Gastric perforation secondary to T-cell lymphoma.

Introduction: Malignant primary lymphoma represents only 1%-5% of all gastric tumours. Spontaneous gastric perforation in the absence of chemotherapy in these cases is extremely rare. The vast majority of primary gastric lymphomas have a B-cell phenotype that originates from mucosa-associated lymphoid tissue and primary gastric lymphomas with a T-cell phenotype are rarely reported. This report describes a case of a primary gastric T-cell malignant lymphoma associated to spontaneous perforation and peritonitis. Case presentation: An 80-year-old woman referring 24 hours of abdominal pain associated to cognitive impairment consulted to our Emergency Department. Her past medical history revealed smoking, hypothyroidism, dilated cardiomyopathy, hypertension, celiac disease with poor adherence to gluten-free diet and a Non-Hodgkin T cell lymphoma associated to enteropathy in 2010. At physical examination, she presented with tachycardia, hypotension and abdominal tenderness. Lab test revealed low red cell count and an abdomen computed tomography scan showed pneumoperitoneum secondary to a large gastric perforation located in the anterior wall of the antrum. Urgent surgery was performed. At exploratory laparoscopy, a 5 cm perforation of the anterior wall of prepyloric antrum was observed associated to a 4-quadrant peritonitis. Conversion to open surgery was decided to perform an open antrectomy and Billroth II gastro-jejunostomy. The patient was transferred to ICU after surgery under mechanical respiratory assistance for closed monitoring but evolved with a cardiogenic shock and deceased on the first postoperative day. The final histopathological and immunohistochemical analysis reported enteropathy-associated T-cell lymphoma of gastric localisation with concomitant celiac disease. Discussion: We present a rare case of a patient with a history of celiac disease who developed a gastric perforation secondary to an enteropathy-associated T-cell lymphoma of gastric localisation. To the best of authors' knowledge, there have been reported less than 30 cases of spontaneous perforation of gastric lymphoma in the absence of chemotherapy in the last 35 years. Malignant gastric lymphoma, accounting only for 1% of primary gastric malignancies, is usually a diffuse large B-cell lymphoma. Incidence of perforation of gastric lymphomas in patients receiving chemotherapy rounds 0.9%-1.1%. However, it is a rare condition in patients not receiving chemotherapy. Conclusion: This is a rare case of a patient with an enteropathy-associated T-cell lymphoma of gastric localisation, who developed a spontaneous gastric perforation in the absence of chemotherapy. Despite it is a rare condition, it must be suspected in patients with a history of lymphoma in the context of acute abdominal pain.

Laparoscopic treatment of a pericaecal internal hernia.

We present the case of a pericaecal hernia treated successfully with a laparoscopic approach and full recovery after surgery. A 53-year-old female patient with a personal history of depression, osteoporosis and irritable bowel syndrome consulted to the emergency department for abdominal pain and distension in the last 12 h, associated with one episode of vomit and diminished frequency in the passage of stools. The right abdomen was tender to palpation, and blood work revealed no leucocytosis. A computed tomography scan showed small bowel loops distended and displaced to the right parietocolic recess, lateral to the ascending colon. Exploratory laparoscopy was performed confirming the presence of small bowel loops incarcerated in the paracaecal fossa. These ones were reduced with gentle manoeuvres, and the peritoneal folds incised to prevent recurrence. The patient was started on an oral diet 2 days after surgery and discharged home on the 3rd post-operative day.

Does Treatment of the Hiatus Influence the Outcomes of Magnetic Sphincter Augmentation for Chronic GERD?

BACKGROUND: Hiatal dissection, restoration of esophageal intra-abdominal length, and crural closure are key components of successful antireflux surgery. The necessity of addressing these components prior to magnetic sphincter augmentation (MSA) has been questioned. We aimed to compare outcomes of MSA between groups with differing hiatal dissection and closure. METHODS: We retrospectively reviewed 259 patients who underwent MSA from 2009 to 2017. Patients were categorized based on hiatal treatment: minimal dissection (MD), crural closure (CC), formal crural repair (FC), and extensive dissection without closure (ED). The primary outcome was normalization of postoperative DeMeester score (≤ 14.72). Univariable and multivariable logistic regression was used to assess which preoperative predictors achieved normalization. RESULTS: Of the 197 patients, MD was used in 81 (41%); FC in 42 (22%); CC in 40 (20%); and ED in 34 (17%). Normalization occurred in 104 (53%) patients, with MD achieving normalization in 45/81 (56%); FC in 25/42 (60%); CC in 21/40 (53%); and ED 13/34 (38%). After regression, FC was most likely to normalize acid exposure. The presence of a hiatal hernia, defective LES, and higher preoperative DeMeester score were less likely to achieve normalization. CONCLUSIONS: Hiatal dissection with restoration of esophageal length and crural closure during MSA increases the likelihood of normalizing acid exposure.