Jejunal Limb Research Articles

Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing a pancreatic mass; however, EUS-FNA for patients with surgically altered upper gastrointestinal (UGI) anatomy has not yet been investigated sufficiently. Therefore, the feasibility and safety of EUS-FNA in these patients were retrospectively investigated. Patients in whom EUS-FNA was performed between March 2008 and April 2017 were retrospectively investigated in terms of EUS-FNA technical success, procedure time, diagnostic accuracies of cytology and histology, and procedure-related adverse events. Twenty-five EUS-FNAs were performed for 15 pancreatic body-to-tail and 10 head lesions. All patients underwent EUS-FNA successfully; however, changing of the echoendoscope to a forward-viewing echoendoscope and preplacement of a nasobiliary catheter by balloon-assisted enteroscopy for guidance were needed in one and two cases, respectively. The median procedure time was 26 min (range, 16-70). The diagnostic accuracies were 76%, 84%, and 88% for cytology, histology, and combined use, respectively. Adverse events were not observed. Endoscopic ultrasound-guided FNA is a safe and efficient method for diagnosing a pancreatic mass even in patients with surgically altered UGI anatomy. Nevertheless, some sophisticated techniques are required for pancreatic head lesions if reaching the duodenum after passing through the jejunal limb is required for visualization of the pancreatic mass.

A case of esophagojejunal varices rupture after proximal gastrectomy with double-tract reconstruction

BackgroundThe varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration.Case presentationA 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days.ConclusionPTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.

IR-guided endoscopic pancreaticojejuostomy for post-whipple pancreaticocutaneous fistula

Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 67yF presented with biliary obstruction and computed tomography (CT) suggested a distal bile duct tumor. She underwent an ERCP with brushings for stenting and to but unfortunately developed severe acute pancreatitis (SAP). Although technically resectable after complete staging without evidence of distant disease, she was not felt to be a surgical candidate and was referred for neoadjuvant chemotherapy while. Unfortunately, after one cycle of gemcitabine and cisplatin, her SAP progressed to walled-off necrosis (WOPN) requiring percutaneous and endoscopic drainage. Therefore, after a period of recovery, she was taken to the operating room for an attempt at curative resection. A pylorus-preserving pancreaticoduodenectomy (PD) was performed, however, the pancreas was scarred without a visible duct and adherent to a thrombosed splenic vein with sinistral portal hypertension form WOPN. Decision was made to suture the pancreatic remnant without an anastomosis. The patient did well until POD#4 when a CT performed for abdominal pain revealed a large fluid collection. This was drained percutaneously and was consistent with a pancreatic leak. The patient convalesced from her operation but was left with a pancreaticocutaneous fistula. Methods: Since transgastric internalization was not feasible post-PD, a combined interventional radiology (IR) and gastroenterology (GI) rendezvous approach was utilized. An endoscopic ultrasound (EUS) scope was passed into the afferent limb while a balloon catheter was passed through the drain tract. The balloon was visualized by EUS and punctured in order to grab an IR wire and pass it into the afferent jejunal limb. Two pigtail stents were then deployed in order to create a pancreaticojejunostomy (See Figure). Results: The patient did well post procedure and deemed ready for adjuvant therapy for her T2N1 distal cholangiocarcinoma. Conclusion: This challenging case highlights the multidisciplinary strategy required not only for optimal oncologic treatment of biliary tumors but also to manage the complications of therapy.

2179 Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

INTRODUCTION: The incidence of pancreatic cancer has increased in the last decade. There have been improvements in pancreatic cancer through a multidisciplinary approach including chemotherapy, surgery, and radiation. The Whipple procedure is the mainstay operation for pancreatic head tumors; however, long term complications include cholangitis and pancreatitis. Cholangitis can be managed with drainage or stenting. Although PTC stent allows for drainage of the biliary system, an obstruction may call for internal stent placement. This case highlights placement of a stent using a pre-existing PTC drain for guidance. CASE DESCRIPTION/METHODS: A 71-year-old Caucasian male with history of pancreatic cancer status post a Whipple and chemoradiation presented with obstructive jaundice. EGD demonstrated a malignant stricture of the afferent jejunal limb. Attempted endoscopic stenting was unsuccessful. An 8.5 Fr PTC with internal and external biliary drainage catheter was performed by IR with the internal drainage catheter placed beyond the stricture. The patient over the course of the next month had decreased output from his biliary drain and was re-admitted with increased bilirubin and leukocytosis. The external/internal biliary drain catheter was replaced without significant improvement. A repeat EGD and ERCP demonstrated a PTC drain in the afferent jejunum and using a biliary wire through the side hole of the PTC drain, the PTC drain was removed over the wire. An uncovered metal stent was placed across the afferent jejunal stricture into the normal jejunal limb. Post procedurally the patient had improved LFTs. However, the patient had an interval rise in bilirubin and ALP. EGD demonstrated a clogged stent and a pigtail plastic stent was placed through the preexisting metal stent to prevent recurrent clogging. After the patient had improvement in his LFTs. DISCUSSION: Management of biliary obstructions requires biliary drainage with either a stent or surgical drainage. This case highlights a multi-step approach for management of a malignant biliary obstruction. After identifying an obstruction, an internal metal stent was placed in a rendezvous approach. Endoscopic metallic stent placement is a common for malignant biliary obstructions in jaundiced pancreatic cancer patients. In an event of an occluded metal stent, placement of a plastic stent is effective for management. This patient had a biliary obstruction after metallic stent placement prompting placement of a plastic pigtail stent within the metal stent.

1604 Multidisciplinary Approach for Prolonged Survival of Patients With MMIHS

INTRODUCTION: Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS)/Berdon syndrome is a rare disorder characterized by a distended non-obstructed bladder, microcolon, and decreased intestinal peristalsis with average life expectancy less than 6 months. We present case of a patient with MMIHS. CASE DESCRIPTION/METHODS: A 23-year-old female with MMIHS presented to the emergency department for abdominal pain and inability to tolerate oral or feeds through gastrostomy tube for 3 weeks. She had extensive surgical history since birth with LADD’s procedure due to intestine malrotation, exploratory laparotomy and subtotal colectomy for volvulous, colectomy with end ileostomy, Bilroth I, gastrostomy tube, and multiple nephrostomy tube for recurrent urinary infection. Patient had similar recurrent symptoms thought to be due to small intestinal bacterial overgrown and recurrent urinary tract infection. It appeared with each hospitalization her ability to tolerate oral intake declined to a lower baseline. At home patient was on Cisapride 14ml four times daily. During hospitalization lab work and imaging was non-contributory other than urine culture positive for Klebsiella. A small bowel follow through showed delayed gastric empting. Due to inability to tolerate oral intake or feeds patient was started on total parenteral nutrition (TPN). Esophagogastroduodenoscopy showed esophagitis, moderate chronic active gastritis with widely patent gastrojejunostomy anastomosis and jejunal limb. Her symptoms were likely due to progression of hypomotility syndrome. Cisapride was increased by 14%, under direction of outpatient pediatric gastroenterologist, with good response. However, due to prolonged QTc on electrocardiogram, upon discharge she was changed to Lubipristone. DISCUSSION: Our case demonstrates a complex presentation of a rare but fatal intestinal myopathy with most patients not surviving past infancy with even fewer cases surviving long term. Complications such as perforation, sepsis, malnutrition, multi-organ failure and pseudo-obstruction is not well understood in these patients and needs to be ruled out at each hospitalization. A multidisciplinary approach is needed for long term survival of patients with MMIHS. Main goals of treatment include providing a bladder-emptying strategy and adequate nutrition. In our case study, we demonstrate off label use of Cisapride and Lubiprostone for dysmotility. Close long term follow-up is necessary with multidisciplinary approach for long term survival.

2625 Intussusception After Classic Pancreaticoduodenectomy With a Roux-en-Y Pancreatico-hepaticojejunostomy

INTRODUCTION: Intussusception in adults is uncommon, accounting for 1%–5% of all intussusception cases. It usually occurs because of a lead point, frequently malignancy or adhesions from previous surgery. Here we report an exceedingly rare case of jejunal intussusception into the gastric lumen in a patient after classic pancreaticoduodenectomy with a Roux-en-Y pancreatico-hepaticojejunostomy. CASE DESCRIPTION/METHODS: A 49 year-old male with Down syndrome, celiac disease and surgical history significant for classic pancreaticoduodenectomy (Whipple procedure) with a Roux-en-Y pancreatico-hepaticojejunostomy for pancreatic mass with distal bile duct stricture and duodenal stricture presented with one-day history of abdominal pain. He was minimally verbal due to Down's syndrome however pointed to his upper and lower abdomen. Associated symptoms included mild nausea but no emesis, melena or hematochezia. Abdominal examination was negative for any mass or peritoneal signs. Initial labs were remarkable for only mild anemia; while blood cell count and lactic acid were normal. A CT scan demonstrated an approximately 7-cm length of jejunum protruding into the lumen of the stomach at the gastrojejunostomy site concerning for intussusception, but no high-grade mechanical obstruction observed. EGD showed intussusception of the blind jejunal limb with healthy appearing mucosa and jejunum biopsies were obtained to rule out ischemia; examination of gastrojejunal anastomotic site and the jejunum (efferent limb) was otherwise normal. Endoscopic reduction of intussusception was attempted but was unsuccessful. Remaining hospital course was uneventful. He was tolerating diet, having proper bowel movements and his abdominal pain resolved. No surgical intervention for repair was planned as he continued to improve clinically and he was safely discharged home. He was seen in surgery clinic a few months later and remained asymptomatic. DISCUSSION: Intussusception is a rare entity in adults and only a few cases have been reported after Whipple procedure. Diagnosis of intussusception in adults, regardless of previous surgeries, is primarily through imaging because presenting symptoms are often vague and nonspecific. Surgical management is often required. However, in our patient, due to the absence of bowel obstruction or ischemia, surgical intervention was not needed. This case highlights that intussusception should be considered as a potential diagnosis in patients with history of Whipple presenting with vague abdominal symptoms.

348 Endoscopic Management of a Recalcitrant Anastomotic Bile Leak After Pancreaticoduodenectomy

INTRODUCTION: A 64-year-old female with past history of pylorus-preserving pancreaticoduodenectomy for pancreatic adenocarcinoma presented for endoscopic management of anastomotic bile leak and suspected stricture at the hepaticojejunostomy which persisted despite surgical and percutaneous intervention. CASE DESCRIPTION/METHODS: At the time of her surgery she was noted to have bile leakage from the new hepaticojejunostomy anastomosis, which was managed with intraoperative revision of the anastomosis and placement of a T-tube. On follow up after her surgery, she continued to have bilious drainage from her drains and was referred to interventional radiology for percutaneous transhepatic cholangiography. Cholangiogram demonstrated a significant leak from the anastomosis into a new subhepatic fluid collection. A percutaneous drainage catheter was placed. On subsequent catheter change, it was also noted that the biliary catheter was actually placed into a fluid collection adjacent to the small bowel and not across the hepaticojejunostomy. Internalization of the biliary catheter was unsuccessful as no flow of contrast from the bile duct to the jejunal limb could be identified. Her course was also complicated by episodes of cholangitis. To manage the persistent anastomotic leak, ERCP was performed. An adult colonoscope was advanced to the hepaticojejunostomy, which appeared widely patent. Contrast injection through the existing external percutaneous drain in the right hepatic duct confirmed complete distal occlusion of the duct without any contrast passage into the jejunum. Careful exam of anastomosis revealed sutures located superior to the hepaticojejunostomy. A 0.018 inch hydrophilic wire was advanced anterograde alongside the external drain under fluoroscopic guidance. This was unable to be passed into the small bowel but advancement of the wire resulted in a bulge in the mucosa seen endoscopically in the area of sutures, confirming the diagnosis of inadvertent surgical closure of right system. To gain access to the right biliary system, a choleodochojejunostomy was created using a needle knife in the area of the bulge created by the antegrade passage of wire through percutaneous tract. This allowed a 10 mm by 4 cm fully covered metal biliary stent to be deployed into the right hepatic duct across the newly created hepaticojejunostomy. DISCUSSION: In this case, we describe the endoscopic diagnosis and treatment of an iatrogenic biliary stricture leading to persistent anastomotic leak after pancreaticoduodectomy. Watch the video: http://bit.ly/2Z1kewv

The Path to Whipple Reconstruction for Pancreatic Adenocarcinoma: Trans-Mesocolon or Through Ligament of Treitz?

BackgroundThe path of the biliopancreatic limb for reconstruction of the pancreatic anastomosis during pancreatoduodenectomy for pancreatic ductal adenocarcinoma can be trans-mesocolon or through the ligament of Treitz. Even after curative intent pancreatoduodenectomy, incidence of recurrence in the surgical bed remains high and may lead to obstruction of the biliopancreatic limb. However, the association between path of jejunal limb and incidence of biliopancreatic limb obstruction has not been studied. Primary aim was to determine whether path of reconstruction predisposes to biliopancreatic limb obstruction in the setting of local recurrence. MethodsPatients who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma (2008–2018) from a single institution were identified. As disease recurrence is the predominant cause of biliopancreatic limb obstruction, analysis was limited to patients with known recurrence at date of last follow-up. Given a known median time to recurrence of 8 to 10 months after resection for pancreatic ductal adenocarcinoma, analysis was further limited to patients with at least 8 months of follow-up. Primary outcome was incidence of biliopancreatic limb obstruction. ResultsAmong the 517 patients identified, 182 were included. Median age was 65 years; 51% were male. Median follow-up was 22 months. Path of reconstruction was trans-mesocolon in 35% (n = 64) and through ligament of Treitz in 65% (n = 118). There was no difference between the two groups in clinicopathologic factors including age, tumor differentiation, grade, T-stage, N-stage, LVI, or PNI (all p > 0.05). Importantly, there was no difference in retroperitoneal margin positivity between groups (trans-mesocolon 8% vs ligament of Treitz 10%, p = 0.79). Both groups had similar post-operative outcomes including median length-of-stay (trans-mesocolon 6 days vs ligament of Treitz 6 days, p = 0.89) and median follow-up (trans-mesocolon 21 months vs ligament of Treitz 23 months, p = 0.68). Biliopancreatic limb obstruction was detected in 8% (n = 14) of which 14% (n = 2) were in the trans-mesocolon group and 86% (n = 12) were in the ligament of the Treitz group. Therefore, incidence of biliopancreatic limb obstruction was 3.1% in the trans-mesocolon group and 10.4% in the ligament of the Treitz group resulting in an absolute risk increase of 7.3%, risk ratio of 3.4, and relative risk increase of 2.3. There was no difference in median time to biliopancreatic limb obstruction between the groups (17.6 months vs 18.5 months, p = 1.0). Biliopancreatic limb obstruction was caused by locally recurrent pancreatic ductal adenocarcinoma in 93% (n = 13) and kinking of the duodenojejunal anastomosis in 7% (n = 1). Intervention was performed in 71% (n = 10) and included surgical bypass in 29% (n = 4), percutaneous drain in 21% (n = 3), and endoscopic/surgical decompression in 21% (n = 3). ConclusionBiliopancreatic limb obstruction is a known complication after pancreatoduodenectomy for pancreatic ductal adenocarcinoma due to local recurrence in the surgical bed. This study shows that path of jejunal limb through the ligament of Treitz may be associated with a higher incidence of biliopancreatic limb obstruction compared with trans-mesocolon as the position of the biliopancreatic limb in the surgical bed may be more predisposed to obstruction after local recurrence. Larger studies are needed; however, given this potential risk of subsequent obstruction, these data suggest that the reconstruction paths may not be equivalent when performing pancreatoduodenectomy for pancreatic ductal adenocarcinoma.

Hemi-double stapling technique performed with a transorally inserted anvil for esophagojejunostomy in the surgical treatment of gastric cancer.

A transorally inserted anvil has been developed to facilitate the creation of a stapled anastomosis without the need for a purse string to secure the anvil into place during laparoscopic total gastrectomy (LTG). We describe a hemi-double stapling technique and application of a transorally inserted anvil for esophagojejunostomy during LTG, and we report the results of a retrospective study in which we examined the feasibility and safety of this method. We also describe the key technical details of the method. Our anastomotic method has four chief features: (a) the esophagus is cut at a slant, and its left cut end is cut and punched for the hemi-double stapling technique; (b) the anvil and circular stapler are connected, placing the distal jejunum in cranial traction; (c) a single layer of sutures is used to correct dog-earing and overlapping, and these points are completely closed with Lembert sutures; and (d) the jejunal limb is fixed to the duodenal stump to prevent kinking of the jejunal limb and to decrease tension on the anastomosis. This method has been used in 53 patients thus far. LTG with Roux-en-Y reconstruction was successful in all patients, and there was no need for conversion to open surgery. The mean operative time was 313 minutes, and the mean blood loss was 106 mL. The mean postoperative hospital stay was 18 days. There was no anastomotic leakage or stenosis. Hemi-double stapling technique with a transorally inserted anvil for LTG can be performed safely and easily and safely. It can also product good outcomes.

Laparoscopic pancreaticojejunostomy with transpancreatic “blumgart” and running “hopkins” sutures and external pancreatic duct stent (PDS)

Background: Laparoscopic pancreaticoduodenectomy (LPD) has been increasingly used in patients at high risk of pancreatic leak due to soft glands and small ducts. Varying open techniques can mitigate the risk of this complication, but translation to laparoscopy can be challenging. We describe a laparoscopic pancreaticojejunostomy with transpancreatic ‘Blumgart’ sutures, anterior and posterior running internal layers and placement of an externalized pancreatic duct stent (PDS) utilizing a Seldinger technique. Methods: A totally LPD was performed with percutaneous introduction of a 8 Fr pediatric feeding tube, via Seldinger technique and standard 11 Fr introducer sheath into the jejunal limb. Sutures were tied together to create double armed sutures (DAS) of adequate length. Two 3-0 Vicryl DAS were used for the transpancreatic stiches, followed by a posterior running 3-0 V-Loc row. The external PDS was placed in the duct and secured with 5-0 Polydioxanone DAS. A second anterior running row was performed and the anastomosis was completed after the final anterior stiches were placed through the intestine and tied down. The PDS exit site was secured similarly to a feeding tube with a 3-0 Vicryl purse string suture and two Witzel stitches. Results: 70 y/o woman with pT2N2 pancreatic acinar cell cancer underwent uncomplicated totally LPD with external stent placement. Patient tolerated the procedure well and was discharged home on POD 5. The externalized PDS was removed at 6 weeks post op. She is now 3 months out from surgery and has not had any complications. She is currently undergoing adjuvant chemotherapy. Conclusion: LPD is an established procedure for the treatment of pancreatic head lesions. Patients at high risk of pancreatic leak - soft glands, small ducts, and/or high BMI - may benefit from adapting open techniques that have been shown to decrease complications such as pancreatic fistulas. This laparoscopic method for placing an external PDS may further mitigate potential complications.

Median Pancreatectomy

Summary: Surgical resections traditionally involves pancreaticoduodenectomy and distal pancreatectomy, leading to substantial loss of unaffected endocrine and exocrine tissue of pancreas. They are also associated with significant morbidity (diabetes). To minimize the loss of normal pancreatic tissue, limited resections in the form of central (median) pancreatectomy may be done alternatively. We would hereby like to submit the surgical video of this procedure. Case: A 62 yr female without comorbidities, and being symptomatic with intermittent pain abdomen of 45 days duration. Patient was evaluated with ultrasound and CT abdomen which revealed heterogenous enhancing solid lesion in pancreatic neck. Endoscopic ultrasound was done which was suggestive of pancreatic head mass. Needle aspiration cytology revealed neuroendocrine tumour. After pre-operative work up, patient underwent Open Median(Central) pancreatectomy. Intra-operatively a 1.5x1.5 cm firm mass was found at the neck of pancreas. Rest of abdominal findings were normal. Pancreatic duct was dilated. Continuity of distal pancreas was established using a Roux en Y jejunal limb which was anastomosed with pancreatic duct. Blood loss of 250 ml. Immediate perioperative period was uneventful. As an institutional protocol, feeding jejunostomy was placed in the jejunum. Feeds were started on post-operative day(POD)-3 through feeding jejunostomy and was progressively tapered as oral ingestion improved satisfactorily. Histopathological report was suggestive of Grade I, Neuroendocrine tumour of pancreas. Patient had grade II complication according to Clavien Dindo grading system. Follow-up till 16 months patient is alive having an event free survival. Conclusion: Limited pancreatic resections such as central (median) pancreatectomy may be done in selected cases with pancreatic neuro-endocrine and benign tumors affecting neck and body of pancreas with advantages of retaining uninvolved portions of pancreas.

Strangulation with Small Bowel Obstruction of the Ascending Jejunal Limb After Laparoscopic Total Gastrectomy: A Case Report

Strangulation with Small Bowel Obstruction of the Ascending Jejunal Limb After Laparoscopic Total Gastrectomy: A Case Report

Combined laparoscopic-fluoroscopic technique for primary gastrojejunostomy button tube placement

BackgroundGastrojejunostomy (GJ) tubes are frequently used to provide pediatric enteral nutritional support for pediatric patients. Various placement methods have been described, each with attendant advantages and disadvantages. Description of the operative techniqueWe present a technique for primary laparoscopic/fluoroscopic GJ button tube placement designed to avoid delay in placement of the jejunal limb, and difficulties associated with endoscopic-assisted and primary fluoroscopic placement. ResultsThere were 52 gastrojejunostomy button tubes placed via this technique in patients ranging from 3.8 to 90.3 kg in weight. Three postoperative complications were identified; one bowel perforation on postoperative day two, and two tube dislodgements within 30 days. ConclusionThe described technique was uniformly effective and was associated with a low complication rate (5.8%).

Anastomotic Reconstruction and External Drainage of Wirsung's Duct as Treatment for Pancreaticojejunal Stenosis Following Pancreaticoduodenectomy

Stenosis of the pancreaticodigestive anastomosis (pancreaticogastrostomy and pancreaticojejunostomy) is a very rare complication that usually develops several years after pancreaticoduodenectomy (PD). Only a few cases have been previously reported. We have reviewed the literature and present 2 more cases of pancreaticojejunostomy stenosis that started with episodes of recurrent acute pancreatitis 6 years and 1 year after PD, respectively. Diagnosis was based on symptoms of pancreatitis (12–15 episodes between 5 and 20 months after PD) and CT and MRI scans. Both patients were treated by resection of the pancreaticojejunostomy stenosis, including a 1-cm slice of pancreatic parenchyma in contact with the jejunum, followed by a new well-vascularized two-layer end-to-side PJ with external drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both cases, and after a follow-up period of 3 and 2.5 years, respectively, the patients remain asymptomatic but with endocrine and exocrine insufficiency. Resection of the PJ and construction of a new PJ with external stent drainage of the Wirsung duct is our preferred surgical option in the rare cases of PJ stenosis after a Whipple procedure.

Reconstrucción anastomótica y drenaje externo del conducto de Wirsung como tratamiento de la estenosis pancreato-yeyunal posduodenopancreatectomía cefálica

Stenosis of the pancreaticodigestive anastomosis (pancreaticogastrostomy and pancreaticojejunostomy) is a very rare complication that usually develops several years after pancreaticoduodenectomy (PD). Only a few cases have been previously reported. We have reviewed the literature and present 2 more cases of pancreaticojejunostomy stenosis that started with episodes of recurrent acute pancreatitis 6 years and 1 year after PD, respectively. Diagnosis was based on symptoms of pancreatitis (12-15 episodes between 5 and 20 months after PD) and CT and MRI scans. Both patients were treated by resection of the pancreaticojejunostomy stenosis, including a 1-cm slice of pancreatic parenchyma in contact with the jejunum, followed by a new well-vascularized two-layer end-to-side PJ with external drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both cases, and after a follow-up period of 3 and 2.5 years, respectively, the patients remain asymptomatic but with endocrine and exocrine insufficiency. Resection of the PJ and construction of a new PJ with external stent drainage of the Wirsung duct is our preferred surgical option in the rare cases of PJ stenosis after a Whipple procedure.

Non-Malignant Gastric Outlet Obstruction: Therapy With Endoscopic Ultrasound Guided Gastrojejunonostomy

We describe here an 82 year-old male with past medical history of coronary artery disease, sick sinus syndrome s/p permanent pacemaker insertion who presents with a three day history of nausea and vomiting. A CT scan was obtained in the emergency department that showed a markedly distended abdomen. Although no discrete mass was seen, findings were concerning for a gastric outlet obstruction (GOO) (Figure 1). The patient was made NPO and a nasogastric tube was placed for decompression. Of note, the patient was hospitalized at an outside facility 1 month prior due to a severe gastro-intestinal hemorrhage. An endoscopy performed at that time revealed that a ulcerated mucosa encompassing two-thirds of the second portion of the duodenum.2130_A Figure 1 No Caption available.A repeat EGD was performed at our facility revealing a benign appearing high grade stricture in the duodenal bulb at the base of a healing ulcer. Stone-like accretions were found in the pylorus and duodenal bulb which were noted to intermittently occlude the stricture (Figure 2). Biopsies were taken which were negative for malignancy.2130_B Figure 2 No Caption available.The decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ). Sonographic examination of the stricture did not reveal an obvious mass. A stone-extraction balloon over a wire was advanced thorough the duodenal stricture into the jejunum. Sterile water was used to dilate the jejunal limb. The linear echoendoscope advanced to the stomach and the jejunal limb was identified. A 19G FNA needle was used to puncture into the jejunum and a second wire was advanced into this limb. Under endoscopic, fluoroscopic and sonographic guidance a 15mm lumen-apposing metal stent (LAMS) was successfully deployed, creating a gastrojejunostomy (Figure 3).2130_C Figure 3 No Caption available.Post-procedure day one patient tolerated a soft diet and was discharged after a 48 hour observation periord. At outpatient follow-up, six weeks after presentation, the patient has done well without significant complications. EUS-GJ are not common-place, however their utility in the treatment of malignant as well as benign gastric outlet obstruction has been demonstrated in international prospective trials. Here we demonstrate that EUS-GJ can be a reliable intervention in patients with GOO. In the future we hope for a comparison study between LAMS, enteral stents and surgical gastrojejunostomies.

Endoscopic Ultrasound-Guided Gallbladder Drainage After Roux-En-Y Gastric Bypass: It Can Hide, but It Can‘t Run!

In patients with acute cholecystitis who are non-operative candidates, percutaneous cholecystostomy (PC) catheter placement is used for gallbladder decompression Removal of the catheter can lead to recurrence of cholecystitis. Leaving drain in place can cause infection, pain and dislodgment. Routine catheter maintenance and exchanges adversely affect quality of life. EUS-guided approach may be used to convert PC drainage to internal biliary drainage. 33-year-old woman with a history of Roux-en-Y gastric bypass presented with septic shock. She was actively abusing alcohol (MCV 105), malnourished (Albumin 2.0), coagulopathic (INR 2.0), thrombocytopenic (Platelets 58 k), and requiring frequent large volume paracentesis Abdominal CT scan showed acute acalculous cholecystitis. Patient started on broad spectrum antibiotics, vasopressors, deemed to be a prohibitive operative candidate and underwent placement of an 8 French decompression PC catheter (Fig 1) by Interventional Radiology. Due to severe discomfort from the PC catheter, taken for conversion to internal biliary drainage via endoscopic ultrasound. Stricture found at the G-J anastomosis. Contrast injected across the stricture, confirming a patent jejunal limb. Stricture was dilated to 18 mm. EUS scope maneuvered into the jejunal limb, gallbladder visualized endosonographically. Hyperechoic material consistent with sludge seen within an enlarged gallbladder. Site within the jejunum chosen, where gallbladder wall was within 1 cm (Fig 2). Gallbladder punctured with a 19 gauge FNA needle under EUS guidance. 10 mm by 10 mm cautery-enhanced LAMS placed creating a cholecystojejunostomy. 7 Fr by 4 cm plastic double pigtail stent placed through LAMS to maintain patency of the metal stent and prevent the backwall of gallbladder from impacting the metal stent causing bleeding or dislodgement (Fig 3). The patient did well following EUS-guided cholecystojejunostomy. 3 weeks later, a cholecystogram was performed. Contrast flowed from a decompressed gallbladder and into the jejunum across a patent cholecystojejunostomy via the LAMS. The PC catheter was then removed. The patient did well and was discharged home. EUS guided-conversion of percutaneous gallbladder drainage to internal drainage via a cholecystojejunostomy using a LAMS in a non-surgical patient with Roux-en-y gastric bypass is feasible, although the procedure is technically challenging and requires more expertise compared to primary EUS-guided gallbladder drainage.1702_A Figure 1 No Caption available.1702_B Figure 2 No Caption available.1702_C Figure 3 No Caption available.Watch the video: https://goo.gl/rfav8w

Itʼs Not Recurrence?

Case presentation A 53-year-old man was evaluated for nausea, fatigue and progressive weakness. He had a history of a 20cm (figure A) stage IIIb gastric high-grade, predominantly epithelioid, GIST (figure B, note the epithelioid appearing GIST within the black arrows, the oxyntic mucosa within the blue arrows and the muscularis separating the two areas) extirpated by partial gastrectomy and Billroth II ˜18 months prior. A 3cm LUQ mass was found on surveillance imaging 12 months later while being treated with adjuvant tyrosine-kinase inhibitors. Repeat imaging demonstrated an enlarging 6.7x7.0cm mass within the abdominal mesentery anterior to the left kidney. He was referred for laparoscopic partial small bowel resection and excision of a 10 cm mesenteric mass at the level of the efferent jejunal limb, a 3cm nodule at the level of the proximal ileum and 6 smaller nodules within the small bowel mesentery. Histopathology of the resected masses demonstrated a vimentin positive, uniform, spindled cell lesion with minimal inflammation and a rare mitotic figure. The lack of inflammation, storiform spindled pattern, mucin and obliterative vasculitis, helped exclude inflammatory myofibroblastic tumor and IgG4 disease. CD117 (c-kit) and CD34 were negative, excluding residual or recurrent GIST. However, the spindled cell did demonstrate nuclear and cytoplasmic positivity for beta-catenin, supporting the diagnosis of intra-abdominal mesenteric fibromatosis (figure C). Discussion Mesenteric fibromatosis or desmoid tumor is group of rare benign tumors that can be locally aggressive but do not metastasize. They develop in ˜20% of patients with FAP but can appear spontaneously, with tissue trauma and radiation exposure as reported risk factors. To date, there are about 30 reported cases of mesenteric fibromatosis following GIST resection. Co-existence of mesenteric fibromatosis with GIST has been reported as well. Distinguishing mesenteric fibromatosis from recurrent GIST may be difficult given common similarities in radiologic appearance and c-kit expression. Accurate diagnosis can only be made after surgical removal and histopathologic examination. Unfortunately, surgery for mesenteric fibromatosis is not always curative and high rates of recurrence are common. Watchful waiting should be considered after resection, especially in patients with minimal symptoms.2701_A Figure 1. CT of the abdomen2701_B Figure 2. Epithelioid GIST, 10X2701_C Figure 3. Jejunal mesenteric mass, desmin stain, 20x

Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb.

Laparoscopic gastrectomy is a treatment for gastric cancer, and isoperistaltic side-to-side reconstruction is called “overlap anastomosis.” The physiological advantages of preserving the autonomic nerves in the jejunal limb for digestive reconstruction are well known. Here, we focused on overlap anastomosis with autonomic nerve-preserved mesojejunum of the lifted jejunal limb for laparoscopic distal gastrectomy with intentional lymph node dissection. Our surgical techniques and technical pitfalls were described in detail. The jejunum was partially sacrificed to preserve the autonomic nerves in the lifted jejunal limb. The length of the staple line was 35 – 40 mm. The endostapler entry was carefully closed to avoid even subtle stenosis. Twelve patients were retrospectively evaluated with a follow-up of 5.0 ± 0.6 years. Histological findings according to the Japanese classification were stage IA or IB. Dietary intake and postoperative ambulation occurred at 3.3 ± 1.0 and 1.3 ± 0.5 days after surgery, respectively. Postoperative complications according to Clavien–Dindo classification were one each of grade I and grade II. Postoperative hospital stay was 6.7 ± 1.6 days. Five patients were medication-free at final follow-up, with no recurrence in any patient. Overlap anastomosis with autonomic nerve-preserved jejunal limb was safe and feasible for laparoscopic distal gastrectomy with lymph node dissection.

External Wirsung-drainage plus redo pancreatico-jejunostomy as treatment for pancreatico-jejunostomy stenosis after pancreaticoduodenectomy

Introduction: Stenosis of pancreaticodigestive anastomosis (pancreaticogastrostomy and pancreaticojejunostomy) is a very rare complication that usually develops several years after pancreaticoduodenectomy (PD). Only a few cases have been previously reported. We review the literature and present 2 more cases of pancreaticojejunostomy stenosis Results: We report two patients, 66 and 45 years old respectively, presenting with a clinical picture of recurrent acute pancreatitis at 6 years and 1 year after PD. Diagnosis of anastomotic stricture was established based on symptoms of pancreatitis (12–15 episodes between 5 and 20 months after PD), and CT scan and MRI findings. ERCP was attempted in both patients prior to surgery, being unsuccessful in both cases. Resection of the pancreaticojejunostomy stenosis was performed, including a slice of 1cm of the pancreatic parenchyma in contact with the jejunum, followed by a new well-vascularized two-layer end-to-side PJ with external drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both cases, and after a follow-up period of 3 and 2.5 years respectively, the patients remain asymptomatic but have developed endocrine and exocrine insufficiency. We believe Witzel technique is useful in patients with pancreatico-jejunostomy stenosis, as it contributes to reduce fistula rate and maintains sufficient Wirsung duct patency in order to avoid postoperative pain. Conclusion: Resection of the PJ and construction of a new PJ with external stent drainage of the Wirsung duct is our preferred surgical option in cases of PJ stenosis after a Whipple procedure.