duct-to-mucosa Pancreaticojejunostomy

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Original Article The biomechanics and pathology in the duct-to-mucosa pancreaticojejunostomy

Original Article The biomechanics and pathology in the duct-to-mucosa pancreaticojejunostomy

Abstract: Background: Pancreatic fistula (PF) remains a significant problem causing the majority of mortality and morbidity after pancreaticoduodenectomy (PD). The aim of the research was to assess the surgical outcomes of duct-to-mucosa pancreaticojejunostomy (PJ) and invagination PJ after PD. Methods: Between 2011 and 2015, 120 patients in our hospital underwent duct-to-mucosa PJ after PD. All patients were recorded with variables factors and the risk factors for PF were studied by statistical analysis. To compare the difference between the duct-to-mucosa PJ and invagination PJ, the beagles (n=24) were divided into the group of duct-to-mucosa PJ (group A, n=12) and in- vagination PJ (group B, n=12). Enteric cavity physical pressure was measured following the postoperative 10 days at the identical pressure in 6 Beagles and bursting pressure was detected by artificial high pressure by double, triple, quadruple above the average pressure, and in the tenth day the breaking strength and pathology were assessed. Results: The incidence of PF is 7/120 (5.83%) and the operative mortality rate is 1/120 (0.83%). The pancreatic duct diameter and texture are related to PF by single factor analysis (*P<0.05) and the independent determinants of PF by logistic regression analysis (*P<0.05). The group A was the same as the group B in enteric cavity physical pressure after postoperative from 1 to 10 days. No PF was observed postoperative day from 1 to 10 days by double, triple and quadruple pressure in the group A but the group B had 2 beagles which appeared in double pressure on postoperative day 3 and day 5. Bursting pressure was 272.13±22.20 mmHg in group A on postoperative day 10 whereas 141±14.51 mmHg in group B (*P<0.05). Breaking strength was 9.35±0.35 N in group A and 6.5±0.30 N in group B on postoperative day 10 (*P<0.05). Anastomotic stoma was well repaired by granulation tissue in group A but no regeneration of the epithelium was found in group B. Conclusion: Anastomotic strength of duct-to-mucosa PJ was stronger than the invagination PJ and the healing in the former operating methods was safer and rapider.
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Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report

Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report

Copyright © 2012 K. Vasiliadis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.
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One layer versus two layer duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial

One layer versus two layer duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial

The two-sided null hypothesis for the primary endpoint measurement states that both study interventions will lead to a similar POPF occurrence rate; the alternative hypoth- esis is that one intervention will perform better than the other. The null hypothesis will be tested by analyzing the covariance while adjusting for pancreatic texture (soft or hard) and main pancreatic duct diameter (<3 mm or ≥3 mm). A binary logistic regression will be applied to compare the POPF occurrence rates between the groups after adjusting for other factors. Background characteristics and surgical outcome measures will be compared using chi-squared or Fisher’ s exact tests for categorical data and two-tailed t tests or nonparametric Mann–Whitney U tests for continuous variables. Categorical data will be presented as frequencies and group percentages, and continuous variables will be expressed as the means and standard Table 2 Complication grades according to the Clavien-Dindo
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THE EVALUATION OF DUCT TO MUCOSAL PANCREATICOJEJUNOSTOMY LEAKAGE IN PANCREATICODUODENECTOMY

THE EVALUATION OF DUCT TO MUCOSAL PANCREATICOJEJUNOSTOMY LEAKAGE IN PANCREATICODUODENECTOMY

BACKGROUND: Anastomotic leakage at the pancreaticojejunostomy remains a common complication after pancreaticoduodenectomy. Postoperative pancreatic Fistula (POPF), due to anastomotic leakage, is often associated with significant morbidity and mortality. The aim of this study was to improve a duct to mucosa pancreaticojejunostomy in order to reduce the anastomotic leakage rate. Methods: Between April 2014 and March 2015, 39 patients with periampullary cancers or cancer of pancreatic head who underwent Whipple surgery and duct- to-mucosa pancreaticojejunostomy technique were evaluated with a drain amylase and blood amylase at the same time. Intraoperative bleeding, operation time, age, sex and other short-term and long-term complications were reviewed. Results: Anastomotic leakage at the pancreaticojejunostomy occurred in 7 patients (17.9%), 6 males and one female. The mean of intraoperative bleeding was 535.90 ml and the mean of operation time was 270.51 minutes. All POPFs in the study group in grade A according to International Study Group on Pancreatic Fistula (ISGPF) classification. Conclusions: The duct-to-mucosa pancreaticojejunostomy technique appears to be one of the safest techniques reported to date. The modifications evaluated in our study can easily be adopted by experienced surgeons already performed other techniques of duct-to-mucosa anastomosis.
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A modified technique of pancreaticojejunostomy for soft pancreas reduces the frequency of postoperative complications

A modified technique of pancreaticojejunostomy for soft pancreas reduces the frequency of postoperative complications

In order to reduce the incidence of pancreatic fistula, various techniques for the creation of pancreaticojejunostomy have been described. The two, most used, are the end-to-side duct-to-mucosa pancreaticojejunostomy and the invagination technique [9]. A randomized controlled study in 2009 compared these two techniques, and according to the results, the incidence of postoperative pancreatic fistula with the invagination technique was 12% and with the duct-to- mucosa technique, 24%. The authors also describe a significantly higher incidence of postoperative pancreatic fistula in patients with soft pancreas. According to this research, the incidence of postoperative pancreatic fistula in presence of soft pancreas was 27% [20]. However, a meta-analysis in 2011, which encompassed ten randomized control studies and 1408 patients, did not show any statistical difference in the incidence of postoperative pancreatic fistula, regardless of the technique for pancreatic reconstruction used [21].
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Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS)

Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS)

Results. There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta- analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies.
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Retrograde installation of percutaneous transhepatic negative pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study

Retrograde installation of percutaneous transhepatic negative pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study

For pancreaticoenteric anastomosis, the divided je- junum was lifted through the mesocolon of the trans- verse colon (retrocolic approach). A duct-to-mucosa anastomosis was made between the pancreatic duct and the jejunal mucosa. A polyvinyl chloride (PVC) stent was inserted in the jejunal opening and pancreatic duct to stabilize the inner strength of the pancreaticoenteric anastomosis. Before starting CJ, we inserted a blunt- pointed probe into the cut bile duct. This probe was passed through the peripheral duct and pulled through the liver parenchyma. A PVC drain tube was docked to the blunt point of the probe and retracted through the cut bile duct (Fig. 1). An end-to-side anastomosis was made between the bile duct and the jejunum (distal from PJ). The retracted end of the PVC drain was inserted into the jejunum during CJ. The opposite end of the PVC drain was pierced through the abdominal wall and was connected to a low-vacuum silicone reservoir. The final scheme of RPTNBD is shown in Fig. 2. To restore the gastrointestinal continuity, Billroth II or Roux-en-Y reconstruction was performed. For Billroth II recon- struction, a Braun anastomosis was added.
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Isolated loop pancreaticojejunostomy vs  conventional pancreatic stump anastomosis following pancreaticoduodenectomy: anobservational study

Isolated loop pancreaticojejunostomy vs conventional pancreatic stump anastomosis following pancreaticoduodenectomy: anobservational study

A 50cm isolated jejunal loop was fashioned and passed through the mesocolon in the retrocolic plane for pancreatico- jejunal anastomosis (see Figure 3). The anastomosis was performed using the duct-to-mucosa technique or the dunking technique using 3.0/4.0 Prolene interrupted sutures for the anastomosis based on the duct size (Figure 2). Pancreatic duct stenting was not performed in any patient. After completing the end-to-side hepaticojejunostomy and gastrojejunostomy to the distal jejunal limb, a side-to-side anastomosiswas performed between both limbs. A feeding jejunostomy was performed for enteral feeding in all patients. Two drains were placed,one near the pancreatic anastomosis and the other in the right sub-hepatic space. Post-operative octreotide was not administered to any patient. Drain fluid amylase levelswere routinely measured on post-operative daysthree and five, and a pancreatic fistula was defined as any measurable drain fluid with amylase levels three times the serum amylaseas perInternational Study Group of Pancreatic Fistula (ISGPF) guidelines (Bassi, 2005). Delayed gastric emptying was defined as a need for nasogastric decompression, reinsertion of the nasogastric tube after post-operative day three, or an inability to tolerate a solid diet by post-operative day seven as perInternational Study Group of Pancreatic Surgery(ISGPS) guidelines (Bassi, 2005). Any drain or nasogastric tube bleeding was considered post pancreaticoduodenectomy hemorrhage.
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Mesh reinforced pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective study of 126 patients

Mesh reinforced pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective study of 126 patients

Pancreaticoduodenectomy (PD) has, for a long time, been used as the standard surgical procedure for the treatment of patients with malignant or benign diseases of the pan- creatic head or the periampullary region. Mortality in pa- tients undergoing PD is recorded to be below 5% for general advance in surgical technique; however, postoper- ative morbidity remains high at 30–50% [1–3]. The main factor is postoperative pancreatic fistula (POPF), which can lead to severe secondary complications such as postoperative hemorrhages and intra-abdominal abscesses [4, 5]. Therefore, prevention and adequate treatment of POPF has always been of high priority [6]. Considerable techniques including pancreaticojejunostomy with duct to mucosa anastomosis or intussusceptions, main duct stent- ing and pancreaticogastrostomy have been described for safe surgical management of pancreatic remnants; how- ever, no single method has made evident to the scientific community its superiority [7–13]. Since August 2005, our institute has attempted to reduce the frequency of pancreatic fistula (PF) by using new method termed mesh-reinforced anastomosis [14]. We have previously re- ported in previous studies that this technique appears to be safe, simple, and quick [14, 15]. The purpose of this retrospective study is to compare perioperative outcomes of mesh-reinforced pancreaticojejunostomy (PJ) with the conventional surgical procedure of pancreaticojejunost- omy (PJ). This study was conducted by the same pancre- atic team of the same institute.
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Single layer pancreaticojejunostomy (PJ) in surgery for chronic calcific pancreatitis – A single centre observational study

Single layer pancreaticojejunostomy (PJ) in surgery for chronic calcific pancreatitis – A single centre observational study

Single layer anastomosis starting at the inferior border of the pancreas, at a point approximately 2 cm medial to the corner of the laid open duct, is carried laterally to include the tail and from there on proceeds medially along the superior border and completed just 1 cm medial to the corner of the laid open duct. Another suture, starting from the same site of the first suture is used to carry through the anastomosis medially along the inferior border ,encompass the head, including the cored out pancreatic margin and turn back along the upper border to finish at the point of completion of the earlier suture line. This anastomosis is generally performed in a continuous fashion. Interval between bites is maintained at 3mm and the distance of the bite from the mucosal edge of the bowel wall is kept at 5mm. The pancreatic full thickness bites includes pancreatic capsule and adequate purchase of the parenchyma. Including the duct mucosa on the pancreatic side is generally avoided in order to avoid inadvertent occlusion of the minor pancreatic ducts, except however in places where the pancreatic parenchyma is too thin for a adequate purchase. Intestinal continuity is reestablished by means of an end-to-side stapled or sutured jejunojejunostomy. The mesenteric and mesocolic windows are closed to prevent internal herniation. All the cored out pancreatic tissue was sent for histopathological examination. Most patients were discharged by 8 th postoperative day after suture removal.
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Neuroendocrine tumor of the common bile duct: a case report and review of the literature

Neuroendocrine tumor of the common bile duct: a case report and review of the literature

Abbreviations: BDr, bile duct resection; CBD, common bile duct; CBDC, congenital bile duct cyst; CCK, cholecystokinin; Ch, cholelithiasis; Ch-C, cholecystectomy; Chrom, chromogranin a; Cytk, cytokeratin; DCBD, distal common bile duct; F, female; GG, glucagon; Gl, Grimelius; HDLLN, hepatoduodenal ligament lymph node; HJ, hepaticojejunostomy; HJ R-Y, hepaticojejunostomy Roux en Y; HPD-AT, hepaticoduodenal anastomosis; I-F, incidental finding; Lap-B, laparotomy-biopsy; LI, local invasion; L-M, liver metastasis; LN, lymph node; LNr, lymph node resection; M, male; MeN-1, multiple endocrine neoplasia syndrome type 1; Mo, month; n/a, not available; NeTs, neuroendocrine tumors; pCBD, proximal common bile duct; pD, pancreatoduodenectomy; pp, pancreatic polypeptide; pppD, pylorus preserving pancreaticoduodenectomy; pTpVe, percutaneous transhepatic portal vein embolization; pV, portal vein; rFa, radio-frequency ablation; rHa, right hepatic artery; rHp, right hemihepatectomy; sph, synaptophysin; ss, somatostatin; Tr, tumor resection; VHLs, Von Hippel–Lindau syndrome; W, weeks; Zes, Zollinger–ellison syndrome; 5-HT, serotonin.
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Adult pancreatic acinar cells give rise to ducts but not endocrine cells in response to growth factor signaling

Adult pancreatic acinar cells give rise to ducts but not endocrine cells in response to growth factor signaling

For comparison, we also examined the formation of basement membrane as endocrine cells normally delaminated from ductal epithelium during late embryonic development. At embryonic day 17.5, laminin marked basement membrane around forming ducts and islets (see Fig. S1 in the supplementary material). However, at discreet points, no laminin was detected between the ducts and forming islets. At these points, laminin formed a continuous layer from the duct, extending out around the forming islet. This continuity of basement membrane from duct to delaminating endocrine cells is similar between embryonic tissue and TGF- induced hyperplastic tissue. However, in the TGF-overexpressing mice, areas of contact between duct and islet clusters that were devoid of laminin were much broader than in embryonic pancreas. For example, approximately 12 endocrine cells were juxtaposed to ductal epithelium in Fig. 2C, whereas only 1-3 endocrine cells were immediately juxtaposed to duct cells in embryonic pancreas (see Fig. S1 in the supplementary material). As larger ductal endocrine clusters were observed in TGF-overexpressing mice, they tended to wrap around the duct, maintaining a close association rather than separating from the ductal epithelium. This morphology suggests that if endocrine cells are indeed delaminating from ductal epithelium, they remain within the original basement membrane structure for some period of time.
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Case Report Uniportal video-assisted thoracoscopy for thoracic duct cyst resection without thoracic duct ligation: a case report

Case Report Uniportal video-assisted thoracoscopy for thoracic duct cyst resection without thoracic duct ligation: a case report

Abstract: Traditional surgical treatment of thoracic duct cyst consists of removal of the cyst and ligation of thoracic duct connected to it. We proposed a novel surgical technique that avoids the ligation of thoracic duct and minimizes the invasion. A 38-year-old woman with thoracic duct cyst was treated with a novel surgical technique that thoracic duct cyst was longitudinally excised without thoracic duct ligation via uniportal (3-4 cm) video-assisted thoracic surgery (VATS). This novel approach avoids the increase of intraluminal pressure of the duct and alleviates the pain for its minimized incision. There was no recurrence or complications during the twelve months follow-up. Compared with traditional surgical treatment of thoracic duct cyst, this novel approach preserves the original structure and function, and more importantly releases the pressure of the thoracic duct, which should be encouraged for its less trauma and complications.
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An ERCP was conducted in January 1994. This showed a sig- nificantly dilated main pancreatic duct with dilatation of the sec- ondary radicals and duct stones at both the head and tail of the pancreas. She had two further episodes of severe abdominal pain between January and May 1994. These episodes of pancreatitis resulted in her admission to hospital for periods of 2 to 3 weeks and treatment with TPN. She had persisting abdominal tender- ness between relapses. Abdominal ultrasounds performed during these exacerbations showed a dilated main pancreatic duct with the diameter varying between 4 and 8 mm and a considerable loss of pancreatic substance.
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Original Article Mirizzi’s Syndrome management: open and laparoscopic technique

Original Article Mirizzi’s Syndrome management: open and laparoscopic technique

fistula itself. The tube should be kept for at least two to three months, Csendes reported an increased incidence of bile leak when the tube was bought out through the fistula rather than a fresh choledochotomy. Though choledochoplasty alone may suffice in nearly all cases of CBF, there are patients who present with complete or near complete obstruction of the bile duct at the initial exploration itself in these cases for better long- term results it is safer to perform bilioenteric anastomosis. The various forms of which could be hepaticojejunostomy end to side or side to side, cholecystocholedochoduodenostomy. The other indication for bilioenteric anastomosis could be presence of concomitant multiple CBD stones or distal obstruction of bile duct due to other cause. A well-defined management guideline was provided by Csendes et al who classified MS on the basis of extent or erosion of CD circumference. The recommended procedures for different types are: type I- partial cholecystectomy, type II-suture closure of fistula or choledochoplasty. Type IlI - choledochoplasty, type IV - bilioenteric anastomosis. A satisfactory outcome in a mean follow up of 5.7year is a testimony to the adequacy of these procedures. This management protocol has been followed by other authors too. Bilioenteric anastomosis has been performed in these series for some of type IlI case too, where bile duct erosion was considered significant. Concomitant choledocholithiasis has been reported in35-62% of patients with MS. Routine exploration of the CD should be carried out in all cases with CBF. For type I, cases one can be more selective. The CD exploration is performed through the fistula itself or a fresh choledochotomy.
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Fabrication and Testing of a Catalytic
Convertor

Fabrication and Testing of a Catalytic Convertor

A Duct is fabricated which has three circular slots of diameter 80 mm, this duct is fitted before catalytic converter, this duct reduces the temperature and velocity at certain amount, so the reaction of the catalyst in honeycomb will be higher with the harmful gases which comes out from the engine exhaust, so this results more reduction of the harmful gases into harmless gases.

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An Analysis of Obstructive Jaundice

An Analysis of Obstructive Jaundice

Metastatic tumours in the porta hepatic lymph nodes ordinarily do not cause jaundice as they tend to push the duct aside rather than fix it. The most frequent cause is carcinoma of the colon. Occasionally, histiocytic non-Hodgkin’s lymphoma, Hodgkin’s disease, or even chloroma may extend from lymph nodes of the retroperitoneal area into the walls of the ducts can cause jaundice. Metastatic involvement of hilar connective tissue of liver rarely produces obstructive jaundice.

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DESIGN & FLOW FEATURES OF AXIAL FAN USED IN AN AIR COOLED HEAT EXCHANGER BY EXPERIMENTAL ANALYSIS

DESIGN & FLOW FEATURES OF AXIAL FAN USED IN AN AIR COOLED HEAT EXCHANGER BY EXPERIMENTAL ANALYSIS

The data of string C show that the observation of air velocity at measuring point 1and 6.Which are close to the end of the duct varies from 14.2 m/s and 13.2 m/s in existing fan respectively. Where as at point 1 and 6 in modified fan, the air flow varies from 15 m/s and 15.2 m/s respectively. The air flow rate at point 2 and 5 in existing fan and modified fan was observed as 13.5 m/s and 14.5 m/s in existing fan and 16.4 m/s and 16.5 m/s in modified fan. Similarly, the air flow velocity rate in existing and modified fan at point 3 and 4 was found 12.3 m/s, 12.5 m/s and 15.6 m/s and 15.2 m/s respectively.
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Abstract This paper describes a predictive model for acoustic transverse transmission loss from ducts with flat oval configuration of

Abstract This paper describes a predictive model for acoustic transverse transmission loss from ducts with flat oval configuration of

Abstract- This paper describes a predictive model for acoustic transverse transmission loss from ducts with flat oval configuration of finite length. The transmission mechanism is essentially that of “mode coupling”, whereby higher structural modes in the duct walls get excited because of non-circularity of the wall. Effect of geometry has been taken care of by evaluating Fourier coefficients of the radius of curvature. Emphasis is on understanding the physics of the problem as well as analytical modeling. Effects of the flat ovality, curvature have been demonstrated. With Anechoic termination, progressive approach modeling has been adopted in this paper.
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Patent arterial duct

Patent arterial duct

Isolated patent arterial duct is found in around 1 in 2000 full term infants, constituting nearly 10% of all congenital heart disease [3] and is the second most common congen- ital heart defect [4]. The overall incidence in infants born prematurely is 8 per 1000 live births with extremely high incidence of ductal patency in low birth weight infants [1]. Siassi et al. [5] reported that the incidence of patent arterial duct was 21% in a prospective study on 150 pre- term infants with low birth weight. However, spontane- ous delayed closure of the arterial duct occurred in 79% of their patients who survived the immediate neonatal period. The majority of reports show that there is a higher incidence in females, with a female to male ratio of ~2:1. Studies have revealed recurrence rates of between 1–5% among siblings of individuals with isolated patent arterial duct [6-10]. There are case reports which have shown much higher recurrence rates in individual families, sug- gesting different inheritance patterns in these families [11]. The familial occurrence of patent arterial duct is uncommon. An epidemiology paper from Carleton cover- ing the period between 1941–58 found only 41 families where the same cardiac defect occurred in two family members and of these only 17 had patent arterial duct [12].
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