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1/12. Fistula involving portal vein and duodenum at the site of a duodenal ulcer in a patient after previous extrahepatic bile duct resection and brachytherapy.

    Fistulas involving the portal venous system and gastrointestinal (GI) tract are rare. However, they can cause life-threatening GI hemorrhage. A case of a fistula between the main portal vein and the posterior wall of the duodenal bulb at the site of a duodenal ulcer in a patient who had previously undergone an extrahepatic bile duct resection and brachytherapy for mucinous cystadenocarcinoma is reported. Consideration should be given to this entity in the differential diagnosis of GI hemorrhage in patients with a history of previous major biliary surgery.
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ranking = 1
keywords = fistula
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2/12. Carcinoid of the papilla of Vater; a case report.

    A 68-year-old Japanese man, without any symptoms, was found to have a carcinoid tumor of the ampulla of vater. A physical examination indicated no anemia or jaundice and no abnormal findings at all in the chest or abdomen. Except for glucose intolerance, the routine laboratory data were normal. An endoscopic biopsy was performed that suggested malignant tumor cells. There were no signs of carcinoid syndrome. A pylorus-preserving pancreatoduodenectomy with extensive lymph node dissection was performed. Histological and immunohistochemical studies resulted in the diagnosis of a carcinoid of the papilla of Vater, without regional lymph node metastases. Although postoperative, an anastomotic leakage of pancreaticogastrostomy was noted; the pancreatic fistula was closed seven weeks later to use the somatostatin analogue.
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ranking = 3780.0067395242
keywords = pancreatic fistula, fistula
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3/12. pancreas-preserving biliary amputation with pancreatic diversion: a new surgical technique for complete resection of the intrapancreatic biliary system.

    Pancreatoduodenectomy is not optimal for organ preservation in patients with mucosal carcinoma of the choledochus. When the lesion spreads near the papilla of Vater, pancreas-preserving biliary amputation may be indicated to achieve complete resection of the biliary system. The first successful case is reported here with technical considerations. First, the pancreatic neck was divided and a tube was inserted into the main pancreatic duct beyond the papilla. The choledochus was dissected downward with division of the posterior pancreatoduodenal vessels. The main pancreatic duct was isolated with the aid of palpation of the tube, and was then ligated and divided. Subsequent dissection was performed to the level of the duodenal mucosa, which was incised circularly. The duodenal defect was then closed. The elevated jejunum was interposed between the pancreatic stumps and bilateral pancreaticojejunostomies were created. The procedure was successfully performed in a patient with superficially spreading cholangiocarcinoma. Postoperative bile leak and pancreatic fistula were controlled with medical management. The patient is currently well without tumor recurrence 19 months after surgery. Her glucose tolerance, which was moderately impaired preoperatively, has been maintained. pancreas-preserving biliary amputation has been developed as an organ-preserving procedure alternative to pancreatoduodenectomy. Indications, methods of pancreatic reconstruction, and long-term results require further study.
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ranking = 3780.0067395242
keywords = pancreatic fistula, fistula
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4/12. A new technique of postoperative pancreatico gastric enterocutaneous fistula repair using de-tubularised afferent loop.

    Postoperative fistula involving upper gastrointestinal tract surgery is a rare but troublesome occurrence. reoperation on these patients is challenging and needs to be individualised. Various methods are described including primary closure, bypass procedures, serosal patch repair and Roux-en-Y repair. We present a new technique of repair using afferent loop that provided a vascularized bowel segment, which used in an anatomical fashion for closure of fistula.
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ranking = 6
keywords = fistula
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5/12. Spontaneous cutaneous biliary fistula: a rare complication of cholangiocarcinoma.

    A rare case of intrahepatic-cutaneous biliary fistula resulted from obstruction of the biliary tree by cholangiocarcinoma in the hilar area. The diagnosis was made clinically by the presence of a constant pus discharge through the fistula opening and confirmed by sonogram, computed tomogram (CT), and surgery. To our knowledge, there have been no previous reports of such a fistula as the presenting symptom of cholangiocarcinoma.
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ranking = 7
keywords = fistula
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6/12. Failure of somatostatin or an analog to promote closure of end pancreatic fistulae.

    somatostatin has been reported to promote closure of pancreatic fistulae, but use of the analog SMS 201-995 (Sandoz, Inc.) has not previously been published. We used this analog to treat two patients with end pancreatic fistulae refractory to conventional therapy. One patient had disruption of a pancreaticojejunostomy after pancreaticoduodenectomy and the other had acute necrotizing gallstone pancreatitis and disruption of the pancreatic duct in the tail. SMS 201-995 (100-150 micrograms/d) abruptly decreased fistula output by 50% in both patients but further increases in dosage had no further effect on output. Neither fistula healed after 3-4 wk of therapy. Treatment with somatostatin or its analogs alone will not lead to closure of a pancreatic fistula complicated by factors such as distal obstruction, infection, or foreign body. somatostatin may promote closure of lateral fistulae and may simplify the management of patients with high output fistulae.
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ranking = 26464.047176669
keywords = pancreatic fistula, fistula
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7/12. The complications of pancreatectomy.

    This paper analyses the early postoperative complications after 285 pancreaticoduodenectomies performed during the past 15 years in the Surgical University Clinic, Mannheim. There were 235 partial (Whipple) and 52 total pancreatectomies performed for pancreatic and periampullary tumors (181 patients) and complicated chronic pancreatitis (104 patients). A total of 92 complications requiring relaparotomy in 42 patients ended fatally in nine patients. The overall operative and hospital mortality rate was 3.1%. The most frequent and most dangerous were complications at or around the pancreaticojejunal anastomosis, which occurred 25 times with five deaths. postoperative hemorrhage was seen in 16 patients; endoscopic treatment in four patients and operation in 12 patients was successful in stopping the bleeding in all but one patient. Eight biliary fistulae either ceased spontaneously (3 patients) or after operative reintervention (5 patients) without any mortality. Control of these complications depends on four lines of approach: (1) before operation: optimal preparation of the jaundiced patient including endoscopic transpapillary decompression of the common duct; (2) during operation: a meticulous and standardized technique is mandatory; (3) after operation: continuous observation in the surgical intensive care unit is essential for the timely detection of possible complications; and (4) early reintervention can salvage the great majority of these patients with deleterious complications.
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ranking = 1
keywords = fistula
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8/12. Pseudocalculus of the common bile duct.

    Common-bile-duct growths are rarely identified unless they cause chronic biliary obstruction. This case report describes a 71-year-old woman who had jaundice and epigastric pain. A cholecysto-colonic fistula was demonstrated by endoscopic retrograde cholangiopancreatography. The patient also had multiple filling defects in the common bile duct. The fistula was closed and stones were removed. A postoperative cholangiogram showed two calculi. One was removed with a basket through the T-tube tract, but the second, which did not appear completely free of the common-duct wall, could not be removed by the basket method. Subsequently at laparotomy this was found to be a benign pedunculated polyp, composed of collagenous and vascular tissue and with no surface epithelium. Surgeons should bear in mind the possibility of a common-bile-duct growth in cases of extrahepatic biliary obstruction.
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ranking = 2
keywords = fistula
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9/12. Pulmonary bile emboli. Sequelae of iatrogenic trauma.

    A 58-year-old man manifested obstructive jaundice secondary to adenocarcinoma of the common hepatic duct. The markedly icteric patient underwent multiple diagnostic and therapeutic procedures, including percutaneous needle biopsy of the liver, curettage, catheterization and washing of the hepatic ducts, and percutaneous transhepatic cholangiography. Three months later the patient died of a bleeding gastric ulcer. autopsy confirmed the presence of adenocarcinoma of the common hepatic duct. Microscopic examination of the lungs disclosed numerous bile emboli in the smaller arteries, arterioles, and in a few alveolar capillaries. Histochemical reaction of the emboli was positive for bilirubin. Organizing fibrin was seen around occasional bile emboli, but most were without microscopic reaction. review of the literature disclosed nine cases of pulmonary bile embolism, six of which had a history of marked cholestasis and trauma to the liver, like the present patient. Bile reaches the systemic circulation through a biliary-venous fistula that, in our case, was probably iatrogenic.
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ranking = 1
keywords = fistula
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10/12. Porta choledochal fistula: an unusual complication of a cholangiocarcinoma arising from a type I choledochal cyst.

    A vena porta choledochal fistula caused by an adenocarcinoma arising from a type I choledochal cyst was detected in a 42-year-old woman. The diagnostic and therapeutic aspects of this malignancy are discussed.
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ranking = 5
keywords = fistula
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