Supradiaphragmatic Jejunal Perforation Following Total Gastrectomy With Esophagojejunostomy Reconstruction for Gastric Adenocarcinoma.

Nasogastric tube decompression is a common technique used after abdominal surgery as it is widely accepted to play a role in the management of postoperative ileus and possibly reduce anastomotic leaks after gastrointestinal surgery. However, the routine practice of nasogastric/nasoenteric tube decompression in elective abdominal surgeries has been challenged due to the increased incidence of pulmonary complications and the argued lack of expected benefit. Here, we present a rare complication of nasogastric tube drainage following a routine total gastrectomy for signet-ring cell adenocarcinoma of the cardia in a 43-year-old female. Her postoperative course was complicated with a supradiaphragmatic jejunal perforation presumably from nasogastric tube decompression resulting in a left pleural effusion. The workup included an endoscopy showing the perforation, after which the nasojejunal tube was removed and the patient was managed conservatively. She was eventually discharged on postoperative day 28.

Feasibility of combining oncology surgery with bariatric surgery; a two-patient case series of sleeve gastrectomy with cytoreductive surgery and HIPEC.

Patients with an oncologic disease requiring cytoreductive surgery and hyperthermic intraperitoneal chemotherapy may also present with morbid obesity. In some patients, it may be possible to offer bariatric surgery such as sleeve gastrectomy in combination with their cancer resection to treat both diseases concurrently. Two such cases are described where sleeve gastrectomy was done alongside the primary oncologic surgery in the same procedure. Our patients had long-term follow-ups and their overall outcomes were favorable. They achieved remission and acceptable levels of weight loss over their several years of follow-up appointments. The added benefit of bariatric surgery may decrease long-term morbidity and mortality in carefully selected patients. More studies are indicated to fully understand the risks of benefits of this combined procedure in order to offer it on a wider scale.

Missed Gastric Cancer Metastasis to the Appendix: Case Report and Literature Review.

BACKGROUND Gastric cancer metastasis to the appendix is a rare condition that might present with symptoms of acute appendicitis or remain asymptomatic and be diagnosed incidentally. This report summaries 6 previously reported cases in addition to the presented case. CASE REPORT We report a 54-years-old female patient who presented with gastric cancer metastasis to the appendix that was found incidentally in the second surgery when she underwent bowel resection due to bowel entrapment in internal hernia, a complication of her primary gastric cancer surgical intervention. Six case-reports on gastric cancer metastasis to the appendix were reviewed. The metastasis was symptomatic in 4 cases, and solitary in 3 cases. The diagnosis was delayed in 4 cases as there was no evidence of metastasis at the diagnosis of the primary tumor; appendectomy was performed in all cases. The prognosis of the cases varied considerably. CONCLUSIONS We question the real incidence of appendiceal metastasis in gastric cancer, and the benefit-risk ratio of appendectomy in every gastrectomy. Guidelines on management of similar cases is also needed.

Chronic abdominal pain after laparoscopic hernia repair due to mesh graft migration to the cecum: a case report.

BACKGROUND: Hernia repair with mesh graft is one of the most common procedures in general surgery. Mesh graft repair is the treatment of choice for umbilical and periumbilical hernias to minimize recurrence. One of the rare but serious complications is mesh graft migration to viscus. These complications can occur months to years after repair and their diagnosis can be challenging as they may present as vague abdominal pain only. CASE PRESENTATION: A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints. CONCLUSION: It is important to consider mesh graft migration to viscus as a cause of persistent abdominal pain and bleeding per rectum irrespective of the time of presentation post hernia repair.

Ultrasound guided sparing resection of locally recurrent abdominal wall desmoid tumor.

Desmoid tumors are uncommon benign tumors with locally aggressive behavior. Even with aggressive resection with or without radiotherapy, the relapse rate is relatively high. Surgical resection can be challenging especially in large size tumors, as the resultant post-operative wide wall defect can lead to cosmetically undesirable bulging and functional loss. The use of Ultrasound may be useful to aid in radical resection of the desmoid tumor with adequate margins. In our 30-year-old patient with recurrent abdominal wall desmoid tumor, intra-operative ultrasound was utilized in successful resection of the tumor followed by a minimal but adequate margin. The patient has recovered well and within the 6 months follow-up period and has not reported any functional limitations or recurrence.

Laparoscopic intrapancreatic accessory splenectomy: A case report of recurrent immune thrombocytopenia in a 33 years old male patient after 6 years of splenectomy.

INTRODUCTION: Intra-pancreatic Accessory Spleen (IPAS) is a rare benign abnormality of splenic embryology that should be considered in any patient with recurrence of immune thrombocytopenia (ITP). The case demonstrates that remission could be achieved if an IPAS is correctly identified and safely removed. CASE PRESENTATION: We report a 33-years-old male patient who presented with chronic ITP relapsed 3 years post initial splenectomy. The patient presented with severe thrombocytopenia requiring steroids and intravenous immunoglobulin (IVIG). DISCUSSION: IPAS can be identified using enhanced CT scan along with Tc-99m sulfur colloid scintigraphy. Our patient underwent CT scan of abdomen and pelvis and was found to have an IPAS originating from the tail of the pancreas which was subsequently removed laparoscopically. The patient was then tapered off steroids and was followed up regularly and found to have acceptable platelet levels and no symptoms for 30 months post-surgery. CONCLUSION: The diagnosis of IPAS can be non-invasively made by an experienced radiologist with the recent advancement of medical imaging. Recognizing IPAS as a possible cause of ITP recurrence, and using minimally invasive approach can be performed safely and lead satisfactory outcomes.

Incisional hernia repair with plication and utilization of Botox injections: First case report from Saudi Arabia for a 19-year-old female.

This article reports on the use of Botox preoperatively for the treatment of a complex ventral hernia which would have typically been treated with component separation technique. The case demonstrates that using the recently developed technique can aid in performing a tension-free hernia repair with potentially lower complication and recurrence rates.

First endoscopic submucosal dissection of gastroesophageal junction carcinoma in a 72-year old male from Saudi Arabia.

INTRODUCTION: Esophageal and gastric tumors are very lethal malignancies. Their most common histology is adenocarcinoma for more than 90% of all gastroesophageal tumors. CASE PRESENTATION: Herein, we report a case of endoscopic submucosal dissection for gastroesophageal junction carcinoma, the first of its kind to be performed in the Kingdom of Saudi Arabia for a 72-year-old patient, who was found to have a gastroesophageal junction mass extending to the cardia. Complete excision was performed via endoscopic submucosal dissection. There were no complications in the postoperative period and the patient was discharged in good condition. DISCUSSION: Over time, the management of gastroesophageal junction carcinoma has evolved along with the surgical approach. Endoscopic submucosal dissection preserves the anatomical structures and not only leads to a better quality of life, but also decreases morbidity and mortality. The procedure shows favorable results for early-stage gastroesophageal junction carcinoma as a treatment option with excellent en bloc resection rates. CONCLUSION: Endoscopic submucosal dissection is an acceptable management for T1 gastroesophageal junction carcinoma.

Secondary Omental Infarction in a Patient with a Hypercoagulable State.

Omental infarction is a rare cause of acute and non-specific abdominal pain. We report a case of a 46-year-old man who presented to the emergency room with right upper quadrant cramping pain that was of sudden onset. The patient's presentation was later diagnosed as an omental infarction, by an abdominal CT. After extensive work-up, it was revealed that the cause of the patient's omental infarction was secondary to a hypercoagulable state caused by antiphospholipid syndrome, based on his thrombophilia work-up. The patient was successfully managed conservatively and was started on lifelong anticoagulation. The patient was followed up with an abdominal CT after 2 months into therapy, which showed a decrease in the size of the omental infarction and a significant improvement in his state.

A simple method for tension-free Billroth I anastomosis after gastrectomy for gastric cancer.

Billroth I anastomosis (B-I) is a popular reconstructive procedure performed after distal gastrectomy for the treatment of gastric cancer. Herein we introduce a new and simple technique to minimize tension after Billroth I for gastric cancer.

Is microsatellite instability a prognostic marker in gastric cancer? A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVE: The relationship between survival in gastric cancer patients and the status of microsatellite instability (MSI) has not yet been established. The purpose of this meta-analysis was to obtain integrated and more precise data for the value of MSI as a prognostic marker in gastric cancer. METHODS: A comprehensive systematic review and meta-analysis were conducted using major electronic databases (PubMed, EMBASE, and the Cochrane Central) with keywords related to "microsatellite instability," "gastric cancer," and "prognosis." RESULTS: Twenty-four studies with 5,438 participants (712 cases were MSI gastric cancer) were included for pooling risk estimates of MSI in gastric cancer. Seventeen studies reported overall survival. The pooled hazard ratio (HR) for overall survival of MSI vs. non-MSI was 0.72 (95%CI: 0.59-0.88, P = .001) in a random-effects model. In the sensitivity analysis, the result from the most recent study showed the most heterogeneity. CONCLUSION: MSI gastric cancer was associated with good prognosis but there was heterogeneity in the recent studies. Changed epidemiology and effects of chemotherapy are potential causes of heterogeneity. Establishing a consensus for defining MSI in gastric cancer should be preferred for future studies.