Department of Surgery, University of New Mexico Hospital, Albuquerque, NM.

ABSTRACT

We report a case of a 21-year-old male who presented with adult-onset dysphagia after previous Nissen fundoplication initially created at age 10.5 months. The patient first presented one year ago to a different hospital, where he underwent extensive workup for his symptomatology. Physiologic tests performed were esophagogastroduodenoscopy (EGD), ab- dominal ultrasound, hepatobiliary iminodiacetic acid scan, esophageal manometry, and lactulose breath test. The EGD identified stricture at the level of the gastroesophageal junction. The other studies did not reveal other physiologic causes for his symptoms. The patient then presented to our institution, at which time a repeat EGD showed evidence of tight Nissen fundoplication. The patient subsequently underwent laparoscopic exploration, which revealed that the fundopli- cation had was partially disrupted, herniated, and twisted causing a long-segment distal stricture. To alleviate the patient’s presenting symptom of dysphagia as well as prevent possible future reflux, it was decided to convert repair the hernia and revise the Nissen into a partial fundoplication. This was successfully accomplished laparoscopically with sub- sequent resolution of the patient’s symptoms.

Key Words: Pediatric GERD, Nissen fundoplication, Toupet fundoplication, Dysphagia.

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Colorectal Surgery Department, Hospital Central Militar, México City, México (Dr. M. Gurieb-Trueba)
Advanced Endoscopy Department, Hospital Central Militar, México City, México (Dr. V. M. Rivera-Méndez)
Hospital San Ángel Inn Chapultepec, México City, México (Dr. J. C. Sánchez-Robbles)

ABSTRACT

Colorectal cancer prevention relies on effective screening through colonoscopy and polypectomy. Several techniques and methods have been described to manage complex colonic polyps such as the ones that are endoscopically unresectable. Across time, we have been able to perform less invasive techniques that include different types of colonic resections, ranging from partial thickness, full-thickness and, segmental colectomies, however, none has proven to be the treatment of choice for these lesions. The technique presented here is an attractive alternative to segmental colectomy using a robotic platform to perform a full-thickness resection.

Key Words: Robotic surgery, Combined approach, Polyp, Colon, Colonoscopy, Colon cancer, Minimally invasive surgery.

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Geisinger Wyoming Valley General Surgery Residency Program, Wilkes-Barre, PA (all authors).

ABSTRACT

Introduction: A parastomal hernia (PSH) is an abnormal herniation of an intra-abdominal organ or other tissue through an intentionally created fascial defect at an ostomy site. PSHs commonly involve reducible mobile segments of omentum, intra-abdominal fat, and bowel. However, PSHs may rarely involve fixed intra-abdominal organs such as the stomach.

Case Description: A 68-year-old female underwent emergent Hartmann procedure for Hinchey III diverticulitis and subsequently developed a large reducible parastomal hernia. She was scheduled for an elective laparoscopic colostomy reversal. Prior to her scheduled reversal, the patient presented to the ED with anorexia, lack of colostomy output, emesis, and pain localized to her left lower quadrant. She was found to have gastric outlet obstruction secondary to herniation of the stomach through the left lower quadrant colostomy site. The patient was admitted and treated conservatively with resolution of her symptoms, but due to the high likelihood of recurrence, the decision was made to proceed with laparoscopic Hartmann colostomy reversal with coloproctostomy and primary clo- sure of the fascia without mesh.

Conclusion: The contents of a PSH can become incarcerated causing obstruction, strangulation, necrosis and even perforation over time. Fortunately, in this case, herniation of the stomach was recognized early. The patient underwent repair of the hernia defect in order to prevent recurrence of gastric herniation and its potential detrimental complications. The decision regarding the technical aspects of ostomy reversal in terms of mesh selection require further study. In our case, mesh was not used due to patient-specific factors and comorbidities.

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Department of Clinical Education, Taipei Tzu Chi Hospital, Buddhist Tzu, Chi Medical Foundation, New Taipei, Taiwan (Dr. Y-H Lin)
Department of Radiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi, Medical Foundation, Chiayi, Taiwan (Dr. C-W Lin)
Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan (Dr. W-Y Yin) School of Medicine, Tzu Chi University, Hualien, Taiwan (Drs. Y-H Lin, C-W Lin, and W-Y Yin)

ABSTRACT

We report a case of bile leaks post-laparoscopic cholecystectomy (LC) with initial treatment failure by common bile duct stent insertion. The injury of a subvesical duct running from gallbladder fossa toward an area of fluid accumulation that was not revealed by computed tomography and endoscopic retrograde cholangiopancreatography previously, was even- tually found by magnetic resonance cholangiopancreatography (MRCP) and proved to be the cause of bile leak. Also, several tiny branches in the right liver instead of a main trunk and another subvesical duct draining into the common bile hepatic duct was noted. These anatomic variations were scarcely reported, especially by MRCP.
The aim of this case report is to discuss the link between biliary tree anomaly and bile leak due to bile duct injury during LC in our experience treating one patient. Also, we review related literature to understand more on prevention or man- agement of subvesical duct injury.

Key Words: Subvesical duct injury, Laparoscopic cholecystectomy, Bile leak, Biliary tree anomaly.

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Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey (Drs. Mackowsky and Borao).
Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey (Drs. Hadjiloucas and Lira).

ABSTRACT

Background: Concurrent laparoscopic paraesophageal repair with colectomy has yet to be described in the literature.

Case Description: An 88-y-old male with shortness of breath and rectal bleeding presented to the emergency depart- ment. Workup ultimately revealed a nonobstructing ascending colon mass within the sac of type IV paraesophageal hernia. The decision was made to proceed with laparoscopic colectomy with concurrent paraesophageal hernia repair.

Conclusion: To reduce overall operative time and optimize recovery, the decision was made to perform both operations synchronously. The patient suffered no intraoperative or postoperative complications and experienced a full and timely recovery. To the best of our knowledge, simultaneous colon resection with paraesophageal hernia repair has not been described in the literature. Despite the inherent high risk, performing both procedures in a single operation helped to decrease the patient’s anesthesia time and overall recovery time as well as risks of reoperation.

Key Words: paraesophageal hernia repair, colectomy, adenocarcinoma.

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Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA (Dr. Kim)
Department of Surgery, Hackensack Meridian Health JFK Medical Center, Edison, New Jersey, USA (Dr. Bryczkowski)
Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA (Drs Pereira, Rosenstock, Zumba, Mazpule)
Department of Pathology, Rutgers New Jersey Medical School, Newark, New Jersey, USA (Dr. Zheng)

ABSTRACT

Introduction: Colonic gastrointestinal stromal tumors are rare and never have been reported to present as diverticulitis.

Case Description: We describe a case of a 63-year-old female who was treated for a perforated sigmoid diverticulitis which was secondary to a gastrointestinal stromal tumor.

Conclusion: While most major guidelines suggest treatment with adjuvant imatinib for immediate or high risk gastrointestinal stromal tumors, there are discrepancies among the guidelines on the management of perforated tumors which warrant further studies to manage these patients.

Key Words: Gastrointestinal stromal tumor; Perforated GIST; Perforated diverticulitis.

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Department of Pediatric Gastroenterology, NY Medical College, Westchester Medical Center, Valhalla, New York, USA (Drs Shaban, Cukaj, Sood, and Bostwick).
Department of Surgery, Division of Pediatric Surgery, NY Medical College, Westchester Medical Center, Valhalla, New York, USA (Dr Stringel).
New York Medical College, Westchester Medical Center, Valhalla, New York, USA (Dr. Helfgott).

ABSTRACT

Introduction: Vascular malformations remain a rare cause of gastrointestinal (GI) bleeding, and they can present a diagnostic challenge. The diagnostic utility of video capsule endoscopy in identifying these malformations in the pediatric population is not well documented.

Case Description: A 7-y-old male with chronic iron deficiency anemia had a clinical history of melon and occasional hematochezia of 1-year duration requiring multiple admissions to the hospital and blood transfusions. Ultrasound, Meckel scan, magnetic resonance imaging, and computed tomography (angiogram) did not demonstrate the source of bleeding. Upper and lower endoscopy studies showed no abnormalities. A video capsule endoscopy showed a lesion in the small intestine suggestive of an arteriovenous malformation. Diagnostic laparoscopy identified the vascular malformation in the mid jejunum. Laparoscopic-assisted intestinal resection including the malformation was successfully performed. After surgical resection, the anemia resolved, and the patient had no further episodes of bleeding.

Conclusions: This case illustrates the utility of video capsule endoscopy combined with laparoscopy in the management of a suspected GI arteriovenous malformation in pediatric patient.

Key Words: Anemia; Arteriovenous Malformation; Gastrointestinal Bleeding; Laparoscopy; Pediatric; Video Capsule Endoscopy.

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Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA (Drs Villano, Metchik, Bamba, and Bhanot)

ABSTRACT

Introduction: Percutaneous endoscopic gastrostomy (PEG) tube placement is generally a safe and effective method for establishing long-term enteral access in a minimally invasive fashion. Placement through an intervening loop of colon is a surgical pitfall that ultimately requires operative exploration to correct. Delayed perforation remote from the initial PEG placement is not yet described in the literature and represents an unusual but serious form of this complication.

Case Description: A 62-year-old male with history of Down syndrome and severe intellectual disability, chronic PEG, and tracheostomy developed free air during his admission. Subsequent exploratory laparotomy demonstrated that the PEG traversed the sigmoid colon and entered the gastric lumen, with a small perforation along the exit site of the sigmoid colon. Segmental colonic resection with end colostomy was performed without complication, and the gastrostomy was revised in a Stamm fashion. He was able to resume tube feeds prior to hospital discharge.

Conclusion: Intestinal perforation secondary to a misplaced PEG tube with gastrocolocutaneous fistula can occur in a delayed fashion, even long after the tube was placed and feeding was initiated. Utilization of the “safe tract” method must carefully be employed to minimize the risk of placement through an intervening hollow viscous such as colon or small bowel. Perforation or coloenteric fistulae require surgical intervention to correct.

Key Words: Gastrostomy, Cutaneous Fistula, Endoscopy.

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Department of Surgery, Kuwana East Medical Center, Kuwana, Mie, Japan (all authors).

ABSTRACT

Introduction: Duodenal stricture with malrotation is rare in adults. Anatomical anomalies of malrotation include narrowing of the root of the mesentery associated with volvulus and the presence of Ladd’s band, which causes duodenal obstruction. Two case reports of duodenal stricture not associated with Ladd’s band have been published in the English literature.

Case Presentation: A 36-year-old thin man was admitted for vomiting after meals and was diagnosed with superior mesenteric artery (SMA) syndrome by endoscopy and computed tomography.

Management and Outcomes: He received conservative treatment but returned 3 more times with the same symptoms. He underwent laparoscopy during his fifth admission after he was diagnosed with duodenal stricture with malrotation based on preoperative examinations. A membrane-like adhesion affecting the retroperitoneum to the duodenum and several cordlike adhesions wrapping around the right dorsal side of the SMA to the anal side of the duodenum were dissected to divide the adhesions. Ladd’s band was not observed. No recurrence has been observed for 1 year and 7 months.

Discussion: The jejunum was located on the dorsal side of the SMA and the duodenum was pulled by the cordlike adhesions wrapping around the right dorsal side of the SMA, and a concomitant duodenal obstruction was identified; therefore, the jejunum appeared to be compressed between the SMA and the aorta. Consequently, this case masqueraded as SMA syndrome. We successfully performed laparoscopic surgery for an adult patient with malrotation, especially with regard to dissection of the cordlike adhesions originating from the root of the SMA. This minimally invasive procedure is feasible for duodenal strictures with malrotation.

Key Words: Duodenal stricture, Ladd’s band, Malrotation, Superior mesenteric artery syndrome.

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Department of Bariatric Surgery, Grand View Hospital, Tijuana Baja California, México (Dr Reyes). School of Medicine, University Studies Center Xochicalco, Tijuana Baja California, Mexico (Dr Hernández). Faculty of Medicine and Psychology of the Autonomous University of Baja California. Campus Tijuana, Mexico (Drs Ávila, González, Romero, and Reyes; Mr. Méndez; Ms Sánchez).

ABSTRACT

Introduction: Intragastric band migration (IGBM) is a rare but serious late complication of laparoscopic adjustable gastric banding (LAGB). It is the result of a complete transmural migration with a simultaneous effective resolution of the gastric wall perforation. In some rare cases, the band can migrate distally into the jejunum, ileum, colon, and rectum, causing mechanical obstruction or intestinal perforation.

Case Descriptions: We present a case of a 58-year-old woman with an unusual and infrequent complication of gastric band erosion through the stomach, and its subsequent migration to the colon and spontaneous excretion per rectum 7 years after its placement.

Discussion: IGBM can be completely asymptomatic. If the patient presents with prolonged epigastric pain or regains weight, diagnostic studies should be performed to prevent more severe associated complications. This situation went unnoticed by the patient who reported only general symptoms, and did not reach the stage of severe complication, such as mechanical obstruction and intestinal perforation. In the literature, reports of distal migration to the intestine are even rarer, and migration to the sigmoid colon and rectum, as in our patient, is extremely rare.

Key Words: Band erosion, Gastric band complication, Laparoscopic gastric banding, Migration.

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