Department of Medicine, Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College, Westchester Medical Center, Valhalla, New York (Drs. Olivier-Cabrera, Tewari, Gollapudi).
Department of Surgery, Division of Pediatric Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York (Dr. Stringel).

ABSTRACT

Introduction: Symptomatic intraperitoneal collections in difficult anatomical locations can present a management chal- lenge. Even after access and drainage are accomplished, reaccumulation of thick material inside the cavity can continue to cause problems. The use of fibrinolytic agents has been reported to facilitate drainage of thick material, hematomas, purulence, and fibrin.

Case Description: We present a 16-year-old male with idiopathic thrombocytopenic purpura who developed a symp- tomatic intraperitoneal hematoma with dimensions of 5
6
6.7 cm, abutting the spleen, pancreas, and left kidney, caused by blunt trauma. Interventional radiology could not drain the cyst because of the location. Initial drainage was done with endoscopic ultrasound (EUS)-guided placement of a lumen apposing self-expandable 1.5 cm wide metal stent designed for cystogastrostomy. The patient continued to be febrile despite saline irrigation used in the initial procedure. Two endoscopic sessions employing thrombolytic agents (4 mg of tissue plasminogen activator and 5 mg of deoxyribonuclease) instillation into the collection at weekly intervals were used. The stent was removed after 8 weeks with complete resolution of the collection. He was discharged home and remained asymptomatic after 1 year of follow-up.

Conclusion: The present case demonstrates the successful and safe use of EUS-guided transgastric drainage in conjunc- tion with fibrinolytic/thrombolytic agents to facilitate dissolution of thickened internal debris, especially in collections with a capsule when mechanical debridement can lead to spillage of infected material and cause generalized peritonitis. To the best of our knowledge, this is the first report of endoscopic drainage utilizing thrombolytic agents.

Key Words: Endoscopic drainage; Intraperitoneal hematoma; Transgastric drainage; Fibrinolytic agents; Thrombolytic agents.

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Westchester Medical Center, New York Medical College, Valhalla New York, USA (all authors).

ABSTRACT

Background: Sponge bezoars will absorb luminal contents, enlarge, and subsequently harden. There is significant potential for the development of intestinal obstruction and perforation.

Methods: We report the case of an unsuspected polyurethane foam (PUF) sponge bezoar causing intestinal obstruction in an 8-year-old boy undergoing laparoscopy for an ingested lithium battery that was adherent to the cecum or the appendix.

Results: The PUF sponge bezoar was removed from the small intestine via laparoscopic-assisted enterotomy. The battery was removed from the colon via colonoscopy after multiple attempts failed to retrieve it during surgery and after surgery with laxatives.

Conclusion: This case raises awareness about the presence of unsuspected multiple ingested foreign bodies causing complications and the benefits of laparoscopy in identifying them and facilitating safe retrieval.

Key Words: Bezoar intestinal obstruction, Intestinal foreign batteries.

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Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York (all authors).

ABSTRACT

Introduction: Abdominal mesenteric cystic lymphangiomas are congenital lymphatic malformations found most commonly within the small bowel mesentery, omentum, and mesocolon. These lesions may be detected incidentally on imaging studies or may present with bowel obstruction. Treatment of choice is surgical enucleation with possible segmental intestinal resection.

Case Description: This report describes the use of minilaparoscopy in the treatment of abdominal mesenteric cystic lymphangioma (MCL) in a child, along with a review of the current literature on laparoscopic treatment. Our patient, who had a prenatal diagnosis of an intra-abdominal mass, had developed postprandial emesis. Imaging work-up with ultrasonography and CT scan revealed an intra-abdominal mass suspicious for lipomatous tumor. The patient underwent minilaparoscopy-assisted resection of the intra-abdominal mass, along with the resection of small bowel that was adherent to the tumor. The final pathology showed that the mass was an MCL.

Discussion: The traditional treatment for MCL has been open surgical resection. Recently, laparoscopic surgical excision of mesenteric cysts in children has been reported in the literature.

Key Words: Abdominal mesenteric cystic lymphangioma, Minilaparoscopy

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Department of Surgery, Westchester Medical Center, Valhalla, NY, USA (Dr. Alemayehu). Department of Pediatric Surgery, Westchester Medical Center/New York Medical College, Valhalla, NY (Drs. Pandya, McBride, Stringel).

ABSTRACT

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia has increased with the use of prosthetic material. When the defect cannot be repaired primarily, a variety of materials have been used. The ideal prosthetic material has not been identified yet. The use of biologic tissue matrix prosthesis is appealing because this material may serve as a framework to support the patient’s own tissue regeneration. We report on 2 newborns with congenital diaphragmatic hernia repaired by thoracoscopy with placement of a Strattice patch (LifeCell, Branchburg, New Jersey). The hernia recurred in both cases.

Case Description: Two neonates born at term, weighing 3.5 kg and 4.0 kg, had left-sided congenital diaphragmatic hernias repaired by thoracoscopy with a Strattice patch. The repairs were performed at 1 and 4 days of age after a period of stabilization. There were no other congenital anomalies. There were no operative complications. The neonates recovered uneventfully and were discharged in good condition. Recurrence of the diaphragmatic hernia was identified by chest radiographs at routine follow-up visits 16 and 22 months postoperatively. One patient had mild abdominal pain and increasing shortness of breath, whereas the other patient was asymptomatic. One patient had an abdominal open primary repair of the recurrent diaphragmatic hernia, whereas the other patient had a laparoscopy-assisted repair with AlloDerm patch (LifeCell). They both recovered uneventfully.

Discussion: Postoperative follow-up at regular intervals is extremely important after repair of diaphragmatic hernia, especially when prosthetic material is used, because of the high incidence of recurrence. We do not recommend the repair of diaphragmatic hernia with the Strattice patch at this time.

Key Words: Congenital diaphragmatic hernia repair, Thoracoscopy, Strattice mesh

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