized gastric tube biliary enteric drainage: a paediatric case series experience

Background Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used. Results IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years. Conclusion IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.

Roux En Y drainage of a large hepatic hydatid cyst as treatment for recalcitrant bile leak: a case report

Background Hydatid disease is relatively uncommon in children and thus rarely reported in literature. Pediatric patients with large hydatid cysts can have grave complications due to mass effect. Postoperative bile leak is the most common morbidity and continues to be a challenge for the treating surgeon. Case presentation A 7-year-old boy diagnosed with a giant hydatid cyst of the liver, almost replacing the right lobe, and underwent a laparotomy and excision of cyst with tube drainage. He developed postoperative major bile leak which did not subside even after a redo laparotomy and closure of the suspected bile leak areas. The child underwent a third laparotomy after a hepatobiliary scintigraphy (HIDA scan) which confirmed a persisting major leak. A Roux En Y cystojejunostomy was done this time which drained the bile adequately postoperatively with no evidence of bile in the subhepatic drain. Oral feeds were resumed on the fifth postoperative day. He was discharged in a satisfactory condition and is doing well in the follow-up. Repeat HIDA scan showed no evidence of spillage, with adequate bilio-enteric drainage. Conclusion Persistent major bile leak requiring ERCP with sphincterotomy can be managed successfully in children by internal drainage as Roux En Y cystojejunostomy.

Nonoperative management of gastrointestinal bleeding after a simultaneous pancreas and kidney transplant

With a shift toward enteric drainage techniques, the complications associated with simultaneous pancreas and kidney (SPK) transplant have also changed. Gastrointestinal (GI) bleeding is one of the most common complications associated with SPK. This case report describes the treatment of a postoperative GI hemorrhage using the push endoscopy technique. A 48-year-old male underwent an uneventful SPK transplant with entero-systemic drainage and developed hematochezia. The push enteroscopy technique was utilized to treat the bleeding ulcer. Historically, the use of the push enteroscopy technique to treat GI bleeding from the small bowel is not described in the literature. One of the limitations of duodenojejunostomy is that standard endoscopy cannot be readily used to visualize the duodenojejunostomy. However, the use of push enteroscopy may prove to be a minimal invasive and cost-effective intervention for GI bleeding after SPK.

Beware the band adhesion: an unexpected cause of double obstruction following intraperitoneal kidney transplantation

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.