Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!

Purpose: Feeding jejunostomy (FJ) is a critical procedure to establish a source of enteral nutrition for upper gastrointestinal disorders. Minimally invasive surgery has the inherent benefit of better patient outcomes, less postoperative pain, and early discharge. This study aims to describe our total laparoscopic technique of Witzel FJ and to compare its outcome with its open counterpart. Methods: A retrospective database analysis was performed in patients who underwent laparoscopic (n = 20) and open (n = 21) FJ as a stand-alone procedure from July 2018 to July 2022. A readily available nasogastric tube (Ryles tube) and routine laparoscopic instruments were used to perform laparoscopic FJ. Perioperative data and postoperative outcomes were analyzed. Results: Baseline preoperative variables were comparable in both groups. The median operative duration in the laparoscopic FJ group was 180 minutes vs. 60 minutes in the open FJ group (p = 0.01). Postoperative length of hospital stay was 3 days vs. 4 days in the laparoscopic and open FJ groups, respectively (p = 0.08). Four patients in the open FJ group suffered from an immediate postoperative complication (none in the laparoscopic FJ group). After a median follow-up of 10 months, fewer patients in the laparoscopic FJ group had complications such as tube clogging, tube dislodgement, surgical-site infection, and small bowel obstruction. Conclusion: Laparoscopic FJ with the Witzel technique is a safe and feasible procedure with a comparable outcome to the open technique. Patient selection is vital to overcome the initial learning curve.

Gall bladder tuberculosis: Review of literature.

Gall bladder tuberculosis (GB TB) is a very rare disease and scarce data is available on exact incidence and clinicopathogenesis even in endemic areas. The aim is to provide an insight into epidemiology, pathophysiology and management for better understanding of gall bladder tuberculosis. We collected data available from the literature on all histologically proven gall bladder tuberculosis. Case reports with either no article or only abstracts were available excluded from the study. Fifty two case reports and series with total 73 patients were included in this study. Mean age of patients was 48 years (Range 8-86 years) with male: female ratio of 1:1.7. 53 (73%) patient had isolated disease and 18 (24%) had associated abdominal tuberculosis. 3 (4%) of patients had concomitant and 7 (9%) had past history of pulmonary tuberculosis. 39 patients presented as cholecystitis and 25 as gall bladder mass. 44 (60%) patients had gall stones and majority of them (56%) are multiple. Granuloma and caseous necrosis was found in 80% & 60% of patients respectively. In conclusion, Gall bladder tuberculosis is a very uncommon presentation of abdominal tuberculosis. Pre-operative diagnosis is not possible due to lack of specific diagnostic test so increase in awareness and a high index of suspicious is required.

Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults.

INTRODUCTION: Choledochal cyst (CDC) excision with bilio-enteric anastomosis has been reported by a laparoscopic approach. With the advent of robotic surgery, it is likely to simplify the performance of such complex procedures. Herein, we present our technique of total robotic CDC excision with intra-corporeal Roux-en-Y hepaticojejunostomy (RYHJ). METHODS: The patient was placed in a reverse Trendelenburg position. The robotic ports were placed in a "C"-shaped manner, with the camera port placed ~2 cm below the umbilicus. A 12-mm assistant port was placed in between the camera and the left-sided robotic port. Robotic dissection and excision of extrahepatic part CDC were performed, and subsequently, intra-corporeal robotic RYHJ with jejunojejunostomy was completed. Intra-operatively, indocyanine green dye was used to delineate the biliary anatomy and to check the anastomotic integrity. RESULTS: All three patients were female with a median age of 21 (18-34) years. Two patients had type IVa, and one had a mixed variant of type I(C) with type VI. The median operative time was 420 min, whereas docking and console time was 22 (20-25) min and 400 (360-450) min, respectively. The median blood loss and length of hospital stay were 50 (50-100) ml and 6 (5-6) days, respectively. One patient has mild acute pancreatitis in the post-operative period, which was managed conservatively. CONCLUSION: Robotic CDC excision and reconstruction seem to be a safe, feasible, and effective surgical option that provides the benefits of minimal access surgery but also greatly aids in complex dissection and reconstruction.

Synchronous Small Bowel Gangrene With Pyelonephritis Secondary to Mucormycosis: A Disastrous Complication of COVID-19 Pandemic.

Mucormycosis is a rare infection caused by fungi of the order Mucorales. The infection frequently involves the rhino-cerebral or respiratory system and involvement of the gastrointestinal (GI) tract and kidney are rare. It usually infects immunocompromised individuals due to various causes and an upsurge is hypothesized to be linked with irrational use of steroids during coronavirus disease 2019 (COVID-19) pandemic. We encountered a rare case of systemic mucormycosis that involved both renal as well as mesenteric vessels and led to ischemia of both vital organs. The patient developed massive bowel gangrene involving the duodenum, proximal jejunum, and left kidney due to angioinvasive mucormycosis. The diagnosis of GI mucormycosis may further increase during the current pandemic. The physicians, as well as surgeons, should be aware of this unwanted complication and keep a high index of suspicion for this rare disease.

Minimally Invasive Esophagectomy: Feasibility in Esophageal Carcinoma With Inferior Vena Cava Anomaly.

Inferior vena cava (IVC) and azygos vein anomaly is very rare. Available case studies report difficult esophagectomy in patients with esophageal carcinoma with IVC anomaly. Minimally invasive esophagectomy with preservation of the azygos vein in such patients is technically challenging. We report a case of a 44-year-old woman diagnosed with middle thoracic esophageal carcinoma with double IVC and dilated azygos vein. Thus minimally invasive surgery is feasible in such patients but requires high technical skills and ample experience to carry out this kind of surgery, and it should only be attempted by a multidisciplinary team.

Hepatic Arterial Variations and Its Implication During Pancreatic Cancer Surgeries.

PURPOSE: Aberrant hepatic artery anatomy is a considerable challenge during pancreatic surgery as it warrants extreme caution for the preservation of vascular supply as well as achievement of R0 resection margin. METHOD: We reviewed the literature about the aberrant anatomical variations of the hepatic artery and its relevance during pancreatoduodenectomy and distal pancreatectomy. RESULT: Preoperative deliberation of peri-pancreatic vascular anatomy using advanced imaging methods is crucial for surgeons. At the same time, intra-operative suspicion and early identification of aberrant anatomy may help to prevent vascular injury and related complications. Yet, vascular reconstruction may be needed in many situations; several techniques like pre-operative embolization provide new options for management in specific situations. CONCLUSION: We have provided here an overview of the anatomical variants of the hepatic artery and their implication during pancreatoduodenectomy and distal pancreatectomy.

Postcholecystectomy Duodenal Injury: Role of Conservative Management.

Postcholecystectomy duodenal injuries are very rare complications. Early surgical intervention is a common practice due to its fatal consequences. Most of the patients with post laparoscopic cholecystectomy duodenal injury reported in literature have been successfully managed by early surgical repair. We present here a case of a 32-year-old female who underwent open cholecystectomy and had an injury in the second part of the duodenum. She was subsequently managed conservatively.

Mid to long term outcomes of Laparoscopic Sleeve Gastrectomy in Indian population: 3-7 year results - A retrospective cohort study.

INTRODUCTION: Few studies have addressed the mid to long term impact of Laparoscopic Sleeve Gastrectomy (LSG) on weight loss and obesity associated co-morbidities, particularly in Indian population. The aim of this study is to assess the efficacy of LSG in morbid obesity over 3-7 years follow up. MATERIALS AND METHODS: Data of all patients who underwent LSG between January 2008 and March 2015 and completed their at least 1 year follow up till March 2016 was retrospectively reviewed using a prospectively collected database. RESULTS: 424 patients undergoing primary LSG were included. The mean age (±2SD) was 39.8 ± 22.5 years and the mean Body Mass Index (BMI) (±2SD) was 46.67 ± 15.8 kg/m2. 124 patients (29.2%) were super-obese (BMI >50 kg/m2). The percentage follow-up at 1 year, 3 years, 5 years and 7 years was 78.3%, 66.7%, 42.3% and 38.4% respectively. The mean percentage Excess weight Loss (%EWL) (±2SD) at 1year, 3years, 5years, and 7years was 71.8 (±50.5%), 64.95% (±41.8%), 61.7% (±46.2%) and 57.15% (±50.2%) respectively. The preoperative BMI significantly correlated with %EWL at 5 year (r2 = 0.107, p = 0.018). The overall complication rate was 5.8%. Early complications included staple line leak (1.2%), bleeding (1.2%), deep venous thrombosis (0.4%) and 30-day mortality (0.21%). Late complications included stricture formation (0.21%) and new onset Gastro-esophageal Reflux Disease (GERD) (2.8%).At 5 years, 83.3% of diabetic patients showed remission while rest showed improvement in glycemic control with decrease in dosage. 69.3% patients showed improvement in hypertension, 100% patients showed improvement in Obstructive Sleep Apnea Syndrome, 75% patients showed improvement in hypothyroidism after surgery. GERD resolved in 62.8% patients while worsened in 11.4% patients. CONCLUSIONS: LSG has durable weight loss at 5 year with %EWL of 61% and significant resolution of obesity associated co-morbidities.