A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

AIM:To present a new technique of end-to-side, ductto-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. METHODS:We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. RESULTS:There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. CONCLUSION:This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.

Transanal polypectomy using single incision laparoscopic instruments

Transanal excision of rectal polyps with laparoscopic instrumentation and a single incision laparoscopic port is a novel technique that uses technology originally developed for abdominal procedures from the natural orifice of the rectum. Transanal endoscopic microsurgery (TEM) is a well established surgical approach for certain benign or early malignant lesions of the rectum, under specific indications. Our technique is a hybrid technique of transanal surgery, a reasonable method for polyp resection without the need of the sophisticated and expensive instrumentation of TEM which can be applied whenever endoscopic or conventional transanal surgical removal is not feasible.

Capsule endoscopy retention as a helpful tool in the management of a young patient with suspected small-bowel disease

Capsule endoscopy is an easy and painless procedure permitting visualization of the entire small-bowel during its normal peristalsis. However, important problems exist concerning capsule retention in patients at risk of small bowel obstruction. The present report describes a young patient who had recurrent episodes of overt gastrointestinal bleeding of obscure origin, 18 years after small bowel resection in infancy for ileal atresia. Capsule endoscopy was performed, resulting in capsule retention in the distal small bowel. However, this event contributed to patient management by clearly identifying the site of obstruction and can be used to guide surgical intervention, where an anastomotic ulcer is identified.

Persistent omphalomesenteric duct causing small bowel obstruction in an adult

An extremely rare case of persistent omphalomesenteric duct causing small bowel obstruction is presented. A 20-year-old female patient without medical history presented with colicky abdominal pain, vomiting, absence of passage of gas and feces, and abdominal distension of 24 h duration. Physical examination and blood tests were normal. Abdominal X-ray showed small bowel obstruction. Computed tomography of the abdomen demonstrated dilated small bowel and a band originating from the umbilicus and continuing between the small bowel loops; an omphalomesenteric duct remnant was suspected. In exploratory laparotomy, persistent omphalomesenteric duct causing small bowel obstruction was identified and resected. The patient had an uneventful recovery and was discharged on the 5^th postoperative day. Although persistent omphalomesenteric duct is an extremely infrequent cause of small bowel obstruction in adult patients, it should be taken into consideration in patients without any previous surgical history.

Rectal carcmosarcoma: A case report and review of literature

A 60-years old male was admitted to our department for investigation of constipation and hypogastric discomfort intensified during defecation of a few weeks duration. The cause proved to be a rectal carcinosarcoma that was treated by abdominoperineal resection and postoperative chemo-radiotherapy. The patient died 6 months later due to hepatic failure, showing evidence of disseminated disease. In general colonic carcinosarcomas constitute a rare category of malignant neoplasms whose nature is still incompletely understood. No specific treatment guidelines exist. Surgery is the mainstay of treatment and regardless of the addition of adjuvant therapy the prognosis is very poor. Systematic genetic analysis may be the clue for understanding the pathogenesis of these mysterious tumors.

Acute esophageal necrosis: A systematic review and pooled analysis

BACKGROUND Acute esophageal necrosis(AEN)is a rare entity with multifactorial etiology,usually presenting with signs of upper gastrointestinal bleeding.AIM To systematically review all available data on demographics,clinical features,outcomes and management of this medical condition.METHODS A systematic literature search was performed with respect to the PRISMA statement(end-of-search date:October 24,2018).Data on the study design,interventions,participants and outcomes were extracted by two independent reviewers.RESULTS Seventy-nine studies were included in this review.Overall,114 patients with AEN were identified,of whom 83 were males and 31 females.Mean patient age was 62.1±16.1.The most common presenting symptoms were melena,hematemesis or other manifestations of gastric bleeding(85%).The lower esophagus was most commonly involved(92.9%).The most widely implemented treatment modality was conservative treatment(75.4%),while surgical or endoscopic intervention was required in 24.6%of the cases.Mean overall followup was 66.2±101.8 d.Overall 29.9%of patients died either during the initial hospital stay or during the follow-up period.Gastrointestinal symptoms on presentation[Odds ratio 3.50(1.09-11.30),P=0.03]and need for surgical or endoscopic treatment[surgical:Odds ratio 1.25(1.03-1.51),P=0.02;endoscopic:Odds ratio 1.4(1.17-1.66),P<0.01]were associated with increased odds of complications.A sub-analysis separating early versus late cases(after 2006)revealed a significantly increased frequency of surgical or endoscopic intervention(9.7%vs 30.1%respectively,P=0.04)CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management.Although the frequency of surgical and endoscopic intervention has increased in recent years,outcomes have remained the same.Therefore,further research work is needed to better understand how to best treat this potentially lethal disease.