Heineke-Mikulicz Pyloroplasty Research Articles

Recurrent Retroperitoneal and Subhepatic EGIST – Case Report

Background GISTs (gastrointestinal stromal tumors) are a common mesenchymal tumor of the gastrointestinal tract. It is a diverse pathology that can occur in any portion of the gastrointestinal tract, from distal esophagus to anus. However, the stomach is the most common origin. GISTs evolve from small neoformations, to a large, metastasizing sarcoma. Their pathogenesis is linked with the KIT or PDGFRA mutations. GIST is to be suspected in cases where a round mass is encountered in close relations to the stomach, intestine or lower esophagus. It has to be differentiated with other neuroendocrine tumors, lymphomas and other rare cancers by means of a biopsy. Case presentation The 62 y/o male patient was diagnosed 4 years prior to the current events with GIST for which a surgical procedure of distal pancreatectomy, splenectomy and partial resection of curvatura major of the stomach was performed at another hospital. This was followed by chemotherapy as advised by the treating doctors. The patient presents to our clinic with the complaints of left flank pain for over a week, dysphagia and weight loss. CT shows a giant formation of the left flank, at the splenic lodge, with dimensions of 30 × 32 cm, with close proximity to the left kidney, abdominal aorta, the lienal flexure of colon, the stomach, superior mesenteric artery. Besides this, another 8 × 9 cm subhepatic formation is noted, which has a close vicinity to the portal vein and hepatic hilum. He underwent the surgical procedure for the extirpation of the both masses, also partial resection of curvatura major, vagotomy, Heineke-Mikulicz pyloroplasty, segmental hepatic flexure colon resection and end-to-end anastomosis. The procedure was tolerated well and he was discharged in good health. The following pathology report confirms GIST. Discussion Treatment of GISTs and EGISTs consists on the R0 resection of the mass, without the need for radical removal of healthy tissue since these types of tumors do not normally infiltrate adjacent tissue. If other organs are invaded it is recommended to perform an en-bloc resection, taking care to avoid the rupture of the mass, as to minimize the chances of peritoneal dissemination. A prompt adjuvant therapy including the use of selective tyrosine kinase inhibitors (imatinib) is strongly advised. The patient should be followed with periodic controls for recurrence. Conclusion There is a clear role surgery can play in improving the outcomes in such patients. However, some authors still debate whether surgery improves results in such patients. For this purpose, it is necessary to involve a team of oncologists, imaging specialists and experienced surgeons in the treatment plan of GIST patients to provide the best treatment. Keywords: General Surgery, Retroperitoneal EGIST, Hepatic EGIST, GIST. DOI: 10.7176/JEP/14-9-06 Publication date: March 31 st 2023

Accidental acid ingestion in children: case series and literature review

Acid ingestion in children is a common problem in developing countries. Immediate complications of acid ingestion are oesophageal perforation, laryngeal trauma, bleeding and fistula formation but stricture is a delayed complication. Gastric outlet obstruction is known complication of acids and surgery is the mainstay of treatment. Heineke-Mikulicz pyloroplasty was done in five cases without complications and the outcomes were satisfactory.

223. INTRAOPERATIVE PYLOROPLASTY DURING OESOPHAGECTOMY: A 12 YEAR TERTIARY CENTRE EXPERIENCE

Abstract Delayed gastric emptying (DGE) is a known complication following oesophagectomy with gastric conduit reconstruction. Pyloroplasty is often performed to mitigate the consequences of DGE. It remains contentious whether performing a pyloroplasty has a significant role in reducing DGE. We discuss our twelve-year experience at a single centre routinely performing Heineke-Mikulicz pyloroplasty for all oesophagectomies. This retrospective study employed an electronic database containing information on all patients who underwent elective Ivor Lewis oesophagectomies from April 2009 to December 2021 in a tertiary upper gastrointestinal cancer centre. Across six surgeons in the centre, a standardised pyloroplasty technique was performed. DGE was defined as patients who had high nasogastric output (> 1.5 litres per day) after ten post-operative days or required endoscopic pyloric balloon dilatation within one year following oesophagectomy. 578 patients underwent Ivor Lewis oesophagectomy during the study period. The mean age was sixty years and the male to female ratio was 1.8:1. The median length of stay was 13 days (3–148). DGE was seen in 9.9% (n = 57) patients. Of these patients, 39.7% (n = 29) cases required oesophageal dilatation within 12 months after their oesophagectomy. 50.8% (n = 21) required in-patient endoscopic dilatation, 14.0% (n = 8) required out-patient endoscopic dilatation. From those who developed DGE, the 30- and 90-day mortality was nil. There were 1.2% (n = 7) leaks specifically from the pyloroplasty which were all managed conservatively. The rate of delayed gastric emptying is reported to be approximately 15% (Zhang & Zhang, 2018). Our study demonstrates that performing a pyloroplasty reduces this risk to 9.9% and is worthwhile as the complication rate from pyloroplasty is low. Although there are various methods employed in overcoming pyloric sphincter denervation following oesophagectomy (pyloroplasty, pyloromyotomy, digital or instrumental pyloric stretching or intra-operative balloon dilatation), the most effective method of reducing DGE warrants a randomised control trial.

Uncommon Cause of Chronic Vomiting in Children

Gastric outlet obstruction (GOO) is unusual and must be suspected in children with chronic vomiting and abnormal weight status. The treatment depends on etiology, and surgery is not always the first remedy. Diagnosis is easily confirmed by upper gastrointestinal fibroscopy.We report the case of an 11-year-old girl, who was presented with non-bilious emesis and weight loss. Abdominal computed tomography, ultrasound, and upper gastrointestinal fibroscopy showed dilated stomach with pyloric stenosis, which was confirmed by abdominal laparoscopic exploration and cured by Heineke-Mikulicz pyloroplasty. We also compare our study to previously reported cases.

Is the Use of Transanastomotic Tube Beneficial in Pyloric Atresia?

Introduction: Congenital pyloric atresia (CPA) is a rare gastrointestinal system anomaly characterized by gastric outlet obstruction. This study evaluated patients operated for CPA in the past 15 years. The impact of use or non-use of transanastomotic feeding tubes (TATs) on the follow-up results was examined. Material and Method: Patients operated for CPA between 2005 and 2020 were evaluated. Further, cases in whom TATs were used and cases in whom TATs were not used were evaluated in two sub-groups. The impact of presence orabsence of TATs on postoperative follow-up results was examined. Results: In this study, a total of 12 patients consisting of 7 boys and 5 girls were evaluated. The mean birth week was 35.1 ± 2.4 (31-38) weeks and the mean birth weight was 2602.9 ± 599.6 (1680-3620) grams. The mean time of operation was postnatal 3.8 (1-10) days. Among the cases, 8 (66.7%) had type 1 atresia, and 4 (33.3%) had type 2 atresia. Heineke-Mikulicz pyloroplasty was performed on 9 (75%) cases, and gastroduodenostomy was performed on 3 (25%) cases. 4 (33.2%) patients had various additional anomalies. The patient with EB (8.3%) died due to sepsis in the early postoperative phase. In 8 cases (66.7%), intraoperative TAT placement was performed. In cases with TATs, the time to postoperative feeding and length of stay were statistically determined to be lower. Discussion: Pyloric atresia is a rare intestinal system obstruction. Comorbidity with congenital anomalies increases mortality. Intraoperative TAT insertion enables early enteral feeding. Keywors: Congenital pyloric atresia, gastrointestinal system, transanastomotic feeding tubes

Comparative Study of Pyloromyotomy and H-M Pyloroplasty in Proximal Gastrectomy for Adenocarcinoma of Esophageal-Gastric Junction

IntroductionThe incidence of adenocarcinoma of esophageal-gastric junction (AEJ) has been increasing in recent years. Esophagogastrostomy after proximal gastrectomy (PG-EG) is the most commonly used surgical method for this disease which causes a constant spasm of the pyloric sphincter by cutting the vagus nerve around the esophagus, so H-M pyloroplasty (Heineke-Mikulicz pyloroplasty) is often operated after PG-EG to prevent delayed gastric emptying. However, H-M pyloroplasty destroys anti-reflux structure of pylorus and leads to serious bile reflux. The present study was designed to compare pyloromyotomy and H-M pyloroplasty in proximal subtotal gastrectomy through clinical studies and animal experiments. MethodsWe retrospectively evaluated the outcomes of 73 AEJ patients (39 underwent PG-EG with an H-M pyloroplasty and 34 underwent PG-EG with a pyloromyotomy) between January 2016 and August 2020, and perioperative variables were compared. In the animal experiment, 48 rats were randomly divided into four groups (n = 12): vagotomy group (V group), H-M pyloroplasty group (HM group), pyloromyotomy group (PM group), and control group (O group). Gastric emptying and bile reflux were evaluated in each group. ResultsIn the retrospective clinic study, pyloromyotomy and H-M pyloroplasty could all prevent delayed gastric emptying effectively, and the incidence of bile reflux found by electronic gastroscopy in the PM group was significantly lower than that in the HM group (HM, 14/39; PM, 4/34; P = 0.028). In the animal experiment, there was no significant between-group difference of gastric emptying rate (%) in the HM group and PM group (HM, 70.6 ± 16; PM, 72.3 ± 12; P = 0.68) while the gastric emptying rate (%) was significantly lower in the V group than in the HM, PM, and control group (P values were 0.037, 0.021, and 0.001 respectively). The gastric mucosa bile acid concentration was significantly higher in the HM group than other group (P values were all less than 0.001). ConclusionsThe pyloromyotomy could prevent delayed gastric emptying effectively after PG-EG for types II and III AEJ and reduce bile reflux compared to Heineke-Mikulicz pyloroplasty.

Primary Acquired Cicatrizing Gastric Outlet Obstruction in Children.

Background:Gastric outlet obstruction (GOO) is a very rare condition in children, when infantile hypertrophic pyloric stenosis is excluded as a cause. Five cases of pediatric GOO were successfully managed at our institute.Materials and Methods:We retrospectively evaluated children with idiopathic GOO from 2009 to 2016. Medical records were reviewed for demographic data including age, sex, presenting symptoms, diagnostic investigations, treatment methods, complications, and long-term follow-up.Results:During 7 year period (2009–2016), 5 cases of GOO admitted to our hospital with a history of persistent vomiting. The vomiting used to occur 12–18 h after meal and vomitus contained foul-smelling undigested meal. There was no history of any caustic ingestion. Their age ranged from 2 to 10 years, with a median age of 6 years. Out of 5 cases, 2 were females and the rest were males. The diagnosis of idiopathic GOO was confirmed by history, clinical examination, contrast study, endoscopy, and endoscopic mucosal biopsy. The remarkable finding was the cicatrization causing stricture of the pyloric region in all cases. Out of 5 cases; we have done Heineke-Mikulicz pyloroplasty in 1 case, V-Y advancement antropyloroplasty in 2 cases and Kimura's Diamond-shaped Gastroduodenostomy in 2 cases. The length of the strictured segment determined the type of surgical procedure. All cases did well postoperatively with no mortality.Conclusions:Length of the stricture determines the procedure to be done. In long and narrow stricture V-Y advancement antropyloroplasty and in small stricture Kimura's diamond-shaped Gastroduodenostomy are better procedures to be done. Heineke-Mikulicz pyloroplasty should be avoided as it is difficult to suture transversely after vertical incision because of the presence of fibrosis in the strictured segment.

Cholecystoenteric Stent-related Complications: Rendering the Inoperable Patient Operable

Introduction: Cholecystoenteric stenting is as an alternative treatment for cholecystitis. However, complications with this approach can render a need for surgical intervention. Methods: A case series of three patients undergoing surgery for a cholecystoenteric stent-related complication. Results: Patient 1 was a 42-year-old male with history of lung transplant who had a cholecystoenteric stent placed for acalculous cholecystitis. One year later the stent became occluded with return of symptoms. Endoscopic replacement failed. A laparoscopic cholecystectomy with modified Graham patch was performed. Patient 2 is a 73-year-old female with acalculous cholecystitis in the setting of metastatic colon cancer on FOLFOX. Antibiotic treatment failed. A cholecystoenteric stent was attempted, but the stent was dislodged during deployment. The fistula tract was clipped, and a percutaneous cholecystostomy drain was placed, which noted a leak at the gallbladder infundibulum. The patient deteriorated clinically and was taken emergently for an open cholecystectomy. Patient 3 was a 71-year-old male with history of ischemic cardiomyopathy who had a cholecystogastric stent placed for necrotizing gallstone pancreatitis. The stent migrated into the gastrointestinal tract and he developed post-prandial pain. A cholecystectomy and modified Graham patch repair of the gastrotomy was performed. This failed as the gastrotomy was too close to the pylorus. He underwent re-operation with Heineke-Mikulicz pyloroplasty. All patients recovered without any cardiopulmonary complications. Conclusion: With the increasing utility of cholecystoenteric stents, surgeons should be aware of the complications and have a plan for managing the duodenotomy or gastrotomy. Shared-medical decision-making involving surgeons should be applied when placing these stents.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

Diagnosis and Management of Benign Gastric and Duodenal Disease

The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy. This review contains 15 figures, 2 tables, and 43 references.

Duration, Stress, and Pain Evaluation of Laparoscopic versus Conventional Heineke-Mikulicz Pyloroplasty

Pyloric stenosis is an uncommon but important gastric outflow disease. Heineke-Mikulicz (H-M) pyloroplasty is one of the pyloroplasty techniques used for the treatment of such diseases. A laparoscopic pyloroplasty is an effective and preferred alternative technique to conventional surgeries. This study aims to compare the duration of surgery, surgical stress level measurement, and postoperative pain in laparoscopic H-M pyloroplasty in normal dogs with a conventional pyloroplasty technique. Eight intact adult mixed breed dogs (5 females and 3 males) were used in this study. Animals were randomly divided into two groups of conventional open (n = 4) and laparoscopic (n = 4) H-M pyloroplasty. Blood glucose concentration, plasma cortisol level, as well as pyloric features including a pyloric lumen, pyloric diameter, pyloric width with ultrasonography, and gastric emptying time with contrast radiography and the University of Melbourne Pain Scale (UMPS) value, were measured in both groups. The mean operation time in the laparoscopic group was longer than that of the conventional group (55.00 ± 15.00 vs. 35.00 ± 4.56 min); however, this difference was not statistically significant. Blood glucose concentration in the laparoscopic group elevated rapidly until 3 hours after the operation and then decreased in 24 hours while blood glucose concentration in the conventional group slowly increased until 24 hours. The UMPS value at 3 hours after conventional H-M pyloroplasty was higher than that of laparoscopic H-M pyloroplasty (19.25 ± 0.75 vs. 6.50 ± 0.96, p < 0.001). Gastric emptying time significantly decreased in both groups. According to the results, in addition to reducing pain and stress, laparoscopic H-M pyloroplasty decreased gastric emptying time in all patients with no morbidity and appears to be a less invasive alternative technique for the management of gastric outflow disease.

Laparoscopic treatment of pyloric atresia in a newborn

Introduction. Pyloric atresia is one of the rarest surgical diseases in newborns. Laparotomy is the most common modality for correcting this abnormality. In modern scientific literature, there is only one report on the endosurgical treatment of pyloric atresia. The case of laparoscopic correction of gastric outlet atresia presented in this study is one more reference to the successful care of this condition.Material and methods. The presented clinical case is a newborn boy in whom a prenatal ultrasound examination at the 31st week of gestation revealed polyhydramnios and an enlarged stomach. The baby’s birth weight was 2660 grams. In the first hours of life, the child showed symptoms of high intestinal obstruction in the form of gastric content vomiting. Postnatal ultrasound and X-ray examination confirmed the diagnosis of pyloric atresia. During laparoscopy, performed on the 2nd day of life, the morphological type of anomaly was examined, and the type I atresia of membranous form was established. A laparoscopic membranectomy with Heineke–Mikulicz pyloroplasty was performed. In the final part of this research, early and late outcomes of the performed surgical treatment were analyzed.Results. The surgery lasted for 70 min. Postoperative period was uneventful. Enteral nutrition started on day 3 after the surgery. A complete enteral diet was possible on day 7. The newborn patient was discharged from the hospital on the 9th postoperative day. Histological examination confirmed the pyloric atresia of membranous type. During 12-month follow-up, no complications associated with the surgical procedure were seen.Conclusion. The described case of laparoscopic treatment of type I pyloric atresia in a newborn expands laparoscopy application in pediatric practice.

Diagnosis and surgical correction of pyloric stenosis in a dog – a case study

Pyloric stenosis, which could occur as a congenital or acquired condition, is more common in dogs when compared with other domestic animals. This condition has not been reported in Sri Lanka probably due to unfamiliarity with it and lack of diagnostic facilities. This communication discusses the clinical signs, radiographic and ultrasonographic findings, and treatment of pyloric stenosis in a one-year old female Cocker Spaniel presented to the Veterinary Teaching Hospital (VTH), Peradeniya. The patient developed projectile vomiting and distended, gas filled abdomen after meals as clinical signs. Survey radiographic findings included the 'gravel sign' in the stomach. In ultrasonography, thickened pylorus was observed. Contrast radiographs after oral administration of barium sulphate suspension showed a delay of gastric emptying. All the above findings suggested that the patient had pyloric stenosis. Complete blood count and serum biochemistry demonstrated no abnormalities. Surgical intervention was performed as treatment, using Fredet-Ramstedt pyloromyotomy together with Heineke-Mikulicz pyloroplasty to clear the obstruction in the pyloric canal. Since there were no post-surgical complications, patient was discharged in 4 days following the surgery. The prognosis was satisfactory and the animal has been healthy after the surgery. The pyloric stenosis observed in this case could be congenital, with hypertrophy and subsequent stenosis gradually worsening over time.

Jodhpur disease complicated by postoperative intussusception in St. Mary's Hospital Lacor

Abstract Jodhpur disease, now known as primary acquired gastric outlet obstruction (GOO) during infancy and childhood is a rare entity with less than 100 cases. Heineke mikulicz pyloroplasty (HMP) is the mainstay of treatment while other methods of treatment such as gastrojejunostomy and pneumatic balloon dilatation of pylorus have also been effective in some patients. No study has been done to compare the efficacy of these interventions in the management of Jodhpur disease and therefore the choice of operation has been surgeon dependent. Herein, we described a 2 years and 11 months old female child managed for Jodhpur disease with retro colic gastrojejunostomy after a failed HMP complicated by postoperative intussusception who recovered uneventfully with a 1500 g weight gain one month later. Conclusion A clear grading system for antropyloric stricture severity in Jodhpur disease is lacking making gastrojejunostomy a more effective surgical approach that can alleviate complications of repeated surgery.

Epidemiology and treatment of perforated duodenal ulcer in Kemerovo Region

Aim.To estimate the frequency of ulcerative bleeding, pyloric stenosis, need for pyloroplasty and the justification of vagotomy for perforated duodenal ulcer.Materials and Methods.We analyzed the surgical treatment of patients with perforated duodenal ulcer admitted to Podgorbunskiy Regional Clinical Emergency Hospital during 1999-2019.Results.In 2018, the number of surgical interventions due to perforated duodenal ulcer decreased by 56.4% in comparison with 1998. In 8.6% and 2.1% of patients, perforated duodenal ulcer was combined with pyloric stenosis and bleeding, respectively, requiring Judd pyloroplasty (diamond- shaped transverse excision) or gastroduodenotomy followed by Heineke-Mikulicz pyloroplasty (transversely closed longitudinal incision across the pylorus) and vagotomy. Distal gastric resection by Billroth’s operation II was required in 2.8% of patients. Repeated admission of patients with duodenal ulcer complications has been observed after isolated suturing of perforated duodenal ulcer.Conclusion.Over the last 20 years, the amount of surgical interventions because of perforated duodenal ulcer in Kemerovo Region decreased more than twofold. In &gt; 10% patients, pyloric stenosis and bleeding require a gastric drainage. In &gt; 8% patients, perforated duodenal ulcer is combined with pyloric stenosis; in these cases, Heineke-Mikulicz pyloroplasty may be a treatment of choice. In &gt; 2% patients, perforated duodenal ulcer is combined with ulcerative bleeding requiring excision of the ulcer and optional distal gastric resection. Pyloroplasty may be combined with vagotomy to normalise the proteolytic activity of gastric acid.

Need for pyloroplasty and vagotomy in case of perforated duodenal ulcer

Aim. Estimation of the incidence of stenosis, need for pyloroplasty and validity of vagotomy for perforated duodenal ulcer (PDU).&#x0D; Materials and methods. Twenty-year nature of surgical treatment of patients with PDC in the hospital surgery clinic is analyzed.&#x0D; Results. Over 20 years, 726 patients were operated on: 151 women (20.8%), 575 men (79.2%), mean age 39.1±6.3 years. Surgeries were performed both from laparotomic access and video laparoscopically. It is found that PDU is combined with stenosis in 8.5% and with bleeding in 1.6%, which requires Jadd excision of an ulcer on the anterior wall or gastroduodenotomy for flashing a bleeding ulcer on the posterior wall (0.7%) with subsequent Heineke — Mikulicz pyloroplasty and vagotomy. Both stem vagotomy and selective proximal were used by the method of skeletonization of lesser curvature or chemoneurolysis. Suturing with selective proximal vagotomy was performed in 567 patients, isolated suturing — in 77. B-II distal gastric resection was required in 2.1%. Repeated admission of patients with complications of a duodenal ulcer is observed after isolated suturing of PDU without surgical intervention in the mechanisms of ulcer formation.&#x0D; Conclusion. During surgical treatment of PDU are found in 79.2% of men, in 20.8% of women. There is an emerging stenosis in 8.5% of those who have PDU, which requires a gastric drainage operation. The subjects of choice may be Heineke-Mikulicz pyloroplasty or Jadd excision of an ulcer on the anterior wall. It is advisable to suture or excise an ulcer with pyloroplasty accompanied by vagotomy that normalizes the acid-proteolytic activity of gastric juice in the postoperative period and eliminates need for antisecretory drugs to prevent the recurrence of the disease.

Diagnosis and treatment of gastric antral webs in pediatric patients.

Gastric antral webs are mucosal structures, varying from fenestrated diaphragms to mucosal crescents, resulting in varying degrees of foregut obstruction. Patients commonly present with vomiting, failure to thrive, and abdominal pain. Prevalence is unknown, and diagnosis can be difficult. We performed an IRB-approved retrospective review of patients from 4/1/2015-4/1/2018at a Level I Children's Surgery Center undergoing gastric antral web resection. Data obtained included demographics, preoperative workup, surgical repair, and outcomes. Twenty-one patients were identified; 67% were male with an average age of 30months at diagnosis. Initial diagnosis was established by a combination of fluoroscopy and esophagogastroduodenoscopy (EGD) in all patients. Patients presented with emesis (76%), failure to thrive (57%), need for post-pyloric tube feeds (33%), and abdominal pain (14%). Web localization without intraoperative EGD (n = 3) was initially challenging. As a result, intraoperative EGD was combined with operative antral web resection to facilitate web localization (n = 18). Web marking techniques have evolved from marking with suture (n = 1) and tattoo (n = 2), to endoscopic clip application (n = 12). All 21 patients underwent web resection, 2 were performed laparoscopically. Twenty underwent Heineke-Mikulicz pyloroplasty during the initial surgery. Average length of stay was 5.5days. There were no intraoperative complications or deaths. Permanent symptom resolution occurred in 90% of patients immediately, with a statistically significant decrease in emesis (p < 0.001), failure to thrive (p < 0.001), and need for post-pyloric tube feeding (p = 0.009) within 6months of surgery. Gastric antral webs should be considered in the differential diagnosis for a child with persistent vomiting. Web resection with the use of intraoperative endoscopic localization can result in permanent symptom resolution in the majority of these patients.

AB009. 93. Minimally invasive oesophagectomy

: Ivor-Lewis oesophagectomy is the standard treatment for resectable oesophageal carcinoma, although it is associated with significant postoperative morbidity and mortality. Minimally invasive oesophagectomy (MIO) is increasingly adopted as the preferred surgical approach in order to decrease perioperative morbidity and facilitate earlier functional recovery. (I) stage I: with the surgeon on the right and the assistant on the left a 5-port technique is used to perform a laparoscopic gastric mobilisation with an en bloc lymphadenectomy of the common hepatic, left gastric and splenic artery lymph node stations. The stomach is fully mobilized with preservation of the right gastroepiploic arcade. After full mobilisation of the stomach a 3.5–4 cm gastric conduit is fashioned by sequential firing of an EndoGIA 4.8-mm stapler. The gastric conduit is then sutured to the transected stomach for retrieval later in the chest. A Heineke-Mikulicz pyloroplasty is fashioned in selected cases. Using a seldinger technique a 9-Fr feeding jejunostomy is inserted into the jejunum and secured to the anterior abdominal wall with a purse-string suture. (II) Stage II: a 5-post thoracoscopy is performed in the left lateral decubitus position. The oesophagus is fully mobilized to the thoracic inlet and an en bloc lymphadenectomy is performed of the paraesophageal, subcarinal, right and left bronchial and lower paratracheal lymph node stations. The 9th intercostal port site is converted to a 3–4 cm mini-thoracotomy. A 28 mm circular anvil is placed in the proximal oesophagus and secured with a purse-string suture. A gastrotomy is made in the tip of the gastric conduit through which an EEA circular stapler is inserted. An esophagogastric end-to-side anastomosis is fashioned and the redundant fundal tissue excised with a linear stapler. A 16 French chest tube is placed prior to closure of the wounds. MIO has been successfully implemented in the Mercy University Hospital with a median length of stay of 8 days and an in-hospital mortality of 3.5%.

Brunner’s gland hyperplasia: a rare case report

A rare case of Brunner’s gland hyperplasia mimicking duodenal malignancy is reported. A 21-year old man had a lesion in the second portion of the duodenum on endoscopy. The biopsy specimen suggested moderate and chronically active duodenitis. However, since the CT features strongly suggested malignancy, pyloroduodenotomy, excision of the lesion and Heineke-Mikulicz pyloroplasty was performed. The final pathological diagnosis was Brunner’s gland hyperplasia.

Gastric outlet obstruction in a 12 year old male

Abstract Pyloric stenosis presenting beyond infancy is uncommon and poorly understood. Here, we present a case of primary acquired gastric outlet obstruction due to pyloric stenosis in a 12-year-old male child. The patient presented after a four-year history of persistent non-bilious, post-prandial emesis and failure to thrive. A Heineke-Mikulicz pyloroplasty was performed. Pyloric biopsy was without diagnostic abnormality. A gastrostomy tube was also placed at the time of pyloroplasty. The patient was asymptomatic after surgery and had gained 25 pounds after three and a half months. The gastrostomy tube was removed 4 months after the pyloroplasty. Literature review yielded 42 cases, including the current report, of patients ages 4 months to 17 years with a diagnosis of primary acquired gastric outlet obstruction. Useful studies for diagnosis of these cases include abdominal ultrasound, upper GI contrast study and esophagogastroduodenoscopy. The most common curative procedure reported in the literature was a pyloroplasty (31 cases). The remaining patients underwent Bilroth I gastrectomy (7 cases), balloon dilatation (3 cases) and pyloromyotomy (1 case).