META-ANALYSIS ON ETIOPATHOGENESIS OF SMALL BOWEL OBSTRUCTION IN THE DEPARTMENT OF GEN. SURGERY P.M.C.H. & K.M.C.H., BIHAR

Background:The small intestine is the longest and convoluted portion in the digestive tract. It starts from pylorus and ends at ileocaecal valve. The small bowel consists of three parts measuring about 5 to 6 meters. The rst 25cm is the duodenum. Out of the rest part of small gut, jejunum th th. constitute the proximal 2/5 and ileum distal 3/5 The jejunum and ileum extend from the peritoneal fold that supports the duodeno-jejunal junction (Ligament of Treitz) down to ileocaecal valve. Material and Methods:All the patients admitted to PMCH, Patna and KMC, Katihar as intestinal obstruction was included for the study. The time period of study was from October 2014 to November 2016 in PMCH and December 2016 to January 2019 in KMC, Katihar. Out of all Intestinal obstruction 59 cases only of adult small gut obstruction were recorded for comparison and conclusive study.Conclusion: Small bowel obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding delayed operation, whatever surgery is indicated, not every patient is always best served by immediate operation

EP.FRI.265 Laparoscopic Right Hemicolectomy with Complete Mesocolic Excision for a T4 Caecal Tumour with Associated Phlegmon

A 67-years-old female presented with right lower abdominal pain and raised inflammatory markers. A computed tomography scan showed marked inflammatory changes with collections adjacent to terminal ileum. Patient was managed with intravenous antibiotics initially. Subsequent colonoscopy showed a bulky 8cm caecal pole tumour involving ileocaecal valve. Histopathology confirmed a diagnosis of moderately differentiated adenocarcinoma. Staging CT was negative for distant metastases. The patient subsequently proceeded to laparoscopic right hemicolectomy with complete mesocolic excision (CME). Intraoperatively the ileocolic vein was clipped just at the level of its confluence with superior mesenteric vein. The ileocolic artery was divided at its origin form superior mesenteric artery followed by division of right colic artery. The caecal mass was dissected off the abdominal wall. Proximally small bowel was resected 25cm form the ileocaecal valve and distally colon was divided up till mid transverse point. The specimen was extracted through a 9 cm Pfannenstiel incision. An intracorporeal isoperistaltic ileocolic side to side anastomosis was performed using a novel technique.1 The patient made full recovery and proceeded to adjuvant chemotherapy. Histology showed moderately differentiated T4 adenocarcinoma with tumour free lymph nodes. This case demonstrates intraoperative steps of laparoscopic complete mesocolic excision. CME is now becoming a standard due to improved oncological outcomes as it yields higher number of resected lymph nodes and better tumour clearance margins. This approach can be challenging due to variability in vascular anatomy, however, in experienced hands it is feasible and safe resulting in extensive lymphadenectomy and better oncological radicality. 1.https://www.ncbi.nlm.nih.gov/pubmed/28833963/

Inflammatory bowel disease in patients with congenital chloride diarrhoea

Introduction Congenital chloride diarrhoea (CLD) is a rare autosomal recessive disease caused by mutations in the solute family carrier 26 member 3 (SLC26A3) gene. Patients suffer from life-long watery diarrhea and chloride loss. Inflammatory bowel disease (IBD) has been reported in individual patients with CLD and in scl26a3-deficient mice. Methods We performed an international multicentre analysis to build a CLD cohort and to identify cases with IBD. We assessed clinical and genetic characteristics of subjects and studied the cumulative incidence of CLD-associated IBD. Results In a cohort of 72 patients with CLD caused by 17 different SLC26A3 mutations, we identified 12 patients (17%) diagnosed with IBD. Nine patients had Crohn’s disease, two ulcerative colitis, and one IBD-unclassified (IBD-U). Prevalence of IBD in our cohort of CLD is higher than the highest prevalence of IBD in Europe (p < 0.0001). The age of onset was variable (13.5 years, IQR: 8.5 – 23.5 years). Patients with CLD and IBD had lower z-score for height than those without IBD. 4/12 patients had required surgery (ileostomy formation n=2, ileocaecal resection due to ileocaecal valve stenosis n=1, and colectomy due to stage II transverse colon cancer n=1). At last follow-up, 5/12 were on biologics (adalimumab, infliximab, or vedolizumab), 5/12 on immunosuppressant (azathioprine or mercaptopurine), one on 5-ASA and one off-treatment. Conclusions A substantial proportion of patients with CLD develop IBD. This suggests potential involvement of SL26A3-mediated anion transport in IBD pathogenesis. Patients with CLD-associated IBD may require surgery for treatment failure or colon cancer.

Duplicated appendix with an acute abdomen in 16 years old female with both appendices inflamed: a rare case report

Duplicated appendix is a rare congenital anomaly with incidence of 0.004-0.009% and its mostly an incidental finding on table, when one of them is acutely inflamed and very rarely both of them can be inflamed as in this case. Report a case of young girl who presented with complain of pain abdomen and vomiting in the last 2 days. Clinically patient was diagnosed to have acute appendicitis and on laparoscopy, patient had duplicated appendix one at the ileocaecal valve and the other 2cm away near the caecum with pus and faecolith. Histopathology confirmed appendicitis in the both appendices. Reported about this interesting rare case because even though the incidence of duplicated appendix is too low (0.004-0.009%), should always search for the missed appendix in patients who underwent appendicectomy earlier and complains of severe pain in right iliac fossa. Aim was to report such a rare interesting case and give a small gentle reminder to the surgeons as duplicated appendix even though rare but still a possibility.

Short- and Long-term Outcomes Following Side-to-side Strictureplasty and its Modification Over the Ileocaecal Valve for Extensive Crohn’s Ileitis

Background and Aims Postoperative recurrence remains a challenging problem in patients with Crohn’s disease [CD]. To avoid development of short bowel syndrome, strictureplasty techniques have therefore been proposed. We evaluated short- and long-term outcomes of atypical strictureplasties in CD patients with extensive bowel involvement. Methods Side-to-side isoperistaltic strictureplasty [SSIS] was performed according to the Michelassi technique or modification of this over the ileocaecal valve [mSSIS]. Ninety-day postoperative morbidity was assessed using the comprehensive complication index [CCI]. Clinical recurrence was defined as symptomatic, endoscopically or radiologically confirmed, stricture/inflammatory lesion requiring medical treatment or surgery. Surgical recurrence was defined as the need for any surgical intervention. Endoscopic remission was defined as ≤i1, according to the modified Rutgeerts score. Deep remission was defined as the combination of endoscopic remission and absence of clinical symptoms. Perioperative factors related to clinical recurrence were evaluated. Results A total of 52 CD patients [SSIS n = 12; mSSIS n = 40] were included. No mortality occurred. Mean CCI was 10.3 [range 0–33.7]. Median follow-up was 5.9 years [range 0.8–9.9]. Clinical recurrence [19 patients] was 29.7% and 39.6% after 3 and 5 years, respectively. Surgical recurrence [seven patients] was 2% and 14.1% after 3 and 5 years, respectively. At the end of the follow-up, 92% of patients kept the original strictureplasty and deep remission was observed in 25.7% of the mSSIS patients. None of the perioperative variables considered showed a significant association with clinical recurrence. Conclusions SSIS is safe, effective, and provides durable disease control in patients with extensive CD ileitis.