Laparoscopic Resection of Bleeding Dieulafoy's Lesion in the Jejunum Following Intraoperative Localization Using Endoscopy

A Dieulafoy lesion is a relatively rare, but potentially life threatening cause of gastrointestinal bleeding, which accounts for only 1~2% of acute cases. The most common site is the stomach and most extragastric lesions are frequently found in the duodenum followed by the esophagus, the colon, and rectum. However, jejunum and ileum are extremely rare. I report on a case of a 38-year-old female who underwent laparoscopic resection of a bleeding Dieulafoy's lesion in the jejunum following intraoperative endoscopy.

Hemorragia gastrointestinal de grande vulto diagnosticada por enteroscopia intraoperatória: relato de caso / Contribution for the diagnosis of severe gastrointestinal bleeding by intraoperative enteroscopy: a case report

Aproximadamente 5% dos pacientes com hemorragia digestiva ficam sem diagnóstico e uma parcela deles tem como fator etiológico doenças do intestino delgado. Os autores relatam caso de homem de 60 anos de idade, portador de angiectasia de jejuno, diagnosticada somente quando submetido a enteroscopia peroperatória durante episódio hemorrágico. Ressecção de 30 cm de jejuno com base na presença de sangue na luz intestinal, teve o diagnóstico confirmado somente com exame histopatológico, pois a lesão não era visível a olho nu. Um ano após a ressecção o paciente permanecia assintomático e sem anemia.

Surgical Treatment of Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous gastrointestinal polyps and mucocutaneous pigmentation of the lips, buccal mucosa, and digits. It is a rare autosomal dominant disease with an incidence of 1/120,000 live-borns. This syndrome is known to require laparotomy because of intestinal obstruction, intestinal bleeding and recurrent intussusceptions. A 19-year-old male was referred to our hospital complaining of persistent abdominal pain and anemia. At age of 4, he had undergone a 10 cm small bowel resection from 50 cm distal to the Treitz ligament because of abdominal pain and intestinal bleeding due to intussusception. He was diagnosed as PJS based on the multiple intestinal hamartomatous polyposis and buccal hyperpigmentation. A small bowel series and abdominal computed tomography found a 6 cm sized mass and jejuno-jejunal intussusception on the duodeno-jejunal junction. Preoperative gastroduodenoscopy showed two polyps in the upper third of the stomach. Colonoscopic examination found 5 polyps with sizes of 4~8 mm from the ascending colon to the rectum. They were removed completely by colonoscopic snaring polypectomies, preoperatively. At exploration, we found 8 small bowel polyps within 100 cm from the Treitz ligament, 6 gastric polyps and 3 duodenal polyps; they were all removed using two jejunal enterotomies & intraoperative endoscopy. We found a total of 22 polyps from the stomach to the rectum. We performed polypectomies for 15 polyps over 0.5 cm and treated the remaining 7 polyps by electrocautery using intraoperative endoscopy without performing small bowel resection.

Trocar(R)(Ethicon) Used Intraoperative Endoscopy in Acute Lower Gastrointestinal Bleeding

Occasionally it is difficult to preoperatively confirm the bleeding focus in acute lower gastrointestinal bleeding patients. Therefore, many diagnostic evaluations are needed - for example, colonoscopy, selective mesenteric angiography and Tc-99m RBC scintigraphy. However, if the bleeding focus remains unconfirmed preoperatively when the patient's state is unstable hemodynamically, the surgeon must inevitably perform exploratory laparotomy, followed by intraoperative endoscopy. We herein propose a new method of intraoperative endoscopy using Trocar(R) (Ethicon). Trocar(R) (Ethicon) was used in laparoscopic operation. This method has the merits of no air leakage, no contamination, fewer complicatons and ease of evaluation. We recommend that the use of Trocar(R) (Ethicon) in intraoperative endoscopy is essential in emergency operations for acute lower gastrointestinal bleeding.

A Case of Amyloidosis Presenting with Massive Small Bowel Bleeding / 대한소화기내시경학회지

The gastrointestinal (GI) tract is one of the commonly affected organs in amyloidosis. However, it is difficult to make a correct diagnosis of GI amyloidosis because of its varied clinical manifestation and nonspecific endoscopic findings. Moreover, GI bleeding as a presenting symptom is rare, but can be serious in some cases. Therefore, missed diagnosis and delayed management in GI amyloidosis may potentially lead to a critical outcome. We report a 51-year-old man with multiple myeloma whose major symptom was massive hematochezia due to GI amyloidosis. In our case, amyloid deposits could be distinctly visualized endoscopically in the stomach and the colon. They were manifested as submucosal hematomas in the small bowel resulting in massive bleeding that was successfully controlled with the aid of intraoperative endoscopy.

Intraoperative Endoscopic Resection of Small Bowel Polyps through Trocar in Patient with Peutz-Jeghers Syndrome / 대한소화기내시경학회지

The Peutz-Jeghers syndrome is an autosomal dominant disease characterized by mucocutaneous pigmentation and gastrointestinal hamartomatous polyps. This syndrome is clinically important because of the complications caused by polyps and of an increased risk of cancer. We experienced a typical case of Peutz-Jeghers syndrome in a 24-year-old female patient who presented with jejunojejunal intussusception. With the use of combined surgery and intraoperative endoscopy through trocar, 60 polyps were removed, performing only 2 enterotomies. We apply a modified endosocopic technique of intraoperative endoscopic resection of small-bowel polyps using conventional 10 mm metal trocar in conjunction with a corrugated anesthetic tube. This allows fully visualized and optically controlled removal of all small intestnal polyps without air leakage. The usefulness of this technique reduces the complications associated with multiple laparotomies and resections.

The application of intraoperative endoscopy during the emergency exploratory laparotomy in the patients with acute massive small intestinal bleeding / 中国医师杂志

Objective To evaluate the application of intraoperative endoscopy during the emergency exploratory laparotomy in the patients with acute massive small intestinal bleeding.Methods Twenty-six patients with acute massive small intestinal bleeding were examined by intraoperative endoscopy during the emergency exploratory laparotomy and the clinical data were analyzed.Results The hemorrhagic reasons were clarified in 25 patients(96.2%) through the application of intraoperative endoscopy.Of the 25 patients,the results showed that 2 cases were with duodenal leiomyoma,1 case duodenal Dieulafoy' disease,5 cases small bowel leiomyoma,2 cases small bowel leiomyosarcoma,2 cases ileum lymphoma,3 cases ileum ulcer,4 cases small bowel cavernous hemangioma,5 cases small bowel arteriovenous dysmorphosis and 1 case pancreaticojejunostomy cut bleeding.The average examination time was 15 min and no complications related to intraoperative endoscopy occurred in all patients.Conclusion The application of intraoperative endoscopy,which may increase the detection rate,is efficient and safe during the emergency exploratory laparotomy in the patients with acute massive small intestinal bleeding.