Unexpected duodenopancreatectomy in an "awake" gastrectomized patient: Case report and technical notes.

INTRODUCTION AND IMPORTANCE: Early diagnosis, surgical techniques and adjuvant therapy in patients undergoing gastrectomy for cancer have prompted an increase in the number of long-term surviving patients. The detection of pancreatic head tumours in patients undergoing gastrectomy is challenging, even for expert surgeons. CASE PRESENTATION: A 78-year-old woman presented with a previous history of gastric cancer treated 2 years before D2 total gastrectomy and Roux-an-Y reconstruction. The patient reported uneven tissue located on the head of the pancreas 6 months after the operation. MRI showed dilation of the intrahepatic bile ducts and common bile duct stones. During the preoperative evaluation, neuraxial-type anaesthesia was proposed to the patient given her frailty. After choledochotomy, solid tissue involving the ampulla of Vater was found. Although not originally planned, a duodenopancreatectomy (DP) was performed under neuraxial anaesthesia. CLINICAL DISCUSSION: The approach to DP in patients with a history of gastrectomy and Roux-en-Y reconstruction requires a modified surgical approach, which is not standardized. Other cases of DP performed on patients under neuraxial anaesthesia are not described in the literature. Performing a modified reconstruction, we can reduce the number of intestinal anastomoses and the risk of anastomotic dehiscence. The choice of neuraxial anaesthesia has been demonstrated to be a suitable solution for the patient with rapid recovery. CONCLUSION: In our experience, DP is a safe and feasible procedure in gastrectomized patients. Mechanical hepaticojejunal (HJ) anastomosis is a possible alternative to traditional manual anastomosis. Neuraxial anaesthesia in selected patients can be considered a safe practice for rapid postoperative recovery compared to general anaesthesia.

The management of esophago-gastric necrosis due to caustics ingestion: Anastomotic reinforcement with Cyanoacrylate glue and damage control with Vacuum Assisted Closure Therapy-A case report.

INTRODUCTION: The surgical treatment of a complete gastric necrosis due to caustic ingestion is extremely challenging and life threatening. In this emergency scenario, a first-time reconstruction of the gastrointestinal tract is often dangerous for the patient because of the high risk of infections and anastomosis leakage. Literature lacks of clear indications for the management of this condition. PRESENTATION OF CASE: Male patient with history of major depression disorder was admitted to our Emergency Unit after the ingestion of muriatic acid. CT scan showed massive pneumo-peritoneum with esophago-gastric thickening. Free fluids in the abdominal cavity were detected. Intraoperative finding was a complete necrosis of the stomach and corrosion of the lower esophagus. DISCUSSION: In this case report we proposed a first approach with the drainage and lavage of the abdomen cavity. Then, an esophago-jejunum anastomosis reinforced by Cyanoacrylate glue was performed and a damage control with VAC therapy (Vacuum Assisted Closure) was carried out. CONCLUSION: Cyanoacrylate glue could be considered useful and efficient in the reinforcement of anastomosis even in emergency surgical procedures. Damage control using VAC allows to keep a good control of the surgery performed.

Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation.

AIM: To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation. METHODS: A retrospective study (June 2012-December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark's and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients' satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry. RESULTS: Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0 cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6). CONCLUSION: Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

A novel reconstructive strategy for pancreaticoduodenectomy following Roux-en-Y distal gastrectomy.

The rate of pancreaticoduodenectomy (PD) performed for both benign and malignant periampullary diseases has increased. In addition, Roux-en-Y reconstruction after distal gastrectomy for cancer or ulcer is still widely used. Therefore, a surgeon may be confronted with a partially- gastrectomized patient who needs a PD. This is a very challenging circumstance for surgeons because of adhesions, bloodstream, anatomical changes and length of the remnant intestine. In our experience, we performed two pancreaticoduodenectomies after distal gastrectomy in patients with periampullary tumors. We preserve gastrojejunal anastomosis and perform an end-to-side pancreaticojejunostomy (PJ) on the afferent limb of gastrojejunal anastomosis and a termino-lateral hepaticojejunal anastomosis on an independent transmesocolic Roux-en-Y limb. In literature, few cases of PD after distal gastrectomy are reported and most of them consider only PD after Billroth II reconstruction. Many authors have demonstrated pancreaticogastrostomy (PG) is superior to PJ in terms of lower risk of pancreatic and biliary fistula, but it is not possible to anastomose pancreas stump with gastric wall in patients who have been undergone distal gastrectomy. For this reason, we retrospectively review our experience about PD following distal gastrectomy and suggest a novel standardized technique which allow surgeons to benefit from same advantages of a typical PG also in this group of patients.

Complicated duodenal-jejunal diverticulosis: case report.

BACKGROUND: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur. CASE REPORT: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump. CONCLUSION: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Intestinal occlusion by stenotic neuroendocrine tumours of left colon and concomitant association with small bowel gastrointestinal stromal tumours: A case report.

INTRODUCTION: The association between Gastrointestinal Stromal Tumours (GIST) and Neuroendocrine Tumours (NET) is very rare. These tumours have various clinical expressions and sometimes are asymptomatic. Synchronous NETs and GISTs have been already described in literature in few case reports. On the other hand, there is no mention of concomitant presence of discending colon NEC-G3 and small intestinal GIST. PRESENTATION OF CASE: we presented a case of a patient with clinical evidence of intestinal occlusion and radiological and intraoperative aspects of an adenocarcinoma of the left colon with a single metastasis on small bowel. The pathology analysis of the tumour showed a stenotic left colon NEC-G3 and a small bowel GIST. DISCUSSION: In this case report GIST was surgically treated as a small bowel ripetitive lesion and NET as a left colon adenocarcinoma. These tumours may have a similar presentation in terms of symptoms, endoscopic findings and imaging results. CONCLUSION: Concomitant NEC and GIST is rare but it is important to investigate patients before surgery in order to distinguish these from other tumours because of the different prognosis.