Superior Mesenteric Artery Syndrome: A Single-institution Experience

Background: Superior mesenteric artery syndrome (SMAS) is a rare disease in adult. SMAS is characterized by acute, or, more commonly, chronic nonspecific symptoms due to duodenal obstruction and severe malnutrition with reduced arterio-mesenteric angle and distance. Surgical treatment may be necessary in most cases with chronic symptoms or when conservative treatment fails in SMAS. Methods: A retrospective chart review was performed on patients who underwent operation for SMAS from January 2008 to August 2020 in Cardinal Tien Hospital. Patients’ clinical presentations, surgical intervention, and outcomes. Results: Data from a total of 14 patients diagnosed with SMAS were analyzed, of which seven were diagnosed with SMAS by abdominal computed tomography and upper gastrointestinal series with water-soluble barium contrast. Six of the confirmed cases underwent surgery, namely, gastric decompression using a nasogastric tube, and correction of electrolyte imbalance. The nasoduodenal tube was placed through the obstructed duodenum to provide a high-nutrient fluid supplement. After conservative treatment failure, the patients underwent surgery. Of the six patients, four underwent duodenojejunostomy, one underwent a mini-laparotomy duodenojejunostomy bypass, and the last one underwent Roux-en-Y duodenojejunal bypass with duodenal feeding tube insertion. Conclusion: Patients with SMAS should initially be treated conservative. Surgical intervention should be considered in patients in whom conservative treatments were not effective. Complete resolution of all symptoms may not always be guaranteed after surgical intervention. Laparoscopy is currently widely used. In well-selected patients, minimally invasive or mini-laparotomy duodenojejunostomy is a safe and effective treatment for SMAS. The main advantages of mini-laparotomy duodenojejunostomy over other surgical approaches include half-length surgical incision and a shorter operative time. Duodenojejunostomy is rapidly becoming the standard procedure of this condition, and it has excellent outcomes comparable with those of open surgery.

Determinants of surgical morbidity in gastric cancer: experience of a single center and literature review

Background This study aimed to evaluate the severity of intraoperative and post operative complications of gastric cancer surgery and to investigate the predictive factors correlated to surgical morbidity. Methods We included 145 patients operated for gastric cancer. We investigated the risk factors associated with complications, length of hospital stay, operative time, and intraoperative blood transfusion (BT). Significant risk factors were analyzed by multiple logistic regression analysis. Results Postoperative complications occurred in 32 patients (22.1 %) and the rate of major complications was 7.6%. The rate of anastomotic fistula was 6.9% and was correlated to diabetes, tumor size, operative time, surgical margin, and extended lymphadenectomy. The mean risk factors for postoperative morbidity were the presence of comorbidities and ASA score (p = 0.021), intraoperative BT (p = 0.045) and prolonged operative time (p = 0.055). Conclusion surgical morbidity of gastric cancer is correlated to the extent of resection as well as the clinical and histological characteristics.

Gastric signet ring cell carcinoma

Zemni I et al. reviewed clinic and pathological characteristics and outcomes of gastric signet ring cell carcinomas (J Gastric Surg 2020; 2(3):71-78) focusing on the major prognostic factors of progression-free survival and overall survival including hypoproteinemia, tumor size, stenosis, advanced stage, and recurrence. The majority of patients were males under 60 years of age. The data were compared with those of non-signet ring cell gastric carcinomas. There was no significant difference in the 5 years overall survival between the compared groups. The increasing incidence of aggressive tumors in an advanced stage with poor outcome is emphasized and additional comments are about gastric signet ring cell tumors that affected a female and an elderly male.

Gastric carcinosarcoma with rhabdomyosarcomatous differentiation: a case report and literature review

Gastric carcinosarcoma with rhabdomyosarcomatous differentiation is a rare tumor. Herein, we report the case of a 34-year-old man with a history of dysphagia, upper abdominal fullness, and poor appetite. Endoscopic findings showed a large friable mass that originated from the gastric cardia and lesser curvature of the high body. Consequently, radical total gastrectomy with Roux-en-Y esophagojejunostomy was performed. Histopathological analysis of the resected specimen revealed that the mass had invaded the serosa without regional lymph node metastasis; moreover, the tumor was positive for desmin and myogenin. Finally, we conclude this report with literature review and discussion.

“Dovetail” gastric resection: a novel model in the treatment of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions of the gastrointestinal tract. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. The stomach is the most frequent site of the disease and many technical solutions have recently been proposed as shown also by the dramatic increase in publications on this field. There are many studies that suggest laparoscopy may be an acceptable surgical treatment option compared to open surgery for gastric GIST. However, open surgery assumes great importance in large tumors located in difficult to access locations. Here, we present a case involving a 60-year-old man who was diagnosed with gastric antrum GIST, according to a preoperative examination and postoperative pathology. Then, the patient successfully underwent an atypical gastric resection. We proposed a novel surgical technique to be considered in case of gastric benign disease or GIST localized at the gastric antrum.

The effect of ERAS management in gastric cancer: assessment from the IMIGASTRIC study

Background: Establish protocols to enhance the surgical management (ERAS) can improve outcomes, shortening hospital stay and save resources. Several studies have carried out for colorectal surgery, while a lack of evidence for gastrectomy remains.This study aims to evaluate the impact of ERAS strategies in a large series of patients underwent gastric cancer surgery. Methods: This is a propensity score-matched case-control study, comparing an ERAS group with a control group. Data were recorded through a tailored and protected web-based system. Primary outcomes: hospital stay, complications rate. Among the secondary outcomes, there are: POD of mobilization, POD of starting liquid diet and soft solid diet. Results: Patients in the ERAS and control groups were 1:1 matched by the closest propensity score on the logit scale and with a Caliber = 0.2. The successful matching resulted in a total sample of 440 patients. The two groups showed no differences in all baseline patients characteristics, type of surgery (P=0.31) and stage of the disease (P=0.61). A benefit in favor of the ERAS management was found in the length of hospital stay (P=0.0004) and complications rate (P=0.001). Conclusion: An ERAS program can safely be established in referral centers for gastric cancer, enabling to significantly improve the main clinical outcomes.

Laparoscopic adjustable gastric banding’s multiple complications: when complications arise even after 30 years, a case report.

Laparoscopic adjustable gastric banding (LAGB) is a popular bariatric surgical procedure. The introduction of laparoscopy has increased the use of this procedure, making it the most commonly performed bariatric surgery. Patients undergoing LAGB have achieved satisfactory results in terms of weight loss, a reduction in co-morbidities, and improved quality of life. Nonetheless, complications with LAGB are well documented and include migration, erosion, prolapse, infection, pouch dilation, gastric perforation, and most commonly, lack of weight loss following the failure of the procedure. This case report presents a patient with slippage and pouch dilation, erosion of the stomach, and port site problems, including infection, occurring 28 years after LAGB.

A Case of Gastroesophageal Cancer after Laparoscopic Sleeve Gastrectomy

Gastric cancer has been reported in relatively few cases after sleeve gastrectomy, which has become a common bariatric procedure. In this paper, we present a 58-year-old woman diagnosed with gastric cancer by esophagogastroduodenoscopy (EGD) 4 years after sleeve gastrectomy. For that, she underwent distal esophagectomy and total gastrectomy with Roux-en-Y esophagojejunostomy. Preoperative endoscopy is recommended before planning surgery in patients with gastroesophageal reflux symptoms. In addition, annual EGD should be considered after sleeve gastrectomy in patients with risk factors for gastric cancer.

Emergent management of complicated paraesophageal hernia due to distal gastrointestinal obstruction: three-case series

Background: The aim of this study is to describe the diagnostic evaluation and treatment in patients with complicated paraesophageal hernia (PEH) and distal gastrointestinal (GI) obstruction. Methods: Three cases with known PEH in the Department of Surgery of the General Hospital of Nea Ionia ‘’Constantopoulion-Patission’’, I woman 78 yrs, II man 88 and III man 78, underwent emergent open surgery for complicated PEH and GI obstruction. Cardiorespiratory distress in all and sepsis in I, were encountered. Case I had coexistent incarcerated abdominal hernia, II had a prepyloric lesion revealed by gastroscopy and III chronic constipation. X-rays and CT scan helped diagnosis. Operative findings: In case I, we found viable incarcerated bowel, gastric fundus and body strangulated in mediastinum, fundus ruptured, and antrum ischemic; total gastrectomy with esophageal and duodenal stapling were performed. In case II, the stomach with an obstructive prepyloric lesion was volvulized in mediastinum; distal gastrectomy, gastrojejunostomy, cruroraphy and fundopexy were performed. In case III, strangulation of the dolichosigmoid was the prominent feature, moreover, incarceration of gastric fundus and transverse colon in PEH sac were also found; reduction of PEH contents, limited resection of thick congenital bands, extended left colectomy, cruroraphy, fundopexy and caecopexy were performed. Results: Case I and II were transferred intubated to ICU. Case I was never stabilized, died after 50 hours; histology confirmed gastric necrosis. Case II was extubated on day 4, discharged on day 28; histology revealed antral ischemia and prepyloric pT2 adenocarcinoma. Case III had uneventful outcome; histology revealed dolichosigmoid ischemia. Follow-up of cases II and III (32 and 30 months respectively) has been uneventful. Conclusion: Obstructive conditions distal to large PEHs may lead to acute complications in hernia contents and emergent surgery is challenging. Obstructive conditions distal to large PEHs may lead to acute complications in hernia contents and emergent surgery is challenging.

Perforated diverticulitis in a patient with very proximal jejunal diverticula

Background: We report a case of an elderly with peritonitis due to perforated jejunal diverticulitis, and we highlight the diagnostic evaluation and treatment alternatives. Case presentation: A 92-year-old woman was transferred to the Emergency Dept. with abdominal pain and vomiting for the past 12 hours. Physical examination revealed diffuse pain, abdominal distension, rebound tenderness and bowel silence. She was febrile, tachycardic, tachypneic, hypotensive and anuric. Blood gas estimation showed metabolic acidosis. She fulfilled the criteria of septic shock. At presentation, she was mildly malnourished. From her medical history, she had cardiac arrythmias, hypertension and diabetes mellitus under proper medication, and laparoscopic cholecystectomy. Laboratory investigations revealed Hct 44.6%, WBC 12.500/dL, glucose 300 mg/dL, creatinine 2.8 mg/dL, CRP 405 mg/L, and electrolyte deficit. Abdominal X-ray showed gastric, small intestinal and colonic gas, with no pneumoperitoneum or air-fluid levels. Chest/abdomen CT showed thickening of proximal jejunal loop and adjacent mesentery, and an extraluminal air bubble, suggesting possible perforation. The patient was given intense resuscitation and broad-spectrum antibiotics and underwent emergency laparotomy. Results: Four jejunal diverticula, sized 1-3 cm, were confined to a segment 12 cm long, located 6 cm from the Treitz ligament; the proximal diverticula was inflamed and perforated. The adjacent mesentery was inflamed and thickened; the bowel lumen remained open. We performed one-layer full-thickness suturing of the perforated diverticulum and omental patch closure. The patient was transferred intubated to ICU. E. Coli was isolated from peritoneal fluid cultures and antibiotic therapy was adjusted to antibiogram. The patient had a first bowel movement at day 5 and was extubated at day 21. She needed mild cardiopulmonary support and was discharged at day 30. Conclusions: Jejunal diverticulitis is a challenging disorder since its rarity makes diagnosis difficult and, thus delayed. The perforation of jejunal diverticulitis requires emergent surgery and poses technical dilemmas.