Duodenal perforation is a rare occurrence and is associated with high mortality, which rises to 30-50% in cases that involve associated peritonitis. The most frequent etiologies include peptic ulcer, post-operative fistula, endoscopic perforation, and trauma. The challenge in managing this pathology lies in the fact that resection with anastomosis is often unfeasible, and the creation of a stoma is not possible. Management must be tailored on a case-by-case basis that always involves medical measures, often endoscopic interventions, and sometimes surgery. Indeed, the surgical option is feasible in selected patients who are diagnosed early and present without complications. Surgical procedures are classified into two categories: preferably, reconstructive procedures-where resection of the perforation and restoration of digestive continuity is possible, provided that local and hemodynamic conditions are favorable; conversely, a duodenojejunal diversion procedure-in which the perforation is left in situ while enteric secretions are diverted-is the preferred approach when conditions are unfavorable. When local conditions are unfavorable, or there is hemodynamic instability, duodenostomy drainage is the preferred option. This technique involves directing duodenal secretions toward the skin, thereby inducing the formation of a fibrotic fistulous tract with eventual wound healing. The management of duodenal perforation is a lengthy and challenging process.
INTRODUCTION:Anoperineal fistula (APF) treated by fistulectomy provides the best anatomical results but carries a high risk of anal incontinence. Sphincter reconstruction might improve these outcomes, but limited comparative data are available in the literature. The purpose of this study was to compare the outcomes of fistulotomy plus sphincter reconstruction (FSR) and sphincter-sparing techniques for APF repair. METHOD:This two-center retrospective study included patients undergoing FSR or ligation of the intersphincteric fistula tract (LIFT) or rectal advancement flap (control group) techniques. RESULTS:Of the 119 patients included, 95 (79.8%) underwent FSR. There were no statistically significant differences in demographic characteristics between groups. More inter- or trans-sphincteric fistulas were included in the control group, while there were more complex fistulas in the FSR group (P<0.001). The healing rate was 76.2% in the control group compared to 91.6% in the FSR group (P=0.056). No statistically significant difference was found in the overall complication (8.4%) or overall anal incontinence rates (14.7%) (P>0.9). In contrast, the recurrence rate was higher in the control group than in the FSR group (P<0.001). In multivariable analysis, FSR was associated with a lower risk of recurrence compared to the control group (OR=0.16; 95% CI: 0.03-0.77). CONCLUSION:This study suggests that FSR may be superior to the other techniques in terms of cure without increasing morbidity or the risk of anal incontinence.
Primary hyperparathyroidism (PHPT) is associated with numerous established clinical manifestations as well as subclinical impairments, including cardiometabolic complications (cardiovascular mortality, hypertension, prediabetes, diabetes, dyslipidemia, vascular abnormalities). These alterations appear to be linked to elevated parathyroid hormone and/or calcium levels, and could play a direct or indirect role in increasing cardiovascular risk in patients with PHPT. In the absence of robust data and given sometimes heterogeneous results, current French and international guidelines do not recognize cardiometabolic complications as an indication for parathyroidectomy in PHPT. Nevertheless, some data suggest a beneficial effect of surgery on these parameters, notably an improvement in blood pressure, lipid profile, or insulin sensitivity after parathyroidectomy. However, results remain variable depending on the studies, methodologies used, and evaluation criteria retained. This review aims to provide an overview of current knowledge on the impact of parathyroidectomy in PHPT regarding cardiovascular and metabolic risk, and to identify open questions to guide future research.
