Recurrent massive bleeding from a small intestinal arteriovenous malformation after surgery for biliary atresia in an infant: a case report and literature review

Background Small intestinal arteriovenous malformation (AVM) can cause bleeding. Most small intestinal AVMs occur during adulthood, rarely in infancy. We report a case of an infant with hemorrhage due to small intestinal AVM early and recurrently after Kasai portoenterostomy (PE) for biliary atresia (BA). Case presentation A 51-day-old male infant was admitted to our institution for obstructive jaundice. Laparotomic cholangiography revealed BA (IIIb1μ), and Kasai PE was performed at 60 days of age. On postoperative day 17, he developed massive melena and severe anemia. Contrast-enhanced computed tomography (CT) revealed that the jejunum around the PE site was strongly enhanced with enhancing nodules in the arterial phase, and a wide area of the Roux limb wall was slightly enhanced in the venous phase. As melena continued, emergency laparotomy was performed. There were no abnormal macroscopic findings at the PE site except for a clot in the Roux limb 5 cm away from the PE site, and the Roux limb was resected 5 cm. On further investigation, a red spot was detected on the jejunal serosa 30 cm away from the Roux-en-Y anastomosis site. PE and wedge resection for the red spot were performed. Histopathologically, both specimens indicated AVM. He was jaundice-free 65 days after the first surgery. However, at 7 months of age, he developed massive melena again. Contrast-enhanced CT and upper gastrointestinal endoscopy revealed no bleeding lesions. Hemorrhagic scintigraphy showed a slight accumulation at the hepatic hilum prompting an emergency surgery. Intraoperative endoscopy detected a bleeding lesion at the PE site, and the Roux limb was resected (approximately 6 cm). Intraoperative frozen section analysis of the stump of the resected jejunum revealed no abnormal vessels. PE was performed, and permanent section analysis revealed an AVM in the resected jejunum. The postoperative course was uneventful without re-bleeding. Conclusions We experienced a case of recurrent massive bleeding from small intestinal AVM in an infant after surgery for BA. Intraoperative endoscopy and frozen section analysis helped identify the bleeding lesion and perform a complete resection of the small intestinal AVM, even after surgery, in the infant.

Intraoperative Endoscopy in Transient Adult Jejunojejunal Intussusception

Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons’ assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging.

Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases

With the advances in the endoscopic technology, most of the small bowel diseases are being diagnosed by capsule endoscopy and device assisted enteroscopy. However, there are many clinical situations such as small bowel obstruction, foreign body impaction were these advanced endoscopic procedures cannot be performed. In such cases, intraoperative endoscopy plays a vital role in the management of these small bowel diseases. Intraoperative endoscopy is also very useful in identification of the site of obscure gastrointestinal bleeding in difficult cases. Moreover, capsule endoscopy and device assisted enteroscopy are expensive procedures and not readily available at all medical centers especially in low income countries. On the other hand, intraoperative endoscopy can be easily performed by conventional gastroscope and colonoscope. In this chapter, we have discussed the indications, techniques, outcomes and complications of intraoperative endoscopy in the current era of deep enteroscopy.

Intraoperative intraluminal endoscopic assistance

Purpose of the study. Clarification of indications, assessment of technical aspects and results of intraoperative intraluminal endoscopic assistance in patients with diseases of the gastrointestinal tract, respiratory tract and in cardiosurgical patients.Materials and methods. Intraoperative intraluminal endoscopic assistance was performed for esophageal diverticula (41), gastroesophageal reflux disease and its complications (32), cicatricial stenoses and tracheal neoplasms (28), gastrointestinal tract neoplasms (17), and a mismatch between the diagnosis of the sending organization with intraoperative data (9) and for the anastomoses control (5). Intraoperative sanation tracheo-bronchoscopy with the definition of “background” flora was performed in 60 cardiosurgical patients with chronic diseases of the bronchopulmonary system.Results. The indications for performing the intraoperative intraluminal endoscopic assistance have been specified taking into account the impact of the study on the surgical course and scope, the method of anesthesia and the tactics of further treatment. Various aspects of the formed fundoplication cuff, completeness of diverticulum resection, and suture tightness were assessed. In a number of patients, the localization of neoplasms and stenoses was clarified, which affected the definition of the resection boundaries. In a number of cases, intraoperative intraluminal endoscopic assistance allowed reducing the average time of intervention and helped to minimize complications.Conclusion. Intraoperative intraluminal endoscopic assistance has its own peculiarities of execution, requires experience in data interpretation, requires a clear coordinated work and communication between the endoscopist, anesthesiologist and surgeon. In general, intraoperative endoscopy improves the results of surgical treatment and prevents complications.

Early Postoperative Anastomotic Obstruction Due to an Intraluminal Blood Clot After Laparoscopic Anterior Resection: A Case Report

Early postoperative anastomotic obstruction after colorectal surgery rarely develops. Herein, we present a case of a 50-year-old healthy woman who had an early postoperative anastomotic obstruction which was revealed caused by a blood clot and successfully managed by endoscopic approach. The patient was discharged after laparoscopic anterior resection and visited the emergency department one day after because of abdominal pain. Computed tomography showed that the anastomosis site was obstructed with low-density material. Intraoperative endoscopy was performed under general anesthesia and blood clot filling the lumen were identified. As the scope was advanced to the blood clot with air inflation, the blood clot was evacuated. The anastomosis site could be obstructed by blot clot with mucous debris albeit it is a rare condition. An endoscopic approach seems to be the first option in the diagnosis and treatment of postoperative obstruction at the anastomosis site and it could prevent unnecessary laparotomy.

Sensitivity of magnetic resonance tomographic angiography for detecting the degree of neurovascular compression in trigeminal neuralgia

Purpose Neurovascular compression (NVC) is hypothesized to be the main pathogenic factor of trigeminal neuralgia (TN). Microvascular decompression (MVD) has become a popular surgery for TN, and the success rate depends on the degree of NVC. As the routine examination before MVD, magnetic resonance tomographic angiography (MRTA) shows high sensitivity for detecting NVC. However, there are no reports on the sensitivity of MRTA for assessing the degree of NVC. Methods This study aimed to evaluate the sensitivity of MRTA for determining the degree of NVC by comparing preoperative MRTA and intraoperative endoscopy findings. A total of 480 patients who suffered from TN and underwent MVD were included. Their preoperative MRTA and intraoperative endoscopy findings were reviewed. The kappa test was used to identify similarities between the MRTA and endoscopy findings. Results The degree of NVC on preoperative MRTA was similar to that on endoscopy (kappa = 0.770). The number of offending vessels according to preoperative MRTA was coincident with that according to endoscopy (kappa = 0.722). Conclusion MRTA had high sensitivity for detecting not only the presence of NVC but also the degree of NVC.