A Case Report of a Bleeding Duodenal Gastro-Intestinal Stromal Tumor and its Emergent Management

A gastrointestinal stromal tumor (GIST) arising in the duodenum is a rare subtype of mesenchymal tumor. GISTs have a reported incidence of 11.9–19.6 per million population and duodenal GISTs make up just 5% of these tumors. Common presentation of duodenal GISTs is through an upper gastrointestinal bleed, of which, they are responsible for less than 1% of all gastrointestinal bleeding. In an elective setting, surgical management remains the mainstay of treatment. In this Case Report, the emergent management of a localized duodenal resection was performed by an acute care surgeon, in an unstable patient. The risk factors for malignancy include tumor size and a high mitotic cell index. Tumor recurrence is determined by tumor size, tumor rupture, high mitotic cell index, a non-gastric location and gastrointestinal bleeding.

P011 THE EARLY OUTCOMES OF ABDOMINAL WALL RECONSTRUCTION WITH POLYVINYLIDENE (PVDF) MESH IN THE INFECTED SETTING: A CASE-CONTROL SERIES

Aim The use of synthetic mesh to repair infected defects of the abdominal wall remains controversial. PVDF mesh was introduced in 2002 as an alternative to polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting. Material and Methods A prospective clinical trial started in 2016 and designed to evaluate the short and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh reinforcement to treat their defects. Results Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and a longer operative and anesthesia time. At 30-days, surgical site occurrences were observed in 18 (47.4%) AI vs. 17 (44.7%) CC; surgical site infection occurred in 4 (10.4%) AI vs. 6 (15.8%) CC, and a higher number of procedural interventions were required in the CC group, 15.8% AI vs. 28.9% CC. At 6-months follow-up, no chronic infections or hernia recurrences were observed in both groups. Conclusions The use of PVDF mesh in the infected setting presented very favorable results with a low incidence of wound infection.

State-of-the-art surgery for ulcerative colitis

Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.

CASE REPORT OF A CHALLENGING CYSTIC INTESTINAL PNEUMATOSIS OF THE SMALL GUT ASSOCIATED WITH ULCER PERFORATION

Introduction:-Cystic Intestinal Pneumatosis represents a challenging clinical condition with various clinical onsets and complications. Altogether, CIP is prone to misdiagnosis and or mistreatment due to delayed management. The aim of our study is to report the challenging diagnosis of a pneumatosis intestinalis clinical case, the therapeutic strategy we chose to adopt and the outcome. Material and Methods:-Forty-five-year-old manwith no past medical and surgical history who presented aggravated acute abdominal pain and absence of bowel movement associated with vomitus in the last 5 days earlier. Physical examination unveiled unstable patient with cardiovascular choc syndrome and generalized abdominal contraction. Prompt medical care was started with abundant IV fluids repletion and antibiotics. Abdominal X-ray without barium showed the presence of air in the abdominal cavity. Diagnosis of pneumoperitoneum was confirmed, and due to the unstable condition, we decided to undergo surgical assessment first without abdominal CT scan. Therefore, laparotomy was carried on. We found perforated anterior duodenal ulcer associated with cystic bubbles filled with air along the gut wall. We decided to preserve the affected segment with cystic pneumatosis as there was no significant signs of inflammation, perforation nor ischemia. Post-operative course was uneventful, and the patient was discharged on day 5. Long-term follow-up at 4 months was uneventful. Discussion:-The abstract underlined the misleading radiology imaging of CIP, highly like the one of pneumoperitoneum. The etiology behind Pneumatosis intestinalis is yet to be understood. Multiple theories have been described, including mechanical disruption of mucosa, the spread of intraparietal gas to operate via lymphatic drainage, pulmonary pathogenesis and bowel necrosis, or finally idiopathic. Although it is a benign condition there arepotentially associated complications requiring both adequate diagnosis and management. Conclusion:-To the best of our knowledge, we report the third case in literature of associated cystic intestinal pneumatosis with perforated duodenal ulcer.Intestinal preservation in cystic intestinal pneumatosis seems to be the best suited approach, both in an elective setting and emergency setting. Though more clinical data and extend follow-ups on this matter should be held in order to affirm the safety of this approach.

Leadless pacemaker vs conventional single chamber pacemaker for urgent permanent implantation in elderly and very elderly patients

Funding Acknowledgements Type of funding sources: None. Background Data on feasibility of leadless pacemaker (LPM) in the elderly and very elderly is scarce. We aimed to investigate the security and feasibility of urgent LPM implantation in elderly patients. Methods Observational study of a prospective register of consecutive patients that underwent LPM insertion in a single centre. Elderly (≥75 years) and very elderly patients (≥85 years) that underwent LPM implantation in a non-elective setting between June 2016 and January 2020 were eligible. We compared pacing thresholds, R wave and impedance at baseline, short- and long term follow-up. Furthermore, we compared complication rate and all-cause mortality of LPM patients to patients that underwent conventional SCP insertion. Results 78 elderly patients (25 LPM, 53 SCP) with a mean age of 82.4 and 83.8 years, respectively (p = 0.82), were included in the study. The mean follow-up time was 11.2 months. 35 patients (11 LPM, 24 SCP) had an age of ≥ 85 years. There were no significant differences with respect to demographic and baseline clinical data between LPM patients and SCP patients. (Table) Furthermore, we did not find significant changes in pacing thresholds, R wave and impedance on short- and long-term follow-up. Complication rates at 12 months of elderly and very elderly LPM patients were similar to those that underwent conventional SCP implantation (0% vs 5.7%, p = 0.35; 0% vs 4.2%, p = 0.41, respectively). Likewise, we did not find significant differences regarding all-cause mortality (12% vs 13%, p = 0.92; 9% vs 25%, p = 0.18). Comparing Kaplan-Meier curves, no significant differences were found regarding 12 month complication rate and all-cause mortality between LPM patients and conventional SCP patients, as assessed by Log Rank test (p = 0.98 and p = 0.91, respectively). (Figure) Conclusion LPM implantation is a feasible and secure alternative to conventional SCP insertion in elderly and very elderly patients, even in a non-elective setting. Basline characteristicsBaseline characteristicsConventional SCP, n = 53Leadless pacemaker, n = 25p-valueAge - years83.8 (±6.4)82.4 (±6.4)N/SSex, male - n (%)28 (52)16 (64)N/SChronic kidney disease - n (%)16 (30)6 (24)N/SAtrial fibrillation - n (%)45 (85)19 (76)N/SCharlson index, (IQR)4 (3-7)5 (4-7)N/SR wave amplitude, mV (IQR)10.5 (7.4-13.3)12.2 (9.3-15.2)N/SPacing threshold, mV (IQR)0.6 (0.5-0.9)0.4 (0.3-0.7)N/SImpedance, Ohm (IQR)669 (±185)713 (±191)N/SIQR, interquartile range; N/S: Not significant; SCP: Single chamber pacemaker​Abstract Figure. Kaplan Meier curves, Mortality

Observational Study of Demographic Factors among Patients Posted for Major Neurosurgical Procedures in an Elective Setting at a Tertiary Care Centre

BACKGROUND Major neurosurgical procedures are to be well planned prior to surgery. For Preventing the mortality a morbidity, preparedness preoperatively is essential for smooth conduct of the prolonged neurosurgical procedures. Both anaesthesia and surgery may carry inadvertent risks to patients. Study of the demographic factors like age, sex, associated disease (in the form of ASA-PS stratification) and type of surgery are useful in this direction. METHODS It is a small group cross sectional study. Major neurosurgical elective procedures are very limited even in tertiary medical centres. Demographic factors are elicited preoperatively in the patients. Since these patients were posted electively for major neurosurgeries, their mentation is usually stable, with good Glascow coma scale scores. RESULTS 36 % of patients were males and 64 % patients were females, 56 % paients belonged to ASA PS I with no systemic illness. Majority of patients belonged to the age group 41-50 years. CONCLUSIONS The mean height of the patients was 164.2 cm with a standard deviation of 7. Mean weight of the patients was 63.2 Kg + 7.1. KEYWORDS CP Angle – Cerebello Pontine Angle, CVP – Central Venous Pressure, NIBP- Non Invasive Blood Pressure, BIS – Bispectral Index, ECG – Electrocardiogram, TBI – Traumatic Brain Injury