Intraoperative HIFU Ablation of the Pancreas Using a Toroidal Transducer in a Porcine Model. The First Step towards a Clinical Treatment of Locally Advanced Pancreatic Cancer

Apart from palliative chemotherapy, no other therapy has been proven effective for the treatment of locally advanced pancreatic tumors. In this study, an intraoperative high-intensity focused ultrasound (HIFU) device was tested in vivo to demonstrate the feasibility of treating the pancreatic parenchyma and tissues surrounding the superior mesenteric vessels prior to clinical translation of this technique. Twenty pigs were included and treated using a HIFU device equipped with a toroidal transducer and an integrated ultrasound imaging probe. Treatments were performed with energy escalation (from 30 kJ to 52 kJ). All treatments resulted in visible (macroscopically and in ultrasound images) homogeneous thermal damage, which was confirmed by histology. The dimensions of thermal lesions measured in ultrasound images and those measured macroscopically were correlated (r = 0.82, p < 0.05). No arterial spasms or occlusion were observed at the lowest energy setting. Temporary spasm of the peripancreatic artery was observed when using an energy setting greater than 30 kJ. The possibility of treating the pancreas and tissues around mesenteric vessels without vascular thrombosis holds great promise for the treatment of locally advanced pancreatic cancers. If clinically successful, chemotherapy followed by HIFU treatment could rapidly become a novel treatment option for locally advanced pancreatic cancer.

Colon cancer in malrotated gut: A case report

Malrotation of the gut is a rare congenital anomaly that mostly presents in the 1st month of life. Very rarely, it is found during adulthood either as an asymptomatic incidental finding or at autopsy. Presenting in adulthood with colon cancers is extremely rare. Here, we present the case of a middle-aged male patient with unexplained anemia which on investigation was found to have adenocarcinoma at the hepatic flexure of the colon. The staging computed tomography scan of the abdomen showed the growth at the hepatic flexure with malrotation of the gut. During the laparoscopic assessment, the cecum and ascending colon were found on the left side, and hence, a formal midline incision was made. Cecum was found on the left of the midline along with Ladd’s band. Extended right hemicolectomy was performed, dividing the Ladd’s band, taking care of the anomalous position of superior mesenteric vessels. The post-operative period was uneventful. Histopathological examination revealed this to be well-differentiated adenocarcinoma (pT3N1b). He thereafter received adjuvant chemotherapy and remains well after 5 years of follow-up. Presentation of malrotation of the gut in adulthood is seen in only 10–15% of cases as an incidental finding or at autopsy. Cancers in the colon in these patients are extremely rare. The treatment for colon cancer remains the same although one has to be careful about the vascular anomaly during the resection.

APPLICATION OF INTESTINAL AUTOTRANSPLANTATION IN TREATMENT OF SURGICAL DISEASES OF THE ABDOMINAL CAVITY

This review is devoted to the relevance of the problem and the assessment of potential surgical indications, surgical methods and clinical results in the intestinal autotransplantation. Radical resection of theneoplasmisperformed. Currently, the main indications for performing intestinal autotransplantation are considered neoplasms of the pancreas, mesenteric and retroperitoneal space with the involvement of the superior mesenteric vessels in the process. Preliminary results demonstrate that radical resection can be effective in carefully selected patients. Although perioperative morbidity and mortality are relatively high, the literature describes some cases with long patient survival, especially when performing radical resection of a benign tumor or a tumor of potentiallow malignant. However, early tumor recurrence remains a serious problem in patients with a high-grade tumor, especially with pancreatic ductal adenocarcinoma (PDAC). It should be noted that when using intestinal autotransplantation, it is possible to perform a radical resection of the organ in patients with separate neoplasms in the abdominal cavity and the involvement of the main mesenteric vessels in the process. However, this aggressive method is associated with significant operational risk and should be only performed in specialized centers. The additional combination therapies have to be developed to optimize the clinical outcome and prolong the survival of patients with pancreatic cancer.

EP.WE.635The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

Case A 73-year-old female was admitted for abdominal pain after eating an out-of-date pie. She was treated for gastroenteritis for 48 hours, after which she became unexpectedly haemodynamically unstable. Computerised Tomography (CT) suggested mesocolic arterial bleed with a large mesenteric haematoma. CT angiography confirmed false aneurysms of the middle colic artery and multiple beading of coeliac branches, small mesenteric vessels and the inferior mesenteric artery. Opinion was sought from multiple specialties, pseudoaneurysm embolisation was undertaken and steroids commenced for presumed vasculitis. Vasculitis screen was negative, and PET CT scan showed no metabolically active vasculitis. It was felt a diagnosis of fibromuscular dysplasia (FMD) was likely. Steroids were weaned and the patient is under active observation. Background FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment. Discussion And Conclusion This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

Bowel Ischemia in COVID-19: A Systematic Review

Background: Gastrointestinal complications of this COVID-19 have been reported over the last year. One such manifestation is bowel ischemia. This study thus aims to provide a more holistic review of our current understanding of COVID-19 induced bowel ischemia. Method and Results: A meticulous search was performed using different keywords in PubMed, EMBASE, and Google Scholar. Fifty-two articles were included in our study after applying inclusion and exclusion criteria and performing the qualitative assessment of the studies. A total of 25,702 patients were included in our study after the completion of the qualitative assessment. Discussion: COVID-19 commonly presents in the GIT as diarrhea, vomiting, and nausea. The mechanism of bowel ischemia is associated with the formation of emboli which is related to COVID-19’s high affinity for angiotensin-converting enzyme-2 on enterocytes, affecting the superior mesenteric vessels. Clinically, patients presented with abdominal pain and vomiting. CT angiography of the abdomen and pelvis showed acute mesenteric ischemia. Management was usually initiated with gastric decompression, fluid resuscitation, and hemodynamic support. Surgical intervention was also sought. Conclusion: Mesenteric ischemia presenting in patients with COVID-19 has to be considered when symptoms of severe abdominal pain are present. More research and guidelines are required to be able to triage patients with COVID-19 to suspect mesenteric ischemia and to help in diagnosis and management.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

1487 The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

A 73-year-old female was admitted for abdominal pain after eating an out-of-date pie. She was treated for gastroenteritis for 48hours, after which she became unexpectedly haemodynamically unstable. Computerised Tomography (CT) suggested mesocolic arterial bleed with a large mesenteric haematoma. CT angiography confirmed false aneurysms of the middle colic artery and multiple beading of coeliac branches, small mesenteric vessels and the inferior mesenteric artery. Opinion was sought from multiple specialties, pseudoaneurysm embolisation was undertaken and steroids commenced for presumed vasculitis. Vasculitis screen was negative, and PET CT scan showed no metabolically active vasculitis. It was felt a diagnosis of fibromuscular dysplasia (FMD) was likely. Steroids have been weaned and the patient is under active observation. Background FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment. Conclusions This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

Small bowel obstruction caused by a true ileo-ileal knot: a rare case successfully treated by prior ligation of mesenteric vessels

Background Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Case presentation An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home. Conclusion We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure.