PURPOSE: After the excision of a choledochal cyst, late complications seldom develop. Herein, we propose a modified surgical classification, which allows surgeons to select an appropriate operation and minimize late postoperative complications. METHODS: A total of 90 Todani type I and IV cases were reviewed to examine the morphologic characteristics of choledochal cysts and to evaluate the clinical outcomes after cyst excision. The cysts were then reclassified based on factors determining the postoperative outcomes. RESULTS: There were 8 intrahepatic complications (4 cholangitis, 4 IHD stones) and 3 intrapancreatic complications (2 pancreatitis, 1 symptomatic remnant distal cyst). Seven of the 8 intrahepatic complications (87.5%) occurred in cases with IHD dilatation, 6 of which were associated with a ductal stricture or isolated intrahepatic cyst. Using the above factors as classification criteria, a modified surgical classification is proposed. Cases were classified as types I or IV cysts according to the presence of IHD dilatation. The type I cysts were further divided into types Ia and Ib according to the cyst multiplicity, and type IV cysts according to the pattern of continuity between the extra- and intrahepatic cyst: IHD dilatation without stricture, IVa; IHD dilatation with ductal stricture, IVb; isolated intrahepatic cyst, IVc. CONCLUSION: According to our classification, the extrahepatic approach is enough for types I, IVa and IVb to improve long-term outcome. For type IVc and some of type IVb with a stricture, where an extrahepatic approach is difficult, and hepatectomy should be combined.
Cholangitis ; Choledochal Cyst* ; Classification* ; Constriction, Pathologic ; Dilatation ; Hepatectomy ; Pancreatitis ; Postoperative Complications

OBJECTIVES: To investigate the clinical application of endoscopic esophageal dilation in the treatment of corrosive esophageal strictures in children. METHODS: A retrospective analysis was performed on the clinical data of 15 children with corrosive esophageal strictures who underwent endoscopic esophageal dilation in Children's Hospital, Zhejiang University School of Medicine. The clinical features, treatment modality of endoscopic esophageal dilation, number of dilations, complications, and prognosis were reviewed. RESULTS: A total of 96 esophageal dilations were performed in the 15 children with corrosive esophageal strictures, with a median of 6 dilations per child. Among them, 9 children (60%) underwent 6 or more dilations. The children with a stricture length of >3 cm had a significantly higher number of dilations than those with a stricture length of ≤3 cm (P<0.05). The children with strictures in a single segment had a significantly better treatment outcome than those with strictures in multiple segments (P=0.005). No complication was observed during all sessions of dilation. The overall effective rate (including significant improvement and improvement) of endoscopic esophageal dilation treatment was 87%, with 2 cases of failure. CONCLUSIONS Endoscopic esophageal dilation is an effective and relatively safe treatment method for corrosive esophageal strictures in children, and children with strictures in a single segment tend to have a better treatment outcome than those with strictures in multiple segments.
Child ; Humans ; Esophageal Stenosis/therapy* ; Constriction, Pathologic/complications* ; Dilatation/methods* ; Caustics ; Retrospective Studies ; Treatment Outcome

From October 1993 to April 1997, 37 patients (30 male and 7 female patients), ranging in age from 23 to 73 years, were operated for annuloaortic ectasia with or without aortic dissection. Four patients were in New York Heart Association Class I, 10 in Class II, 20 in Class III, and 3 in Class IV. In cases of annuloaortic ectasia with aortic dissection, the surgical treatment in all cases consisted of total replacement of the ascending aorta with composite graft and reimplantation of the coronary arteries to the tube graft. The postoperative complication, as postoperative bleeding or LV dysfunction, was 18% (7 cases) and late mortality for entire group was 2.7% (one death). The period of follow-up ranged from 1 month to 36 months (average 9.6 months). In conclusion, Bentall operation for annuloaortic ectasia with or without aortic dissection is reliable method with low mortality and excellent short-term results.
Aorta ; Coronary Vessels ; Dilatation, Pathologic ; Female ; Follow-Up Studies ; Heart ; Hemorrhage ; Humans ; Male ; Mortality ; Postoperative Complications ; Replantation ; Transplants

The aim of this study is to analyze the outcomes of the esophageal atresia with tracheoesophageal fistula over the last 2 decades. The records of 51 patients born between 1987 and 2006 were reviewed. Twenty-seven patients were male. Mean values of the age, gestational age and birth weight were 2.9 days, 296 days and 2.7kg, respectively. All patients had Gross type C anomalies. Thirty-one patients (60.7 %) had one or more associated congenital anomalies and the most common anomaly was cardiac malformation. In 48 cases, primary anastomosis was done and staged operation was done in one case. Circular myotomies in the proximal esophagus were performed in 9 cases. Postoperative complication developed in 26 cases (54 %): pulmonary complication in 12 cases, anastomotic leakage in 10 and anastomotic stricture in 10, recurrent trachoesophageal fistula in one and tracheomalasia in 2 cases. Reoperation was carried out in 2 patients with anastomotic leaks, the remaining leaks were managed non operatively. Three of the strictures were reoperated upon and the others were successfully managed by balloon dilatations. Overall mortality rate was 15.6 %. Mortality rate of the second 10 years (8 %) period decreased significantly compared to that of the first 10 years (23 %) period.
Anastomotic Leak ; Birth Weight ; Constriction, Pathologic ; Dilatation ; Esophageal Atresia ; Esophagus ; Fistula ; Gestational Age ; Humans ; Male ; Postoperative Complications ; Reoperation ; Tracheoesophageal Fistula

PURPOSE: Even after excision of choledochal cyst, late postoperative complications can develop. This study was conducted to examine the long-term outcome of cyst excision. METHODS: Of 50 choledochal cysts treated over a 10-year period (1991~2000), excluding cancer and rare types, 39 patients (type I: 21, IVa: 18) who underwent cyst excision were reviewed to evaluate the late outcome. RESULTS: Median follow-up period was 24 months after surgery. Late complications (5 intrahepatic duct stone, 4 cholangitis, 4 pancreatitis, and 1 malignancy) developed in 14 (35.9%) patients. Of the 5 patients with intrahepatic duct stone, 2 underwent choledochoscopic stone removal, one of whom additionally underwent balloon dilatation for anastomotic stricture. The remaining 3 patients were free of symptoms and didn't need further management. Of the 4 patients with cholangitis, one underwent left lateral sectionectomy for remaining intrahe patic cyst in type IVa and another patient balloon dilatation for anastomotic stricture. The remaining 2 patients developed cholangitis because of incomplete excision and ascending cholangitis, and they were conservatively managed. Of the 4 patients with pancreatitis, 2 developed pancreatitis because of pancreas divisum and probably residual distal cyst. The symptoms of all four patients with pancreatitis were mild and treated with conservative management. Periampullary cancer developed 18 months after cyst excision in one patient. CONCLUSION: To minimize hepatopancreatobiliary complications and malignancy after cyst excision, complete excision of the extrahepatic bile duct should be performed. Moreover, long-term follow-up is necessary because of these late complications.
Bile Ducts, Extrahepatic ; Cholangitis ; Choledochal Cyst* ; Constriction, Pathologic ; Dilatation ; Follow-Up Studies ; Humans ; Pancreas ; Pancreatitis ; Postoperative Complications

PURPOSE: The optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus. MATERIALS AND METHODS: This retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods. RESULTS: The average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien–Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed. CONCLUSIONS: Our procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.
Anastomotic Leak ; Classification ; Constriction, Pathologic ; Dilatation ; Esophagus ; Gastrectomy ; Head ; Humans ; Incidence ; Laparoscopy ; Ligation ; Methods ; Mortality ; Postoperative Complications ; Retrospective Studies ; Sutures

A benign anastomotic stricture is a common complication of upper gastrointestinal (UGI) surgery and is difficult to manage conservatively. Fluoroscopically guided balloon dilation has a number of advantages and is a safe and effective procedure for the treatment of various benign anastomotic strictures in the UGI tract.
*Anastomosis, Surgical ; Balloon Dilatation/adverse effects/*methods ; Constriction, Pathologic/etiology/therapy ; Esophagus/*surgery ; Fluoroscopy ; Humans ; Postoperative Complications ; Stomach/*surgery

PURPOSE: Postoperative biliary stricture is rare, but can result in a dreadful condition unless it is properly treated. This study was undertaken to assess the clinical features of a postoperative biliary stricture and to evaluate the outcome of reconstructive methods according to the stricture locations and types. METHODS: From 1984 to 2001, 28 cases (M=16, F=12) of postoperative biliary stricture, which resulted from surgical injury and had subsequent reconstructive procedures performed in department of surgery of Seoul National University Hospital, during the period of 1984 to 2001, were retrospectively reviewed. Clinical features such as the symptom, type of surgery causing the stricture, laboratory finding, diagnostic modality, interval between the operation and symptoms and the type of stricture were reviewed and clinical outcomes of the reconstructive procedures were also analyzed. The mean follow-up period was 45.9 months (2~157). RESULTS: The most common symptoms of stricture was jaundice. 57.1% of patients showed symptoms within postoperative 6 months and 64.3% showed symptoms within 1 year. A cholecystectomy was most common surgical procedure that caused a postoperative biliary stricture. Bismuth type I was most common type of stricture (52.2%). Bilioenteric anastomosis (Roux-en Y hepaticojejunostomy) showed most excellent result among the many reconstructive methods. One case of an interventional balloon dilatation has maintained a good condition for 3 years after the procedure. The postoperative complications comprises bile leakage, a subphrenic abscess, an incisional hernia, am intrahepatic duct stone, recurrent pyogenic cholangitis. There were 2 cases of postoperative mortality. CONCLUSION: Roux-en Y hepaticojejunostomy is considered to the procedure of choice for a postoperative biliary stricture. An interventional balloon dilatation is expected to show good result with more cases and adequate indications.
Bile Ducts* ; Bile* ; Bismuth ; Cholangitis ; Cholecystectomy ; Constriction, Pathologic* ; Dilatation ; Follow-Up Studies ; Hernia ; Humans ; Intraoperative Complications ; Jaundice ; Mortality ; Postoperative Complications ; Retrospective Studies ; Seoul ; Subphrenic Abscess

A 34-year-old woman was admitted to the hospital because of recently aggravated right heart failure without angina for 5 months. When she was 25 years old, patch repair with Polytetrafluoroethylene (PTFE) was performed for the secondum type of atrial septal defect (ASD) with moderate pulmonary hypertension. The chest PA, echocardiography and cardiac catheterization at current admission revealed Eisenmenger syndrome without intracardiac shunt. Chest CT scan with contrast revealed markedly dilated pulmonary trunk, both pulmonary arteries and concave disfigurement of the left side of the ascending aorta suggesting extrinsic compression, as well as total occlusion of the ostium of the left main coronary artery that was retrogradly filled with collateral circulation from the right coronary artery. The coronary angiography showed normal right coronary artery and the collaterals that come out from the conus branch to the mid-left anterior descending artery (LAD) and that from distal right coronary artery to the left circumflex artery (LCX) and to the distal LAD, respectively. On aortography, the left main coronary artery was not visualized with no stump, suggestive of total occlusion of the ostium of the left main coronary artery. From our experience, it is possible to say that the occlusion of the ostium of the left main coronary can be induced by the dilated pulmonary artery trunk due to ASD with pulmonary hypertension and that, if the ASD closure was too late, the narrowing or obstruction of the left coronary artery could not be resolved even after operation owing to irreversible pulmonary hypertension.
Adult ; Case Report ; Constriction, Pathologic/etiology/radiography ; Coronary Disease/*etiology/radiography ; Dilatation, Pathologic/etiology ; Eisenmenger Complex/diagnosis ; Female ; Heart Septal Defects, Atrial/*complications ; Human ; Hypertension, Pulmonary/*complications ; *Pulmonary Artery/radiography

BACKGROUND: Reoperations on the aortic root or the ascending aorta are being performed with increasing frequency and remain a challenging problem.This study was performed to analyze the results of reoperations on the ascending aorta and aortic root. MATERIAL AND METHOD: Between May 1995 and April 2001,30 patients had reoperations on the ascending aorta and aortic root and were reviewed retrospectively.The mean interval between the previous repair and the actual reoperation was 56 months(range 3 to 142 months).Seven patients(23.3%)had two or more previous operations.The indications for reoperations were true aneurysm in 7 patients(23.3%),prosthetic valve endocarditis in 6(20%),false aneurysm in 5(16.7%),paravalvular leak associated with Behcet's disease in 4(13.3%),malfunction of prosthetic aortic valve in 4(13.3%),aortic dissection in 3(10%),and annuloaortic ectasia in 1(3.3%).The principal reoperations performed were aortic root replacement in 17 patients(56.7%),replacement of the ascending aorta in 8(26.7%),aortic and mitral valve replacement with reconstruction of fibrous trigone in 2(6.6%),patch aortoplasty in 2(6.6%), and aortic valve replacement after Bentall operation in 1(3.3%).The cardiopulmonary bypass was started before sternotomy in 7 patients and the hypothermic circulatory arrest was used in 16(53.3%).The mean time of circulatory arrest,total bypass,and aortic crossclamp were 20 +/- 12 minutes,228 +/- 56 minutes,and 143 +/- 62 minutes,respectively. RESULT: There were three early deaths(10%).The postoperative complications were reoperation for bleeding in 7 patients(23.3%),cardiac complications in 5(16.7%),transient acute renal failure in 2(6.6%), transient focal seizure in 2(6.6%),and the others in 5.The mean follow-up was 22.8 +/- 20.5 months.There were two late deaths(7.4%).The actuarial survival was 92.6 +/- 5.0%at 6 years. One patient required reoperation for complication of reoperation on the ascending aorta and aortic root(3.7%).The 1-and 6-year actuarial freedom from reoperation was 100%and 83.3 +/- 15.2%,respectively.One patient with Behcet's disease are waiting for reoperation due to false aneurysm,which developed after aortic root replacement with homograft.There were no thromboembolisms or anticoagulant related complications. CONCLUSIONS: This study suggests that reoperations on the ascending aorta and aortic root can be performed with acceptable early mortality and morbidity,and adequate surgical strategies according to the pathologic conditions are critical to the prevention of the reoperation.
Acute Kidney Injury ; Aneurysm ; Aorta* ; Aortic Valve ; Cardiopulmonary Bypass ; Dilatation, Pathologic ; Endocarditis ; Follow-Up Studies ; Freedom ; Hemorrhage ; Humans ; Mitral Valve ; Mortality ; Postoperative Complications ; Reoperation ; Seizures ; Sternotomy ; Thromboembolism