Endoscopic features for early detection of superior mesenteric artery syndrome in children

Background Superior mesenteric artery syndrome (SMA) syndrome is a rare cause of duodenal obstruction. Diagnostic delay of SMA syndrome is common due to its rarity and lack of index of clinical suspicion. Present study aims to explore the endoscopic features for early decision to evaluate SMA syndrome in children. Methods In case controlled observation study, we identified three endoscopic findings in enrolled cases like as, finding I: a pulsating band like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 seconds, finding II: marked dilatation of the duodenal second part during air insufflation at the duodenal third part, and finding III: bile lake in the stomach. SMA syndrome was confirmed with upper GI series in patients with endoscopic finding I or I plus more. We analyzed positive endoscopic findings related with SMA syndrome. Results Twenty-nine patients consisted of 18 (62.1%) cases with SMA syndrome and 11 (37.9%) cases without SMA syndrome. The 3 most common presenting symptoms were postprandial discomfort, abdominal pain, and early satiety. The initial impressions before endoscopy were functional dyspepsia (37.9%), gastritis or gastric ulcer (31.0%), and SMA syndrome (24.1%). Sixteen patients (55.2%) had the constellation of three endoscopic findings (finding I + II + III). Of them, 72.2% confirmed with SMA syndrome, and 27.3% had no SMA syndrome in upper GI series (P = 0.027). Conclusions Endoscopic examination down to the third part of duodenum can provide a clue making a decision to evaluate SMA syndrome, which includes a feature composed of three findings like as a pulsating band like luminal narrowing of duodenal third part, a marked expansion of duodenal second part, and a bile lake in the stomach.

Upper gastrointestinal series in children: what surgeons need to know

Background Upper gastrointestinal (UGI) series is the standard imaging tool for diagnosis of structural and functional abnormalities affecting the esophagus, stomach, and proximal small bowel. The aim of this study was to delineate the clinical indications for UGI series in children that are associated with the presence of significant radiological abnormalities aiming for more standardized care for those patients. Results UGI series of 118 patients was analyzed with calculation of clinical score. Vomiting was the most frequent primary complaint (63.6%), followed by dysphagia and recurrent chest infection. Forty-nine patients had positive upper GI findings (42%). The most detected abnormality was related to the stomach and duodenum (21.4%). Variable degrees of idiopathic gastroesophageal reflux were detected in 16 patients (13.6%). Patients with clinical score 2 or more had significantly more prevalence of abnormal findings (p = .001). Vomiting (especially when bilious), underweight, aspiration, and recurrent chest infection were strong predictors of abnormal findings on upper GI series (p = 0.007, 0.001, 0.009, and 0.001, respectively) and increased the diagnostic yield of upper GI series for detection of abnormalities by 3.48, 9.6, 4, and 4.12 times, respectively. Conclusion Diagnostic yield of UGI series was relatively higher in patients having two or more symptoms (clinical score 2 or more) and in children with bilious vomiting, aspiration and underweight, or repeated chest infection.

Sleeve Gastrectomy in a Patient with Obesity and Ehlers-Danlos Syndrome: A Case Report

Ehlers-Danlos syndrome (EDS) is an inherited connective tissue disorder with a huge variety of signs and symptoms. Gastrointestinal manifestations may be present in up to 50% of patients. We here report bariatric surgery in a patient with EDS, focusing on management challenges, preoperative assessment and one-year outcome. A 56-year-old woman with hypermobility-type (HM) EDS, BMI 42,5 kg/m2 and hypertension underwent laparoscopic sleeve gastrectomy (LSG). She was uneventfully discharged on POD3. One-year after the operation her BMI was 28,3 kg/m2 and hypertension receded. Postoperative upper GI series (POD60) did show neither reflux nor esophageal dysmotility. Bariatric surgery in patients with EDS can be challenging due to the potential risks of wound healing. Proper preoperative assessment and follow up should be strongly recommended.

VS02.04: TOTAL THORACOSCOPIC ENUCLEATION FOR GIANT ESOPHAGEAL LEYOMIOMA: A CONSECUTIVE SERIES

Description Giant esophageal leiomyomas (GEL) are challenging benign conditions to treat in a total minimally invasive way. Here we show the management of a complete thoracoscopic enucleation (TE) of three giant esophageal masses in three different patients. Not only the size of these masses but mostly the position of them made the indication for TE borderline. Methods Every patient underwent a full diagnostic pre-op workup with CT scan, PET and EUS guided biopsies to rule out any malignancy. In this video, we show a full thoracoscopic approach with the patient on the left flank in a semi-prone/prone position and under general anesthesia without lung exclusion. We use a 3 trocars approach and low pressure(8mmHg) CO2 insufflation during the whole procedure. The dissection of the mass is carefully performed to keep the whole mucosal layer undamaged and minimizing the incision in the muscular layer. Careful reconstruction of the muscular layer is a mandatory step at the end of the procedure. Azygos vein resection is performed depending on the mass location. We extract the mass in a bag by enlarging the incision of the inferior scapular trocar. The integrity of the mucosal layer was constantly checked during the procedure either by direct endoscopic vision or by insufflation of air through a nasogastric tube. Results All the patients had an uneventful post-operative course, upper-GI series showed no leak, no stricture nor dilatation of the esophagus. On POD 4 a soft diet was administered. Conclusions Esophageal leiomyomas are a rare condition; the ones larger than 10cm are defined as GEL and they represent the 17% of the total. While, in advanced centers, Total TE for small leiomyomas is a standard of care, GELs are usually managed by open surgery, and in many cases, esophagectomy has to be performed. In our series of five consecutive GELs, located in the upper esophagus, TE proved to be safe and effective in all the patients. Disclosure All authors have declared no conflicts of interest.

Successful Gastric Volvulus Reduction and Gastropexy Using a Dual Endoscope Technique

Gastric volvulus is a life threatening condition characterized by an abnormal rotation of the stomach around an axis. Although the first line treatment of this disorder is surgical, we report here a case of gastric volvulus that was endoscopically managed using a novel strategy. An 83-year-old female with a history of pancreatic cancer status postpylorus-preserving Whipple procedure presented with a cecal volvulus requiring right hemicolectomy. Postoperative imaging included a CT scan and upper GI series that showed a gastric volvulus with the antrum located above the diaphragm. An upper endoscopy was advanced through the pylorus into the duodenum and left in this position to keep the stomach under the diaphragm. A second pediatric endoscope was advanced alongside and used to complete percutaneous endoscopic gastrostomy (PEG) placement for anterior gastropexy. The patient’s volvulus resolved and there were no complications. From our review of the literature, the dual endoscopic technique employed here has not been previously described. Patients who are poor surgical candidates or those who do not require emergent surgery can possibly benefit the most from similar minimally invasive endoscopic procedures as described here.