Bottle Gourd Juice: Poison or Panacea.

Ingestion of toxic bottle gourd juice, particularly the bitter one, may pose a significant risk to life if not treated in time. Notwithstanding its usefulness, people drink it routinely without concern for fruit quality, extraction hygiene, and mixture with other fruits. We report two cases of bottle gourd juice poisoning with severe abdominal pain and hematemesis. On evaluation, patients were hypotensive with associated esophagitis, pangastritis, and duodenitis. After conservative management, both were discharged after five days of hospitalisation. We conclude that the chances of bottle gourd juice poisoning are higher in water-stressed arid regions; hence, care should be taken on quality and quantity while consuming it.

Post-Esophagectomy Hiatal Hernia: A Case Series.

Post-esophagectomy hiatal hernia is a rare complication having varied presentation from asymptomatic cases detected incidentally on follow-up imaging to acute surgical emergency for strangulation or gangrene. Patients presenting as a surgical emergency have a prolonged post-operative course with significant morbidity. We present three cases of post-esophagectomy hiatal hernia. Two of the three cases were operated for esophageal squamous cell carcinoma (SCC) and one patient was operated for esophageal leiomyomatosis. Two of the three cases (SCC and esophageal leiomyomatosis) underwent minimally invasive Mckeown's esophagectomy and one case underwent robotic transthoracic Ivor-Lewis esophagectomy. All cases underwent contrast enhanced CT (CECT) and were biopsy proven prior to their index surgery. Both cases of SCC had prior neoadjuvant chemoradiation followed by surgery while esophageal leiomyomatosis underwent upfront surgery. All three cases have improved symptomatically and are doing well on follow up (case 1 - 12 months, cases 2 and 3 - 3 months).  All three of our cases have different clinical presentation in terms of symptoms, severity, and time duration from index surgery. Two of the three cases underwent emergency surgery and one case which was asymptomatic detected incidentally on surveillance imaging and was managed conservatively. Post-esophagectomy hiatal hernia is a rare entity with varying presentation. The management options in such cases vary depending on the severity of symptoms and time after index surgery. In cases presenting as surgical emergency, successful management depends on prompt detection, early surgery, proper post-operative care, and rehabilitation.

Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia.

Background Heller myotomy (HM) with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is controversial. In this study, we compared both types of fundoplication concerning subjective and objective parameters. Methodology This prospective comparative study comprised a total of 30 consecutive patients who underwent laparoscopic/robotic HM with either Dor fundoplication (DF) (n = 15) or Toupet fundoplication (TF) (n = 15). Preoperative baseline characteristics, intraoperative details, and postoperative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, 24-hour pH study, and high-resolution manometry (HRM) at the one-year follow-up. Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and postoperative complications. The HM+DF group had four (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p = 0.79). Symptom scores were similar between the groups at six and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p = 0.483). On HRM, HM+TF showed a trend toward significance in terms of esophagogastric junction (EGJ) relaxation (p = 0.058) with a non-significant difference in median integrated relaxation pressure (p = 0.081). Conclusions The study showed a trend toward lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.

Robotic Ivor-Lewis Esophagectomy for Corrosive-Induced Esophageal Stricture.

Corrosive-induced stricture of the esophagus is associated with long-standing morbidity. Though required in particular situations, esophagectomy circumvents the long-term complications of the remnant scarred native esophagus. We performed a robotic Ivor-Lewis esophagectomy for corrosive esophageal stricture and demonstrated its feasibility for the same. A young male patient presented with a history of caustic ingestion, leading to a long segment stricture in the lower third of the esophagus. He developed absolute dysphagia, which was refractory to endoscopic dilatation. A robotic approach was utilized to create a gastric conduit followed by intrathoracic esophagogastric anastomosis. He had a smooth postprocedure course, was discharged on a soft diet on the seventh postoperative day, and is doing well after six months of follow-up. The robotic Ivor-Lewis approach can be safely performed for corrosive esophageal stricture, akin to esophageal malignancy. Besides the comfort of performing the procedure, especially intra-thoracic anastomosis, it helps alleviate the chances of mucocele formation and sequelae of cervical neck anastomosis.

Mirizzi Syndrome With Bouveret Syndrome: A Rare Amalgam.

Mirizzi and Bouveret syndromes are uncommon but important complications of calculous cholecystitis. Mirizzi syndrome commonly presents with jaundice due to extrinsic compression on the common bile duct by an impacted stone at the gall bladder infundibulum, whereas Bouveret syndrome presents with gastric outlet obstruction due to a large stone in the duodenum. Our case is a 65-year-old lady who presented with pain in the right upper abdomen associated with nausea and vomiting. Contrast-enhanced computed tomography and MRI of the abdomen were suggestive of calculus in the infundibulum of the gall bladder with compression over the common bile duct and a large stone in the first part of the duodenum. Upper gastrointestinal endoscopy confirmed the findings but could not retrieve the stone. Cholecystectomy with the retrieval of calculus from the infundibulum and duodenum was performed with the closure of the fistulous opening. The patient did well in the post-operative period and is doing well after nine months of follow-up. Chronic calculus cholecystitis can present in varied forms, and one should be aware of such rare complications and their management.

Diffusion-Weighted Magnetic Resonance Imaging Is an Ideal Imaging Method to Detect Infection in Pancreatic Collections: A Brief Primer for the Gastroenterologists.

BACKGROUND: The development of infection in pancreatitis significantly increases the mortality rate up to 100% in the absence of any intervention. Therefore, it is extremely important to diagnose these cases at an early stage. The objectives of this study were to assess the diagnostic performance of computed tomography (CT) and diffusion-weighted MR imaging (DW-MRI) in the diagnosis of infection in pancreatic collections. MATERIALS AND METHODS: Prospective observational study of abdominal collections due to pancreatitis that underwent both CT and DW-MRI from August 2018 to July 2020 were enrolled in the study. The collections were analysed for infections - air foci in CT and diffusion restriction on DW-MRI. RESULTS: Of the 39 patients recruited in the study, infected collections were present in 17, and 22 cases had sterile collections. On CT, air foci within the collection were present only in seven of the cases in our study (sensitivity 35%, specificity 95.4%, PPV 85.7%, NPV 65.6%). DW-MRI detected infection in all 17 cases (sensitivity 100%, specificity 72.7%, PPV 74%, NPV 100%). DISCUSSION: Thirteen out of 17 collections suspicious for infection on DW-MR showed microbiological growth on culture examination. We believe that this is likely due to the patient's prior antibiotic use, which might have altered the micro-environment or inflammatory cell and bacterial content of the collection. CONCLUSION: DW-MRI is complementary and superior to CT in detecting infection in pancreatic collections. CT may be used to detect disease burden, extent and vascular complication.

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.

A Rare Complication of Feeding Jejunostomy: Murky Waters of the Surgeons.

Feeding jejunostomy (FJ) is a common surgical procedure for patients presenting with absolute dysphagia. Jejunostomy tube-induced intussusception is an extremely rare complication associated with it and its recognition and proper management are necessary to prevent subsequent bowel ischemia of the intussusception. We present a rare case with simultaneous intussusception at two sites in a patient who underwent FJ with Foley's catheter one month back and subsequently managed by surgical reduction and repositioning of the FJ tube.

Emergency Pancreatoduodenectomy for Ampullary Cancer Post-Iatrogenic Duodenal Perforation: No Option but to Strike.

Endoscopic retrograde cholangiography related duodenal perforation is an infrequent complication and associated with significant morbidity. The management of such perforations, especially in the setting of malignancy, is not standardized given the paucity of literature. We encountered a patient who was diagnosed with periampullary carcinoma and had a perforation in the duodenum during endoscopy. Emergency pancreatoduodenectomy (EPD) was performed considering it to be a resectable disease with minimal contamination. He had a prolonged hospital course due to surgical site infection and hepaticojejunostomy leak, however, which was managed successfully. At one year follow up, he is healthy with no evidence of recurrence. We conclude that EPD can be attempted for selected iatrogenic duodenal perforations with co-existent resectable malignancy in a stable patient. It may help to avoid the morbidity of a second surgery in the setting of a distorted anatomy and simultaneously preventing the probable upstaging of disease due to peritoneal seedling.

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.