Laparoscopic transgastric resection for intraluminal gastric gastrointestinal stromal tumors located at the posterior wall and near the gastroesophageal junction

Objective: Intraluminal gastric gastrointestinal stromal tumors (GISTs) located at the posterior wall and near the gastroesophageal junction represent a surgical challenge. We present our experience of laparoscopic transgastric resection for gastric GISTs of such location. Methods: Data of seven patients undergoing laparoscopic transgastric resection were identified and retrospectively reviewed with regard to procedural steps and patient outcomes. Results: Seven patients (4 men; mean age 64.1 ± 14.6 years) with gastric GISTs underwent laparoscopic transgastric resection from January 2010 to May 2015. Three of the seven GISTs were located near the gastroesophageal junction and the rest were found in the posterior wall of the stomach. All seven patients underwent successful laparoscopic resection without any conversions. There were no mortalities and no significant postoperative complications. Intraoperative endoscopy was performed for all patients. The mean operative time was 164.0 ± 59.1 minutes. Regular diet was resumed within 3 days on average and mean postoperative stay was 3.6 ± 1.3 days. All patients achieved complete R0 resection with a mean tumor size of 5.5 ± 1.1 cm. At a mean follow-up of 48.0 ± 13.4 months, all patients were recurrence free. Conclusions: GISTs of the posterior wall and in close proximity to the gastroesophageal junction can be safely resected laparoscopically using such an approach. Standard technique is required to achieve good oncological outcomes

Acute Massive Lower Gastrointestinal Bleeding Secondary to Obstructive Colitis Proximal to Obstructing Cancer of the Sigmoid Colon

Introduction: Acute massive lower gastrointestinal bleeding (LGIB) is a rare and serious manifestation of obstructive colitis that requires urgent therapeutic intervention. Here, we report a case of LGIB due to obstructive colitis in an adult patient. Presentation of Case: A 34-year-old man with large bowel obstruction secondary to sigmoid colon cancer underwent laparotomy and Hartmanns procedure (resection of rectosigmoid colon with a proximal end colostomy). Post-operatively, he had recurrent episodes of severe bleeding from the colostomy that required transfusion of a total of eleven units of packed cells and four units of fresh frozen plasma over the next two days. Urgent oesophagogastroduodenoscopy showed pan gastritis and insignificant superficial gastric erosions. Colonoscopy via the colostomy showed stigmata of recent bleed but failed to identify the exact site of bleeding. Computed tomography angiogram failed to localize the site of bleeding. A re-laparotomy was performed. On-table colonoscopy through the end colostomy followed by completion total colectomy and ileorectal anastomosis was done. The patient recovered uneventfully after the surgery with no further episode of rectal bleeding. Histology findings of the resected colon were compatible with obstructive colitis. He remains well at five years follow-up with no recurrence. Discussion: The case highlights the rare occurrence of acute massive LGIB as a life-threatening complication of obstructive colitis. The diagnosis should be considered in patients who present with large bowel obstruction. Conclusion: A high index of suspicion is key to early diagnosis and an extended resection of the colon is necessary to arrest bleeding

Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes

Background: In recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes. Methods: The medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes. Results: Fifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days. Conclusions: Laparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Laparoscopic management of symptomatic urachal remnants in adulthood

Background: The traditional surgical approach to the excision of persistent urachal remnants is a lower midline laparotomy or semicircular infraumbilical incision. The aim of this study is to report our experience with laparoscopic urachus excision as a minimally invasive diagnostic and surgical technique. Methods: This study was a prospective study involving patients who were diagnosed with persistent urachus and underwent laparoscopic excision. The morbidity, recovery, and outcomes of surgery were reviewed. Results: Fourteen patients (8 men) with a mean age of 22.8 ± 6.42 years underwent laparoscopic excision. All patients presented with discharge from the umbilicus. Although four patients had no sonographic evidence of a patent urachus, a diagnostic laparoscopy detected a patent urachus that was excised laparoscopically. One patient required laparoscopic reoperation for persistent discharge, and one patient presented with bladder injury, which was repaired via a small Pfannenstiel incision without any morbidity. The mean operative time was 71.1 ± 0.28 minutes, and the mean duration of hospital stay was 1.3 ± 1.38 days. Pathological examination confirmed a benign urachal remnant in all cases. Conclusion: Laparoscopy is a useful alternative for the management of persistent or infected urachus, especially when its presence is clinically suspected despite the lack of sonographic evidence. The procedure is associated with low morbidity, although a small risk of bladder injury exists, particularly in cases of severe active inflammation. Recurrence is uncommon and was caused by inadequate excision of inflammatory tissue in our series that was easily managed laparoscopically

Transcervical diverticulectomy for Killian–Jamieson diverticulum

Surgery for Killian–Jamieson diverticulum of the esophagus is scarcely reported in the literature owing to the rarity of this entity. This is a case report of such a diverticulum and a description of the transcervical diverticulectomy that we performed on a 49-year-old lady. The patient was investigated for symptoms of gastroesophageal reflux disease and was diagnosed with a left-sided Killian–Jamieson diverticulum

Laparoscopic management of symptomatic urachal remnants in adulthood

The traditional surgical approach to the excision of persistent urachal remnants is a lower midline laparotomy or semicircular infraumbilical incision. The aim of this study is to report our experience with laparoscopic urachus excision as a minimally invasive diagnostic and surgical technique. This study was a prospective study involving patients who were diagnosed with persistent urachus and underwent laparoscopic excision. The morbidity, recovery, and outcomes of surgery were reviewed. Fourteen patients (8 men) with a mean age of 22.8 ± 6.42 years underwent laparoscopic excision. All patients presented with discharge from the umbilicus. Although four patients had no sonographic evidence of a patent urachus, a diagnostic laparoscopy detected a patent urachus that was excised laparoscopically. One patient required laparoscopic reoperation for persistent discharge, and one patient presented with bladder injury, which was repaired via a small Pfannenstiel incision without any morbidity. The mean operative time was 71.1 ± 0.28 minutes, and the mean duration of hospital stay was 1.3 ± 1.38 days. Pathological examination confirmed a benign urachal remnant in all cases. Laparoscopy is a useful alternative for the management of persistent or infected urachus, especially when its presence is clinically suspected despite the lack of sonographic evidence. The procedure is associated with low morbidity, although a small risk of bladder injury exists, particularly in cases of severe active inflammation. Recurrence is uncommon and was caused by inadequate excision of inflammatory tissue in our series that was easily managed laparoscopically

Complication and remission rates after endoscopic argon plasma coagulation in the treatment of haemorrhagic radiation proctitis

Purpose: The management of haemorrhagic radiation proctitis is challenging because of the necessity for repeated intervention. The efficacy of argon plasma coagulation has been described before but the optimum treatment strategy remains debatable. This is a review of our experience over a decade treating patients with haemorrhagic radiation proctitis and their follow-up. Methods: This is a retrospective review of consecutive patients who underwent argon plasma coagulation for haemorrhagic radiation proctitis between January 2003 and December 2013. The patients were followed up using a prospectively maintained database. Results: Ninety-one patients were included with a mean follow-up of 13.1 months. Majoity (n = 85, 93.4 %) of the patients were female. Mean age at the time of treatment was 58.2 (range 23–87) years old. Majority of the patients (n = 73, 80.2 %) received radiotherapy for gynaecological malignancies followed by colorectal (n = 13, 14.3 %) and urological (n = 5, 5.5 %) malignancies. Mean interval between radiation and proctitis was 13.8 (range 3–40) months. Seventy-nine percent of patients were successfully treated after 1–2 sessions. Seventeen (18.7 %) patients experienced self-limiting early complications, and three (3.3 %) had late complications of rectal stenosis which was managed conservatively. Severity of bleeding during the initial presentation is an independent factor that predicts the number of sessions required for successful haemostasis (p = 0.002). Conclusions: Argon plasma coagulation is a reasonable treatment option in patients with haemorrhagic radiation proctitis with good safety profile. Our study suggests that the number of APC sessions required to arrest bleeding correlates with the severity of bleeding on initial presentation

Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique

Background/Objective: The objective of this study was to compare the outcomes of patients who underwent laparoscopic and open repair of perforated peptic ulcers (PPUs) at our institution. Methods: This is a retrospective review of a prospectively collected database of patients who underwent emergency laparoscopic or open repair for PPU between December 2010 and February 2014. Results: A total of 131 patients underwent emergency repair for PPU (laparoscopic repair, . n=63, 48.1% vs. open repair, . n=68, 51.9%). There were no significant differences in baseline characteristics between both groups in terms of age (p=0.434), gender (p=0.305), body mass index (p=0.180), and presence of comorbidities (p=0.214). Both groups were also comparable in their American Society of Anesthesiologists (ASA) scores (p=0.769), Boey scores 0/1 (p=0.311), Mannheim Peritonitis Index > 27 (p=0.528), shock on admission (p . 24 hours (p=0.857). There was no significant difference in the operating time between the two groups (p=0.618). Overall, the laparoscopic group had fewer complications compared with the open group (14.3% vs. 36.8%, . p=0.005). When reviewing specific complications, only the incidence of surgical site infection was statistically significant (laparoscopic 0.0% vs. open 13.2%, . p=0.003). The other parameters were not statistically significant. The laparoscopic group did have a significantly shorter mean postoperative stay (p=0.008) and lower pain scores in the immediate postoperative period (p . <. 0.05). Mortality was similar in both groups (open, 1.6% vs. laparoscopic, 2.9%, . p < 0.99). Conclusion: Laparoscopic repair resulted in reduced wound infection rates, shorter hospitalization, and reduced postoperative pain. Our single institution series and standardized technique demonstrated lower morbidity rates in the laparoscopic grou

Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique

Background/Objective: The objective of this study was to compare the outcomes of patients who underwent laparoscopic and open repair of perforated peptic ulcers (PPUs) at our institution. Methods: This is a retrospective review of a prospectively collected database of patients who underwent emergency laparoscopic or open repair for PPU between December 2010 and February 2014. Results: A total of 131 patients underwent emergency repair for PPU (laparoscopic repair, n = 63, 48.1% vs. open repair, n = 68, 51.9%). There were no significant differences in baseline characteristics between both groups in terms of age (p = 0.434), gender (p = 0.305), body mass index (p = 0.180), and presence of comorbidities (p = 0.214). Both groups were also comparable in their American Society of Anesthesiologists (ASA) scores (p = 0.769), Boey scores 0/1 (p = 0.311), Mannheim Peritonitis Index > 27 (p = 0.528), shock on admission (p  24 hours (p = 0.857). There was no significant difference in the operating time between the two groups (p = 0.618). Overall, the laparoscopic group had fewer complications compared with the open group (14.3% vs. 36.8%, p = 0.005). When reviewing specific complications, only the incidence of surgical site infection was statistically significant (laparoscopic 0.0% vs. open 13.2%, p = 0.003). The other parameters were not statistically significant. The laparoscopic group did have a significantly shorter mean postoperative stay (p = 0.008) and lower pain scores in the immediate postoperative period (p < 0.05). Mortality was similar in both groups (open, 1.6% vs. laparoscopic, 2.9%, p < 0.99). Conclusion: Laparoscopic repair resulted in reduced wound infection rates, shorter hospitalization, and reduced postoperative pain. Our single institution series and standardized technique demonstrated lower morbidity rates in the laparoscopic group