Upper gastrointestinal surgery

This chapter outlines the assessment and management of the patient who presents with dysphagia, haematemesis and upper gastrointestinal perforation. The conditions commonly affecting the oesophagus, stomach, duodenum, jejunum and ileum are described; oesophageal motility disorders, pharyngeal pouch, hiatus hernia, gastro-oesphageal reflux disease, oesophageal tumours, peptic ulcer disease, gastric tumours, chronic intestinal ischaemia and small bowel tumours. Procedures such as upper gastrointestinal endoscopy and surgery for morbid obesity are also discussed in this chapter.

Laparoscopic resection of small bowel gist: a case report

Small bowel bleed accounts for approximately 5% of all gastrointestinal bleeding. While arteriovenous malformation is the commonest cause of small bowel bleeding, other causes include inflammatory bowel disease, small bowel tumours, ulcers and polyps make up the rest. Tumours range from benign adenomas, hamartomas and leiomyomas to malignant GISTs, adenocarcinomas or lymphomas. We reported a case of a jejunal GIST causing intermittent bleeding. Upper and lower GI endoscopy did not find any abnormality and the diagnosis was made through computerized tomography. It showed a mid-jejunal tumour that was in close proximity to the distal duodenum. The rest of the hollow and solid organs were normal. The patient was prepared and underwent laparoscopic assessment. The tumour was mobile, arising from proximal jejunum and did not show infiltration or adhesions to nearby viscera. A segmental resection with adequate margin was performed laparoscopically and extracted through the umbilical port wound. The pathology report revealed an intermediate GIST with clear margins. Laparoscopic assessment should ideally be carried prior to any resection of small bowel tumours. Uncomplicated small bowel resections can safely be done laparoscopically with good oncological outcome and faster patient recovery.

Primary mesenteric neuroendocrine tumour with liver metastasis: a common presentation of an uncommon tumour

Neuroendocrine tumours (NET) are rare. They usually arise from the gastrointestinal or bronchopulmonary systems. Most are discovered incidentally and the small bowel tumours pose special difficulty in detection and treatment. Primary mesenteric involvement is very rare. Here we report such a case with a liver metastasis. This was preoperatively diagnosed and treated by enucleation of the mesenteric tumour together with right hepatectomy in a single sitting.

Optimising the use of small bowel endoscopy: a practical guide

The wireless nature of capsule endoscopy offers patients the least invasive option for small bowel investigation. It is now the first-line test for suspected small bowel bleeding. Furthermore meta-analyses suggest that capsule endoscopy outperforms small bowel imaging for small bowel tumours and is equivalent to CT enterography and magnetic resonance enterography for small bowel Crohn’s disease. A positive capsule endoscopy lends a higher diagnostic yield with device-assisted enteroscopy. Device-assisted enteroscopy allows for the application of therapeutics to bleeding points, obtain histology of lesions seen, tattoo lesions for surgical resection or undertake polypectomy. It is however mainly reserved for therapeutics due to its invasive nature. Device-assisted enteroscopy has largely replaced intraoperative enteroscopy. The use of both modalities is discussed in detail for each indication. Current available guidelines are compared to provide a concise review.

Giant jejunal leiomyosarcoma: a rare case

Unlike other gastrointestinal neoplasms, small bowel tumours are often rare. Of this, leimyosarcoma of jejnum is extremely uncommon. Most of these patients are asymptomatic however in few cases may present with acute presentation such as intestinal obstruction, bleeding and perforation. A 35 years old female presented to the hospital with complaints of pain and vomiting. On palpation, an irregular 21x18cms lump with variable consistency and irregular borders which was intraabdominal and intraperitoneal. CECT revealed heterogenous, hypoechoic mass extending from epigastric to hypogastric region with probable diagnosis of mesenchymal tumour (probably GIST/LEIOMYOSARCOMA), however exact site of origin couldn’t be traced. Patient underwent exploratory laprotomy, 25x20cms irregular mass arising from jejunum was resected and sent for histopathological examination. HPE and immunohistochemistry revealed grade 3 leiomyosarcoma.

Ileoileal intussusception in unspecific recurrent abdominal pain in adult: A case report

Primary small bowel tumours are very uncommon accounting about 1% of all gastrointestinal tumours. Intestinal lipomas are a rare entity of benign tumours with an incidence at autopsy ranging from 0.04% to 4.5%, most being asymptomatic. Complications such as obstruction, haemorrhage, intussusception and perforation might demand invasive management. Among these, intussusception is the most rare complication of intestinal lipomas. Here, we present a case of intussusception in a 52-year-old female with a large intramural lipoma of the ileum.