Successful laparoscopic management of paraesophageal hiatal hernia with upside-down intrathoracic stomach: A case report

Introduction: Paraesophageal hernia with intrathoracic mesentericoaxial type of gastric volvulus is a rare clinical entity. The rotation occurs because of the idiopathic relaxation of the gastric ligaments and ascent of the stomach adjacent to the oesophagus through the hiatus defect, while the gastroesophageal junction remains in the abdomen. The open approach remains the gold standard therapy for most patients. Here we report the case of a patient with such a condition who underwent a successful laparoscopic surgery. A literature search revealed that this is the first case report from Southeast Asia. Case presentation: A 55-year-old Chinese woman presented to us with symptoms suggestive of gastric outlet obstruction for one year. A chest radiograph showed an air bubble with air-fluid level in her left thoracic cavity, where a diaphragmatic hernia was initially suspected. A computed tomography scan and barium swallow study demonstrated the presence of a type III paraesophageal hernia with intrathoracic upside-down stomach. A laparoscopy was performed and the herniated stomach was successfully reduced into the abdomen. The mediastinal part of the hernial sac was excised. Adequate intraabdominal length of oesophagus was achieved after resection of the sac and circumferential oesophageal dissection. A lateral releasing incision was made adjacent to the right crus to facilitate crural closure. The diaphragmatic defect and the hiatal closure were covered with a composite mesh. A Toupet fundoplication was performed to recreate the antireflux valve. She had an uneventful recovery. She had no relapse of previous symptoms at her six-month follow-up assessment. Conclusions: Laparoscopic repair of such a condition can be accomplished successfully and safely when it is performed with meticulous attention to the details of the surgical technique

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

Successful laparoscopic management of combined traumatic diaphragmatic rupture and abdominal wall hernia: a case report

Background: Traumatic diaphragmatic rupture and traumatic abdominal wall hernia are two well-described but rare clinical entities associated with blunt thoracoabdominal injuries. To the best of our knowledge, the combination of these two clinical entities as a result of a motor vehicle accident has not been previously reported. Case presentation: A 32-year-old Indian man was brought to our emergency department after being involved in a road traffic accident. He described a temporary loss of consciousness and had multiple tender bruises at his right upper anterior abdominal wall and left lumbar region. An initial examination revealed blood pressure of 99/63 mmHg, heart rate of 107 beats/minute, and oxygen saturation of 93 % on room air. His clinical parameters stabilized after initial resuscitation. A computed tomographic scan revealed a rupture of the left diaphragm as well as extensive disruptions of the left upper anterior abdominal wall. We performed exploratory laparoscopic surgery with the intention of primary repair. The diaphragmatic and abdominal wall defect was primarily closed, followed by reinforcement with PROLENE onlay mesh. The patient’s postoperative recovery was complicated by infected hematomas over both flanks that were managed with ultrasound-guided percutaneous drainage. He was discharged well despite a prolonged hospital stay. Conclusions: We present a complex form of injuries managed successfully via a laparoscopic approach. Meticulous attention to potential complications in both the acute and convalescent phases is important for achieving a successful outcome following surgery

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

When is poem truly equivalent to LHM? A comparison of complication rates during the learning curve

INTRODUCTION: Per-Oral Endoscopic Myotomy (POEM) has been shown to be an effective treatment for Achalasia, but the endoscopic technique required is complex and not routinely performed. We believe that, for any new procedure, competency can be demonstrated when the complication rate of a new procedure (POEM) equals that of an established one, ie Laparoscopic Heller’s Myotomy + Fundoplication (LHM+F). METHODS: A multicentre, retrospective cohort, comparing complication rates during the learning curve of POEM to a historical cohort of LHM+F, was conducted. A direct head-to-head comparison was performed, followed by a population pyramid of complication frequency. Case sequence was then divided into blocks of 5, and the complication rates during each block was compared to the historical cohort. RESULTS: A total of 123 cases ( LHM+F n=60, POEM n=63) were analysed. Mean age was lower for the POEM group (41.7 years vs 48.1 years, p = 0.03), but there was no difference in gender nor type of Achalasia. The POEM group recorded a shorter overall procedural time (125.9 minutes vs 144.1 minutes, p = 0.023) and longer myotomies (10.1cm vs 6.2cm, p = 0.023). Complication rates were higher in the POEM group (20.6% vs 10.0%, p=0.10), but was not statistical significant. Complication frequency tapered off dramatically after the 25th case in the sequence, and subsequently equalled that of LHM+F. Length of stay was shorter for the POEM group (3.4 days vs 4.8 days, p = 0.014). The post-procedural findings favoured LHM+F, with the post-procedural Eckardt scores significantly lower (0.4 vs 1.6, p < 0.001) and the usage of PPIs lower in this group (20.7% vs 39.4%, p = 0.03). CONCLUSION: POEM is challenging even for experienced endoscopists. From our data, complication rates between POEM and LHM+F equalize after approximately 25 POEMs

Stomach gastrointestinal stromal tumours (GIST) intussuscepted into duodenum : A case report

Gastrointestinal stromal tumours are tumours of gastrointestinal tract and mesentery. The commonest site of it occurrence is stomach. Patients with GISTs are usually asymptomatic but they can present as abdominal pain, bleeding and rarely gastric outlet obstruction. In this particular case, patient presents with symptoms of anaemia, partial gastric outlet obstruction and intermittent epigastric pain. Laparotomy was performed and a diagnosis of gastroduodenal intussusception secondary to gastrointestinal stromal tumour was made

Acute Lower Gastrointestinal Haemorrhage Secondary to Small Bowel Ascariasis

Acute lower gastrointestinal haemorrhage secondary to small bowel ascariasis is extremely rare. A high level of suspicion should be maintained when dealing with acute gastrointestinal haemorrhage in migrants and travellers. Small bowel examination is warranted when carefully repeated upper and lower endoscopies have failed to elicit the source of bleeding. Appropriate test selection is determined by the availability of local expertise. We present a case of acute lower gastrointestinal haemorrhage secondary to jejunal ascariasis and a literature search on lower gastrointestinal haemorrhage associated with jejunal infestation with Ascaris

Two Different Surgical Approaches for Strangulated Obturator Hernias

Obturator hernia is a rare condition that may present in an acute or subacute setting in correlation with the degree of small-bowel obstruction. Pre-operative diagnosis is difficult, as symptoms are often non-specific. A high index of suspicion should be maintained for emaciated elderly women with small-bowel obstruction without a previous abdominal operation and a positive Howship–Romberg sign. When diagnosis is in doubt, computed tomography scan of the abdomen and the pelvis (if available) or laparotomy should be performed immediately, as high mortality rate is related to the perforation of gangrenous bowels. We present 2 cases of strangulated obturator hernia, managed differently with both open and laparoscopic approaches. The diagnostic accuracy of computed tomography scan is highlighted followed by a brief literature review with an emphasis placed on surgical management