Extensive gastric necrosis in an infant

Gastric necrosis is a rare condition, more so in children and can be potentially fatal. The sloughing of the necrosed wall results in perforations or large defects in the gastric wall. We report a rare case of extensive gastric necrosis in a 2 months old female infant, managed successfully. Child presented with non-bilious vomiting and excessive cry. There was history of recurrent upper abdominal distension. X-ray of abdomen showed massive pneumoperitoneum. Intra operatively, posterior gastric wall was sloughed off and lower end of feeding tube was lying in the peritoneal cavity. Necrotic wall was debrided and stomach tube was created from remaining anterior gastric wall. Gastrostomy and jejunostomy was done. Post-operative period was uneventful. Dye study at three months showed good gastric capacity. Stomach being a well vascularised organ, necrosis is rare. There is varied etiology of gastric necrosis, volvulus being one of them. Gastric volvulus might be associated with other congenital anomalies like eventration, asplenia, wandering spleen. The incidence of perforation in gastric volvulus with necrosis is 5-28% and a mortality of 50% is reported with such perforations. Vigilant clinical observation in pediatric patients with upper abdominal distension and pain can point the diagnosis and prevent fatal outcome.

“LAPAROSCOPIC INTRAGASTRIC EXCISION OF POSTERIORLY LOCATED GASTRIC GIST USING CONVENTIONAL LAPAROSCOPIC INSTRUMENTS – A CASE REPORT”

Background: Gastro-intestinal stromal tumour (GIST) commonly involves stomach. Recently there has been an inclination towards managing these benign but potentially malignant lesions by minimal invasive techniques. Surgical excision of gastric GIST mostly requires anterior wall gastrostomy especially for intraluminal lesions. The size and location of the lesion are critical from technical point of view. Lesions located at gastro-esophageal junction requires larger anterior gastric wall opening to reach the site of tumour for excision. Endoscopic excision for such lesions is not always amenable. We performed excision of a posteriorly locat Methods: ed gastric GIST at GE junction by hitching the anterior gastric wall with the anterior abdominal wall and by directly creating pneumogastrium percutaneously for placing three intra-gastric trocars. Results: Patient was discharged on post-operative day 3 in a satisfactory condition. Histopathology revealed complete resection of GIST lesion with margins free from tumour. Immuno-histochemistry (IHC) conrmed it to be GIST with low malignant potential and patient was advised regular follow up. Laparoscopic intra-gastric excision of a posteriorly located gast Conclusion: ro-oesophageal junction GIST lesion after creating pneumogastrium and using conventional laparoscopic instruments is a safe procedure

Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure

Background Peroral endoscopic myotomy (POEM) has become the minimally invasive endoscopic treatment for achalasia; however, gastroesophageal reflux (GER) post-POEM has been reported. A pilot study was conducted in which an endoscopic fundoplication was added to the standard POEM (POEM + F) procedure to overcome this issue. We report the technical details of POEM + F and short-term safety results. Methods POEM + F was performed in 21 patients. After completing myotomy, the endoscope was advanced from the submucosal tunnel into the peritoneal cavity. A partial mechanical barrier was created by retracting the anterior gastric wall at the esophagogastric junction with the use of endoclips and an endoloop. Results POEM + F was technically feasible in all cases and created a visually recognizable fundoplication. The clinical course after POEM + F was uneventful. No immediate or delayed complications occurred. Conclusion POEM + F may help mitigate the post-POEM incidence of GER and serve as a minimally invasive endoscopic alternative to a laparoscopic Heller-Dor procedure. This is the largest case series of peroral natural orifice transluminal endoscopic surgery without laparoscopic assistance in the human foregut.

SURGICAL GASTROSTOMY BASED ON ENDOSCOPIC CONCEPTS

Background: Until the early 1980s, Stamm technique was considered standard method to gastrostomy. After description of the endoscopic technique, due to its efficiency and speed, quickly became the method of choice for long-term enteral access. Aim: Describe a technique that combines direct view of the stomach from open surgery with the simplicity and less traumatic endoscopic gastrostomy method. Method: In patient supine under spinal anesthesia the technique stars with small epigastric incision to pull up the stomach. A 3 mm incision in the left hypochondrium is made to pass needle puncture to guidewire passage. The stomach is drilled, guidewire is seizured, connection to catheter and percutaneous approach is made with traction of the stomach to the abdominal wall. Purse suture on the anterior gastric wall is not needed. Results: Twenty-eight patients underwent gastrostomy using endoscopy devices; six had local minor complications without the need for re-intervention; there was no death. Conclusion: The surgical gastrostomy with minimal incision in the stomach to pull off the catheter using endoscopic gastrostomy devices, proved to be safe, easy to perform, less traumatic, quick, simple and elegant.

DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication?

ContextThe occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease.ObjectivesCompare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF).MethodsAnalysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF – n = 160) and Group 2 (Nissen LTF – n = 129).ResultsThe overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF.ConclusionsThe overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

Endoscopic treatment for gastric perforation using T-tag and a plastic protection chamber: a short-term survival study

CONTEXT: The endoscopic gastric perforation is a consequence of some endoscopic procedures and now a way to manage abdominal organs. This is the reason why endoscopists are studying a safe endoscopic repair. OBJECTIVE: To evaluate an endoscopic closure method for the gastric opening in natural orifice transenteric surgery DESIGN: Short-term survival animal study. METHODS: Ten White Landrace pigs underwent a gastric perforation of 1.8 cm in diameter under general anesthesia. The opening was repaired with stitch assembled in a T-tag anchor placed through the gastric wall with a needle. A plastic transparent chamber, adapted to the endoscope tip protected the abdominal organs from the needle puncture outside the stomach. Six T-tags were placed in most cases and the stitches were tied with a metallic tie-knot, forming three sutures. The animals received liquids in the same operative day. One shoot antibiotic was used. The leakage test was performed with a forceps and by air distention. RESULTS: No complication was detected in the postoperative course. One month later the endoscopy revealed a scar and some suture material was observed in all animals. The antral anterior gastric wall was clear with few adhesions in the laparotomy performed in the same time. The adhesions were intense in an animal in which a cholecystectomy was performed before the repair. CONCLUSION: The endoscopic repair using T-tag and a protector chamber is feasible, easy to perform and safe. Further studies are needed to show the real value of this kind of procedure.

Unusual Differential Diagnosis of Upper Abdominal Pain

We here present an interesting unusual case of upper abdominal pain. The patient was a 38-year-old man, who was admitted to our hospital complaining of right upper quadrant pain caused by a toothpick that perforated the anterior gastric wall and penetrated segment I of the liver. After endoscopic removal and an initially uneventful course, computed tomography revealed a perigastric abscess that was treated by repeated gastroscopic rinsing via an endoscopically placed catheter. After another three uneventful weeks, a liver abscess with minor tendency to constrict the portal vein was diagnosed, and a segment I liver resection together with abscess drainage was performed. The peculiarity of this case is the rarity of toothpick ingestion and gastric perforation in a young and healthy white Caucasian followed by development of a liver abscess after primary uneventful endoscopic removal. In light of this case, gastric perforation due to ingested foreign bodies such as toothpicks can be considered a rare cause of upper abdominal pain.