Clinical profile and treatment outcomes of Boerhaave's syndrome: A 13-year experience from an upper gastrointestinal surgical unit.

Objectives: IBoerhaave's syndrome (BS) is a rare, but potentially fatal condition, characterized by barogenic esophageal rupture and carries a high mortality. We aimed to study our institutional experience of managing patients with BS. Material and Methods: A retrospective review of patients with BS presenting to a tertiary care centre from 2005 to 2018 was carried out in this study. Clinical presentation, diagnostic evaluations, treatments received, and treatment outcomes were studied. Perforations were classified as early (<24 hours) and delayed (>24 hours), based on the time elapsed. Surgical complications were graded using Clavien-Dindo grade. The Pittsburgh perforation severity score was correlated with short-term treatment outcomes. Results: Of the 12 patients [male, 75%; mean (range) age, 53 (28-80) years] included, 10 patients had a delayed (>24 hours) presentation. Chest pain was the dominant symptom (58.3%); six patients presented either in shock (n= 1) or with organ failure (n= 3) or both (n= 2). All the perforations were sited in the lower thoracic esophagus, of which three were contained and nine were uncontained. The seal of the perforation was achieved by surgical repair in four patients (primary repair, 2; repair over a T-tube, 2) and endoscopic techniques in four patients (clipping, 1; stenting, 3). Sepsis drainage [surgical, 7 (open-5, minimally-invasive-2); non-surgical, 5] and feeding jejunostomy were performed in all patients. Five (41.7%) patients received a re-intervention. Median (range) hospital stay was 25.5 (12-101) days, 30-day operative morbidity was 50%, and there was one in-hospital death. The Pittsburgh perforation severity score was as follows: 2-5 in two patients and >5 in 10 patients; there were more delayed presentations, increased surgical interventions, post-procedure morbidity, and in-hospital mortality in the latter group, but the differences were statistically not significant. In 11 patients followed-up [median (range):1507 (17-5929) days], there was no disease recurrence, symptomatic reflux or dysphagia. Conclusion: Favourable treatment outcomes, including reduced mortality and organ preservation can be achieved for Boerhaave's perforations, through a multimodality approach. Minimally invasive, endoluminal or open surgical techniques may be safely utilized in its management. The Pittsburgh severity score can be a useful clinical tool that can be used to select the initial intervention and to predict treatment outcomes.

Occult Omental Metastasis in Gastric Adenocarcinoma: An Analysis of Incidence, Predictors, and Outcomes.

Negine PaulIntroduction Traditionally, the concept of complete omentectomy during gastric resection for cancer was based on lymphatic drainage and the occurrence of occult omental metastasis (OM). However, recent emerging evidence has challenged this concept of complete omentectomy. We, therefore, aim to find the incidence and risk factors of occult OM and also evaluate the outcome of patients with and without such metastasis. Methods This is a single institutional, retrospective study of patients with gastric cancer who underwent curative radical gastrectomy for a period of 3 years (April 1, 2016, to March 31, 2019). A complete omentectomy was performed in all patients and the omentum and nodal stations were dissected in the resected specimen and sent for pathological analysis. Clinical and epidemiological data were collected from the hospital patient database and analysis was done. Results A total of 185 patients have been included in the study, with a mean age of 53.84 years. Twenty of the 185 patients had OM (10.8%). Age, sex, location of the tumor, and neoadjuvant chemotherapy were not statistically significant in predicting OM. However, tumor size and tumor depth were found to have a significant association with OM. The occurrence of OM was more likely to be associated with disease recurrence, especially in the peritoneum. The mean overall survival was 38.15 months (±3.33 SD), whereas patients with OM had lower survival, 23.31 months (±7.79 SD), with a p -value of 0.012. Conclusion OM was not encountered in T1 and T2 gastric cancers and the incidence of OM in T3 and T4 tumors was approximately 12.7%. Therefore, complete omentectomy may be omitted in early T1/T2 tumors. OM was associated with poor prognosis, increased peritoneal recurrence, and decreased overall survival, in spite of a complete omentectomy, and may serve as a prognostic indicator for disease recurrence and overall survival.

Surgical Outcomes Associated with Operable Gastric Cancer in a Tertiary Care Indian Hospital.

PURPOSE: Data on operable gastric cancer from India is sparse. The purpose of this study was to investigate the clinical details, histopathological demographics, and 5-year overall survival (OS) and disease free survival (DFS) associated with operable, non-metastatic gastric cancer in a dedicated upper gastrointestinal (GI) surgical unit in India. MATERIALS AND METHODS: Data for patients diagnosed with operable gastric cancer between January 2006 and December 2014 were retrospectively analyzed. Data were collected from electronic hospital records in addition to mail and telephonic interviews when possible. RESULTS: A total of 427 patients were included. The tumor was located in the pyloro-antral region in 263 patients (61.7%). Subtotal gastrectomy was performed in 291 patients and total gastrectomy in 136 patients. Tumor stage classification revealed 43 patients (10.0%) with stage I, 40 patients (9.4%) with stage IIA, 59 patients (13.9%) with stage IIB, 76 patients (17.8%) with stage IIIA, 96 patients (22.5%) with stage IIIB, and 113 patients (26.4%) with stage IIIC disease. Follow-up data were available for 71.6% of the patients with a mean duration of 32.4 months. Five-year DFS and OS were 39% and 59%, respectively. CONCLUSIONS: Despite presenting at an advanced stage, the 5-year DFS and OS of patients with operable gastric cancer treated at a dedicated upper GI unit of a tertiary care center in India was good.

Blue rubber bleb nevus syndrome: a rare cause of chronic gastrointestinal bleed in adults.

Blue rubber bleb nevus syndrome (BRBNS) is a rare condition characterised by venous malformations in the skin, gastrointestinal tract and other parts of the body. Its presentation is usually sporadic, although cases of autosomal dominant inheritance have been reported. Usually seen in children, BRBNS presentation in adults is rare. Symptoms at presentation depend on the organs involved; patients with BRBNS may present with acute or chronic gastrointestinal bleed. We herein report a rare presentation of BRBNS in an adult who suffered from intermittent abdominal pain and melaena for three years. Contrast-enhanced computed tomography revealed a jejunojejunal intussusception with a vascular malformation as the lead point. The patient underwent laparotomy with resection of the intussuscepted bowel segment. Recovery was uneventful. In spite of a wide range of therapeutic options for the management of BRBNS described in the literature, the efficacy of those available therapies, including surgical excision, is not well established.

Gastric intramural and portal venous gas following blunt abdominal injury.

INTRODUCTION: Gastric emphysema or pneumatosis is a rare finding. Early endoscopy and urgent laparotomy is advised in post-trauma patients. CASE PRESENTATION: A 29 year old man presented with blunt abdominal injury following a high-speed motorbike crash He complained of abdominal pain and abdomen was distended. CT abdomen revealed air in the gastric wall with disruption of gastric mucosa. He had normal white cell counts, bleeding parameters and blood gases. He was treated conservatively with nasogastric decompression, intravenous analgesics and antibiotics with which he recovered well. CONCLUSIONS: Early surgical management is indicated in post-trauma patients in whom bowel infarction is suspected. In a stable patient, a negative laparotomy is a major additional stress post trauma - conservative management with close clinical observation is a suitable management alternative.

A Hairy Tail not a Fairy Tale - Rapunzel Syndrome.

Rapunzel syndrome is an unusual and rare type of trichobezoar. Bezoars can be classified according to the primary constituent, as trichobezoar (hair), phytobezoar (plant material) or miscellaneous (pharmacobezoar, lactobezoar, fungal agglomeration and foreign bodies). When a long tail of hair strands extends from the main mass in the stomach along the small intestine and beyond it is known as Rapunzel syndrome. Here we are reporting a case of Rapunzel syndrome with a very long tail who was managed successfully. And reviewing the literature on the pathophysiology and management of these patients. These patients commonly present with obstructive symptoms and needs a high index of suspicion especially, in young female patients who have alopecia circumscripta and underlying psychiatric disorders. Early diagnosis and treatment is required to prevent complications due to this condition. Currently surgical management of this condition is the treatment of choice.

Tracheal injury during oesophagectomy--incidence, treatment and outcome.

BACKGROUND AND AIM: Iatrogenic tracheal injuries are uncommon, potentially lethal and associated with significant morbidity. In this report we analyze the incidence of iatrogenic tracheobronchial injuries sustained during oesophagectomies and the results and outcome of repair using a pedicled intercostal muscle flap. METHODS: A retrospective analysis was done on all patients who underwent an oesophagectomy between June 2000 and May 2011. Data was collected from an electronic database and the medical records of patients, maintained at our hospital. RESULTS: One hundred and fourteen patient records were analyzed. There were 85 male and 29 female patients. Their mean age was 47 years (range 16 to 86 years). Forty two (36%) underwent a transhiatal oesophagectomy, 34 (31%) Mckeown's oesophagectomy, 35 (31%) Ivor Lewis oesophagectomy and 3 (2%) thoracoscopy assisted oesophagectomy. Of the 114 oesophagectomies, 86 (75%) were performed for malignant and 28 (25%) for benign pathologies (benign tumors and corrosive strictures of the esophagus). In our study, four patients sustained injury to the tracheobronchial tree during oesophagectomy. In patients who sustained injury during a transhiatal dissection a right anterolateral thoracotomy was made. All injuries in the thoracic tracheobronchial tree were repaired primarily and reinforced with an intercostal muscle flap. In the patient with injury to the cervical part of the trachea, repair was done primarily and reinforced with cyanoacrylate glue. All patients who sustained injury had malignancy and three patients had received neoadjuvant chemoradiotherapy. Two patients sustained injury during transhiatal oesophagectomy and two during a Mckeown's oesophagectomy. There was one mortality which was due to ventilator associated pneumonia and related complications. The remaining three were alive with no evidence of repair breakdown. CONCLUSIONS: Iatrogenic tracheal injuries are uncommon complications but associated with significant morbidity. Preoperative chemoradiotherapy and malignancy are risk factors for iatrogenic tracheal injuries. Reinforcement of the suture line with a muscle flap is an effective technique of repair. Prompt ontable identification and adequate surgical treatment is necessary for a good outcome.

Aberrant subclavian artery: anatomical curiosity or clinical entity.

Dysphagia lusoria, caused by aberrant subclavian artery, is an uncommon cause of dysphagia. When present it is mostly asymptomatic. Barium esophagogram may indicate the presence of this anomaly. Diagnosis needs to be confirmed by CT/MRI prior to any intervention. No treatment is required for asymptomatic patients. If causing significant symptoms, operative management offers definitive treatment. The choice of treatment depends on local expertise, equipment and experience of the surgical team. However, for those who are unfit or refuse operative intervention, there is a role for symptomatic and supportive treatment. Our cases demonstrate three different manifestations of this single entity.

Jejunogastric intussusception: an unusual cause of hematemesis.

Jejunogastric intussusception is an uncommon but potentially life-threatening complication of a previous gastrojejunal anastomosis. Although jejunogastric intussusception was first described in 1914, fewer than 200 cases have been reported in the English literature thus far. Awareness of this rare complication would help in early diagnosis and appropriate management. Described here is a case report of a patient who presented with hematemesis due to an acute jejunogastric intussusception associated with gangrene of the intussuscepted jejunum.