Creation of a neopylorus after pyloric exclusion using a "double-endoscope" technique.

OBJECTIVE: Pyloric exclusion may be implemented in the setting of a high-grade duodenal or pancreatic injury. After exclusion, the pylorus should spontaneously open in 3-6 weeks. However, we present the case of a critically ill 17-year-old male with a gunshot wound to the abdomen that underwent stapled pyloric exclusion with gastrostomy and jejunostomy tube placement who did not achieve pyloric patency after 5 months, and describe an innovative "double-endoscope" technique to correct it. METHODS: A gastroscope was inserted through the mouth into the stomach, and an endoscope was inserted retrograde through the jejunostomy site to the duodenum. The closed pylorus was seen from both ends with transillumination. A needle knife was pushed through the membrane with clear visualization from the contralateral side. A balloon dilation catheter was then passed over a guidewire, and the neopylorus was sequentially dilated. A gastrojejunostomy tube was placed to ensure patency of the neopylorus. Postoperative imaging showed no evidence of leak or pneumoperitoneum. Serial endoscopic dilations were performed every 1-4 weeks to prevent restricturing. RESULTS: The patient recovered well. After the first follow-up endoscopic dilation, he was eating a regular diet and had no retained food products. After four endoscopic dilations, the patient remained symptom free and the pylorus was widely patent. His gastrostomy and jejunostomy tubes were removed. CONCLUSIONS: Here we presented a rare complication of pyloric exclusion and an innovative approach that used a "double-endoscope" technique and serial endoscopic dilations to establish and maintain a neopylorus, avoiding the morbidity of a major surgical procedure.

Endoscopic Web Localization for Laparoscopic Duodenal Web Excision.

When performing an open duodenal web excision, it is helpful to identify the web using a nasogastric tube because it is often difficult to determine where the web origin is located when looking at the serosal side of the bowel. However, it may be challenging to navigate the nasogastric tube to the web during laparoscopy. We present a novel technique that utilizes intraoperative endoscopy to precisely identify the location of the duodenal web, facilitating laparoscopic excision. Intraoperative endoscopy was implemented in the case of a 3-month-old boy undergoing laparoscopic excision of a duodenal web. With endoscopic visualization and transillumination, the duodenal web was precisely identified and excised laparoscopically. A supplemental video of the case presentation and technique is provided in the online version of this manuscript (Supplemental Digital Content 1, http://links.lww.com/SLE/A134). The procedure was completed successfully and the patient did well postoperatively. Flexible endoscopy is a useful adjunct for duodenal web localization during laparoscopy, improving on the previous method of estimating the location based on a change in duodenal caliber.

Safety and efficacy of adalimumab in pediatric patients with Crohn disease.

OBJECTIVES: Adalimumab has recently become available for adult patients with Crohn disease (CD) as a viable alternative tumor necrosis factor-alpha inhibitor to infliximab. To our knowledge, there have been no studies reviewing the use of adalimumab in pediatric patients with CD. Our aim was to examine the safety and efficacy of adalimumab therapy in pediatric patients with CD. PATIENTS AND METHODS: We performed a retrospective chart review of 15 pediatric patients with CD who received adalimumab at a single institution between January 2003 and March 2007. All of the patients had a history of an attenuated response or anaphylaxis to infliximab. Each patient's chart was reviewed for age at diagnosis, sex, extent of disease, age at start of adalimumab therapy, course of therapy, side effects noted during therapy, concurrent medications, and response to adalimumab. Clinical response to adalimumab was classified as complete, partial, or no response based on the patients' ability to be weaned from steroids, increased or decreased need for steroids, or need for surgery during the course of treatment. This study was approved by the Cleveland Clinic Institutional Review Board. RESULTS: Fifteen pediatric patients with CD received adalimumab for a 33-month period. Of those, 14 patients had adequate follow-up, and 1 patient was lost to follow-up. The mean age at initiation of therapy was 16.6 years (median 17.9 years, range 10.3-21.8 years, SD 3.1 years). The majority of patients received an 80-mg loading dose administered subcutaneously and 40-mg doses subsequently every 2 weeks. The median duration of therapy was 6.5 months (range 1-31 months). A total of 272 injections were given. Of the 14 patients with sufficient data for follow-up, 7 (50%) had a complete response, 2 (14%) had a partial response, and 5 (36%) had no response to adalimumab. Complete response was achieved after a median of 5 injections (range 3-11). Of the 14 patients with adequate follow-up, 5 had fistulizing disease; 3 of these maintained fistula closure, 1 had temporary closure, and 1 required surgery to assist with closure. Twenty-six adverse events occurred during therapy. Eight (57%) patients had at least 1 adverse effect. The most common events were abdominal pain and nausea. No serious adverse events were reported, no serious infections occurred, and no adverse events required discontinuation of adalimumab. CONCLUSIONS: Adalimumab was well tolerated in pediatric patients with CD. Complete or partial response was observed in 64% of patients. No serious adverse events occurred during therapy. Additional studies are needed to evaluate the efficacy and to determine optimal dosing of adalimumab in the pediatric population with CD.