Jejunal Loop Research Articles

Comparisons of short-term outcomes of anastomotic methods of duct-to-mucosa pancreaticojejunostomy: Out-layer continuous suture vs. modified Blumgart method

Postoperative pancreatic fistula (POPF) is the most common and troublesome complication after pancreaticoduodenectomy (PD). To reduce POPF, various types of pancreaticojejunostomy (PJ) anastomosis have been introduced. The study aimed to compare the short-term outcomes of two different anastomotic methods of duct-to-mucosa PJ, out-layer continuous suture anastomosis (OCA) and modified Blumgart method (mBM). In this retrospective cohort study, patients who underwent curative-intent open PD between 2015 and 2020 were enrolled. In in-layer anastomosis, duct-to-mucosa anastomosis using 5-6 interrupted sutures were performed. In mBM, two transpancreatic U-sutures was done in both dorsal and ventral side of jejunal loop with reinforced suture in the central part. Patient's demographics, diagnosis and intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically-relevant POPF (CR-POPF) included grade B, C POPF. OCA was performed in 184 patients (65.7%) and mBM was performed in 96 patients (34.3%). There were no significant differences between the OCA and mBM group in CR-POPF rates (7.1% vs. 7.3%; p = 0.944), and overall surgical complication rates (21.7% vs. 30.2%; p = 0.097). Total operation time (242 vs. 233 minutes; p = 0.103) were comparable, but operation time for PJ is shorter in mBM (20.0 vs. 18.1 minutes; p < 0.001). No significant differences were shown in postoperative outcome between OCA and mBM groups, but operation time for PJ in mBM was shorter. Since mBM is safe, relatively simple, and time-saving technique, it can be a good choice when duct-to-mucosa PJ is performed.

Small bowel obstruction due to internal herniation through a defect in the falciform ligament: a rare case report and review of the literature

BackgroundThe falciform ligament hernia is a type of internal herniation, caused by a defect in the falciform ligament of the liver. The etiology for this defect may be congenital or iatrogenic, created after the laparoscopic intervention.Case presentationA 45-year-old male was presented to our hospital, complaining of abdominal pain for 2 days. The physical examination revealed diffuse abdominal tenderness and guarding. The abdominal X-ray was suggestive of intestinal obstruction. On abdominal CT images, dilated proximal ileal loops between the left hepatic lobe and anterior abdominal wall, forming a closed-loop with mesenteric edema and fat stranding, were observed. There were findings of ileus in the jejunal loops proximal to this segment, but the ileal loops and the colon were completely collapsed, consistent with small bowel obstruction due to internal herniation through a defect in the falciform ligament. The patient underwent surgical intervention, reduction of the herniated bowel loops, and repairing the hernia defect. He had an uneventful recovery with a favorable outcome.ConclusionHerniation through a defect in the falciform ligament is extremely rare but should be considered in the differential diagnosis of acute abdomen. The clinical manifestations of falciform ligament hernia are nonspecific and may underestimate the diagnosis, leading to a delayed treatment that affects the management outcome. Computed tomography plays an important role in the timely diagnosis and planning of surgical intervention, precluding intestinal strangulation.

GALLSTONE ILEUS WITH MULTIPLE GALLSTONES: A CASE REPORT

Gallstone ileus is a rare complication of gallstones and an unusual cause of intestinal obstruction. It typically occurs due to formation of cholecystoduodenal fistula and patients usually present with features of small bowel obstruction. The mainstay of treatment is to relieve the intestinal obstruction with surgical removal of impacting gallstone. Here, we report a case of a male patient presented with features of small bowel obstruction. CT of abdomen demonstrated presence of air in the gallbladder, small bowel obstruction with direct communication of the gallbladder with 1st part of duodenum and multiple calculi in proximal jejunal loops, features suggesting gallstone ileus. The patient underwent exploratory laparotomy and removal of four gallstones via enterotomy. He was discharged after an uneventful postoperative course. The aim of this case report is to report a new unusual case of gallstone ileus and discuss its diagnostic and surgical approaches. Though uncommon, gallstone ileus should always be kept in mind when approaching a case of small bowel obstruction, especially in elderly patients and in patients with known gallstone disease.

Outcomes of Hepaticoduodenostomy over T-tube against Roux-en-Y Hepaticojejunostomy to Restore Bilio-enteric Continuity after Choledochal Cyst Excision in Children:

Introduction: Any surgical procedure which would restore the bilio-enteric continuity after excision of the choledochal cyst with minimal complications would be a feasible alternative to Hepaticojejunostomy using a Roux loop of jejunum. To determine the outcomes of Hepaticoduodenostomy done over T-Tube against Roux-en-Y Hepaticojejunostomy for bilio-enteric reconstruction after excision of choledochal cyst. Materials and Methods: This study was retrospectively done on all patients of choledochal cysts (Types 1 and 4) operated between January, 2014 and December, 2019. The clinical details, intra-operative and post-operative results of patients who underwent Roux-en-Y Hepatico-Jejunostomy (Group-1) and Hepatico-duodenostomy over T-Tube (Group -2) for establishing bilio-enteric continuity after excision of choledochal cyst were compared and analyzed statistically. Results: 78 patients of choledochal cysts were operated during this period with 31 patients in Group-1 and 47 in Group-2; there was no difference in the mean age or size of the cysts in the two groups; Type 1 cysts were the most common with female preponderance in both groups. Group-2 patients had lesser intra-operative time andfewer numbers of sutures were used during surgery. There was no difference in the incidence of anastomotic leaks, strictures, cholangitis or adhesive obstruction and reoperation rates between the two groups. Group 2 showed increased nasogastric bilious aspirates in 19.15% of cases which improved on conservative management. Conclusion: Bilio-enteric reconstruction using Hepaticoduodenostomy over T-Tube is a simpler, lower pressure and less time taking anastomotic technique with comparable complication rates when compared to Roux-en-Y Hepaticojejunostomy in the management of choledochal cysts.

Laparoscopic excision of congenital choledochal cyst in children and modified hepaticojejunostomy with an unequal length of the jejunal loop

Introduction: Complete excision biliary-enteric reconstruction is necessary for a congenital choledochal cyst (CC) to prevent recurrent cholangitis, acute pancreatitis, and cholangiocarcinoma. Among various reconstructions, this study aims to evaluate the therapeutic effect of unequal length jejunal loop for the biliary reconstruction of congenital choledochal cyst.&#x0D; Method: The clinical data of 56 cases of congenital choledochal cyst treated in the pediatric surgery department of Children's Hospital Affiliated to Zheng Zhou University were retrospectively analyzed. All cases were treated with choledochal cyst resection and unequal length jejunal loop biliary reconstruction, including 51 cases with laparoscopic surgery and 5 cases with traditional surgery.&#x0D; Result: Choledochal cyst resection and unequal length jejunal loop biliary reconstruction were successfully completed in all cases. One case of laparoscopic operation developed biliary fistula on the 3rd day after the operation, and the biliary fistula healed after conservative treatment for 8 days. The other cases recovered smoothly without obvious complications. No contrast agent bile loop reflux was found in upper gastrointestinal angiography.&#x0D; Conclusion: The modified jejunal loop biliary reconstruction has many advantages over the traditional biliary reconstruction, which is worthy of clinical application.

P149 Application of revised Pediatric Inflammatory Bowel Disease (PIBD) classes criteria to the Korean PIBD patients

Abstract Background In 2017, Porto group of ESPGHAN published the PIBD classes criteria, a diagnostic classification criteria for PIBD by conducting multi-center study, and the revised PIBD classes criteria were released in 2020 after multi-center verification. Consisting of 19 items classified into a total of 3 classes, this criteria classifies PIBD into UC, atypical UC, CD, and IBD-U through an algorithm. The purpose of this study is to examine the appropriateness of diagnosis and criteria by applying the revised PIBD classes-criteria for PIBD patients diagnosed in a certified tertiary hospital. Methods Among 156 new patients aged 1–18 years old diagnosed with PIBD at Seoul National University Children’s Hospital from January 1, 2014 to August 18, 2020, 102 patients who had no underlying disease, did not administer drugs that affect the immune system, whose key items of PIBD class criteria (upper and lower gastrointestinal endoscopy, gastrointestinal imaging, pathology, etc.) and basic demographic characteristics were verified were analyzed retrospectively through electronic medical records. Results Of the 102 PIBD patients, 85 (83%) were initially diagnosed with CD, 15 (15%) with UC, and 2 (2%) with IBD-U by clinicians. Of the 102 patients, 69 (68%) were male, and the age of first diagnosis was 11.5±3.7 years. After applying the revised PIBD classes criteria, the diagnosis was changed to CD for 2 IBD-U patients, IBD-U for 7 UC patients, and CD for 1 UC patient. Finally, the diagnosis was changed to 86 (84%) CD, 8 (8%) UC and 7 (7%) IBD-U. The two patients whose diagnosis was changed from IBD-U to CD satisfied the items of Class 1, so the diagnosis was changed. All 7 patients whose diagnosis changed from UC to IBD-U did not satisfy all the items of Class 1, but most of the items ‘Focal active colitis on histology in more than one biopsy’ (6/7) and ‘Focal enhanced gastritis on histology’ (7/7) of class 3 criteria were satisfied, and the diagnosis has changed. Conclusion As a result of applying the PIBD class criteria, there was no significant change in the diagnosis of CD, but the diagnosis of UC decreased by 73% and the diagnosis of IBD-U increased by 5 times. In this study group, the positive rates of items ‘Fistulising disease’, ‘‘Thickened jejunal or ileal bowel loops on radiology or other evidence of significant small bowel inflammation on capsule endoscopy’, ‘Focal active colitis on histology in more than one biopsy’ and ‘Focal enhanced gastritis on histology’ tended to be significantly higher than those of the previous study. So, Further validation and confirmation are needed.

Natural orifice transluminal endoscopic one-anastomosis gastric bypass: a feasibility study using porcine model.

Endoscopic bariatric therapies (EBT) are emerging as effective therapies in the management of overweight patient with or without metabolic syndrome. Unfortunately most procedures only restrict the gastric volume without altering the underlying metabolism which is seen in surgical patients. The aim of this study was to investigate the feasibility and limitations of a natural orifice trans-luminal endoscopic surgery (NOTES) one anastomosis gastric bypass (OAGB). NOTES OAGB was performed in three porcine models. The steps of the procedure can be divide as follows: (1) Endoscopic sleeve gastroplasty. (2) Trans-gastric access to peritoneal cavity. (3) Identification of a loop of jejunum. (4) Introduction of the jejunal loop into the stomach. (5) Creation of the gastro-jejunostomy with lumen-apposing metal stent (LAMS). (6) Closure of gastric pylorus with overstitch system. All the animals underwent successful NOTES of OAGB. The mean weight for the animals was 34.3 kg (32-37 kg). The mean procedure time was 250 min (300 min for first animal and 180 min for third animal). The average bypassed bilio-pancreatic limb was 98 cm (range 65-130 cm). This study has provided proof-of-principle in a preclinical model that a NOTES approach can be used to perform OAGB and, therefore, merits additional evaluation and consideration.

An interesting case of left paraduodenal hernia.

Paraduodenal fossa hernias (PDFHs) represent 53% of all congenital internal hernias and 0.2-0.9% of all small bowel obstructions. Most of these hernias are diagnosed incidentally on laparotomy, and carry up to 50% lifetime risk of development of small bowel obstruction. We present our experience in diagnosing and treating a case of a massive left paraduodenal fossa hernia in a 17 year male, containing over 30% of the small bowel (jejunum and ileum), presenting with a history of recurrent incomplete small bowel obstruction. Plain abdominal radiography showed distended loops of jejunum and few air fluid levels. After laparotomy and identification of hernia, small gut was reduced and examined, which was found to be structurally and functionally intact with normal vascularity. The defect was closed with continuous absorbable suture (Vicryl 2-0) sparing the inferior mesenteric vessels. Patient’s post-operative recovery remained uneventful and he was discharged on 4th post-operative day.

Small intestinal metabolism is central to whole-body insulin resistance

ObjectiveTo assess the role of jejunum in insulin resistance in humans and in experimental animals.DesignTwenty-four subjects undergoing biliopancreatic diversion (BPD) or Roux-en-Y gastric bypass (RYGB) were enrolled. Insulin sensitivity was...

Congenital hepatic hemangioma presenting with neonatal intestinal obstruction: A case report

Background: Congenital hepatic hemangioma usually presents with abdominal distension. Rarely it may cause intestinal obstruction. We present a case of congenital hepatic hemangioma causing neonatal intestinal obstruction. Case Presentation: A 4-day-old neonate presented with clinical and radiological features of neonatal intestinal obstruction. On exploration, a loop of jejunum was found adherent with a hepatic mass, arising from the left lobe of the liver. The hepatic mass profusely bled in an attempt of removing the adherent jejunal loop. Thus, the adherent portion was isolated and jejunojejunal end to end anastomosis was done. The hepatic mass along with an adherent small piece of jejunum was also excised. Histopathology showed hepatic hemangioma. The patient is doing fine on the 10-month follow-up. Conclusion: We report a rare presentation of congenital hepatic hemangioma with neonatal intestinal obstruction. Although the optimum therapy for hepatic hemangioma is medical management, at times, surgical resection becomes a necessary option.

Pancreatic malignancy in the backdrop of chronic pancreatitis: How much to push the boundaries to achieve R0 resection

Abstract Tumors of the body and tail of the pancreas are often more aggressive than tumors of the head and would have often undergone metastatic spread to other organs at the time of diagnosis. Most patients with carcinoma of the body and tail of the pancreas present at a late stage. Surgery is only indicated in those patients in whom there is no evidence of metastatic spread. Surgery is often not possible in cancers of the body and tail of the pancreas if the tumor invades celiac artery. Controversy exists regarding the margin status impact of microscopic resection margin involvement (R1) after pancreaticoduodenectomy (PD) for PDAC. There are reports indicating the rate of R1 resections increases significantly after PD if pathological examination is standardized. In this report, we present the case of a 56-year-old female who had undergone lateral pancreaticojejunostomy for chronic pancreatitis 8 years ago, but has now developed malignancy of the body and tail of the pancreas involving multiple organs. This patient underwent en bloc resection involving: 1. distal pancreatectomy with jejunal loop (lateral pancreaticojejunostomy) resection; 2. splenectomy; 3. left nephrectomy; 4. total gastrectomy; and 5. segmental colectomy with reconstruction by esophagojejunostomy, jejunojejunostomy, and colocolic anastomosis. The infrequent occurrence of tumor in the distal gland and advanced tumor stage at the time of diagnosis have both combined to produce therapeutic nihilism/dilemma in the minds of many surgeons. This report highlights the decision on how much to the push limits for multi-organ resection (en bloc resection with distal pancreatectomy, gastrectomy, splenectomy, colectomy, nephrectomy) with the intent of achieving R0 status in spite of the complexity of surgery in selected patients.

ДУОДЕНУМ-СОХРАНЯЮЩАЯ РЕЗЕКЦИЯ ГОЛОВКИ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ ПРИ ХРОНИЧЕСКОМ ПАНКРЕАТИТЕ, ДОБРОКАЧЕСТВЕННЫХ И ПРЕДРАКОВЫХ ОПУХОЛЯХ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ

Objective. To report the institutional experience of the evolution of duodenum-preserving pancreatic head resection (DPPHR) as a surgical treatment for chronic pancreatitis with an inflammatory tumor as well as cystic and benign, premalignant neoplasms and neuroendocrine tumors of the pancreatic head. Methods. DPPHR is associated with preservation of gastric antrum, common bile duct and duodenum/upper jejunal loop, contrary to Kausch-Whipple resection, which is a multivisceral procedure, including duodenectomy. Duodenum-preserving pancreatic head resection was first established in clinical setting in Berlin in 1969. Results. For chronic pancreatitis with an inflammatory infiltrat in the pancreatic head, duodenum-preserving pancreatic head resection has become a standard surgical treatment with worldwide acceptance. In a series of 603 patients with chronic pancreatitis following DPPHR, the frequency of pancreatic fistula was 3.3 %, intra-abdominal abscess 2.8 %, hemorrhage 2.8 %, frequency of reoperation 5.6%, in-hospital mortality 0.82 % and 90-day rehospitalisation 8 %. DPPHR for benign and premalignant cystic neoplasms of the pancreatic head is used predominantly for IPMN, MCN and SPN tumors. In a review of international publications comprising 503 patients, the general morbidity was 38.2 %, severe surgery-related complications 12.7% of them pancreatic fistula B+C 13.6 %, resurgery 2.7 % and 90-day mortality 0.4 %. When pancreatic neuroendocrine tumors of pancreatic head are treated with DPPHR, a local lymph node dissection is additionally recommended. The long-term morbidity following DPPHR revealed new onset of diabetes mellitus and exocrine dysfunctions in only 5-7 % of patients. Conclusion. Kausch-Whipple resection is associated with considerable high metabolic complications. Duodenum-sparing pancreatic head resection for inflammatory tumor, benign and premalignant neoplasms, and neuroendocrine tumors of the pancreatic head has the advantage of the duodenum preservation and maintenance of the pancreatic endocrine and exocrine functions.

SMALL INTESTINAL CARCINOID TUMOR-A CASE REPORT

Carcinoid tumors are neuroendocrine tumours, the most common tumour of the small bowel and its incidence is rising. Most carcinoid tumours grow slowly and mostly asymptomatic or may present with nonspecic abdominal pain or carcinoid syndrome. We had a 38 year old, female patient presented with generalized, intermittent, dull aching abdominal pain accompanied with distension and obstipation for 2 days with associated vomiting. She complained of weight loss and constipation during this period. On examination abdomen showed deep tenderness in periumbilical, right lower quadrant regions. No guarding, rigidity, mass or free uid. On per-rectal examination, there was no tenderness and the rectum was empty. Contrast enhanced computed tomography scan showed enhancing polypoidal lesion noted in distal ileum causing proximal dilatation of small bowel with air uid levels and circumferential wall thickening in dilated ileum proximal to polypoidal lesion, strongly enhancing nodal mass with specs of calcication, multiple mesentric lymph nodes and no liver metastasis. As the conservative management for 48 hours showed no improvement in symptoms, an emergency exploratory laparotomy was performed, and an intraluminal mass was identied from ileocecal junction causing obstruction with dilated loops of ileum and jejunum. Local resection of terminal ileum was performed and a side to side anastomoses was done using GI stapler. Histopathology showed diagnosis of neuroendocrine tumor

POS-695 INTESTINAL OBSTRUCTION COMPLICATING CAMPYLOBATER COLI ENTERITIS IN RENAL TRASNPLANTATION PATIENT

A 30 year old male, with cadaveric renal transplantation 2 years ago , his primary disease was anti-GBM disease diagnosed one year prior to transplantation and treated with 14 sessions of plasma exchange, steroids and cyclophosphamide shortly after that he was initiated on hemodialysis followed by renal transplantation. Two months post renal transplantation his course was complicated by biopsy proven mixed rejection (T-Cell mediated rejection type IA) and active Antibody medicated rejection , however ,C4d negative. The patient received pulsed steroids, 3 sessions Plasma-exchange and IVIG 2g/kg. He completed 2 doses of Rituximab and his serum creatinine was stable at 200-220 micromole/L. The patient was admitted after 3 weeks with persistent vomiting and abdominal pain and abdominal distention, his serum creatinine 304 micromole/L, abdominal x-ray showed multiple air fluid levels with dilatation of small bowel loops. CT scan with oral contrast showed multiple dilated small bowel loops down to the terminal ileum with caliber of 3.5 mm with multiple air-fluid levels and fecal loading in distal ileum loop with collapsed colon. The contrast media reached into the small bowel in left mid abdomen at mid jejunal loop. Stool culture grew campylobacter coli, BK PCR was positive of 371,000 copies. Other infectious causes of diarrhea were excluded. The patient completed 7 days of ciprofloxacin and treated with intravenous immunoglobulins (IVIG) . His mycophenolic acid was stopped, and he was maintained on dual immunosuppression therapy in form of tacrolimus and steroids. The patient was booked for upper endoscopy and colonoscopy in outpatient setting. View Large Image Figure ViewerDownload Hi-res image Download (PPT) Diarrhea is a common symptom in renal transplant patient population. The main causes of diarrhea after transplantation include infections, immunosuppressive drugs, antibiotics, and other drugs. Viral causes of diarrhea are the most frequently reported and usually last up to 3 days. Patients have tendency to develop Clostridium difficile after antibiotics. Other enteric bacteria responsible for diarrhea are Shigella, Salmonella typhi, Salmonella typhimurium and Campylobacter. CMV can cause enterocolitis, with or without fever, gastrointestinal bleeding, perforation, and toxic megacolon are possible complications. Incidence of diarrhea with mycophenolate mofetil dose of 2 g/day was higher than in other immunosuppressants like azathioprine. Campylobacter infection has prominent features like terminal ileitis, cecitis and mesenteric adenitis. Proton pump inhibitors are main risk factor for campylobacter enteritis as it lowers the gastric juice acidity allowing for pathogen survival. Campylobacter was detected in stool culture of a 31-year-old male patient diagnosed with immunoproliferative small intestinal disease (IPSID) and it was positive in tissue biopsy samples. Antibiotics treatment is enough to eradicate campylobacter and reduce the risk of IPSID. Diarrhea is a common symptom post renal transplantation, Campylobacter coli can be one of the main causes of ileocecal enteritis and may cause small bowel obstruction, treatment is usually conservative with antibiotics.

Transvaginal strangulated bowel evisceration through uterine perforation due to unsafe abortion: a case report and literature review

BackgroundInduced abortion, whether therapeutic or elective, is a surgical procedure frequently practiced worldwide. It is a significant cause of maternal morbidity and mortality. When the procedure is performed in precarious conditions, by unqualified personnel, it leads to serious consequences, including uterine perforation and its associated lesions. Its management remains a medico-surgical emergency.Case presentationWe present two cases of unsafe abortions performed by cervical dilatation and intrauterine curettage which resulted in uterine perforation and intestinal evisceration through the vagina leading to acute intestinal obstruction. Both patients underwent intensive resuscitation followed by an emergency laparotomy. The first case was a 26-year-old woman living in rural Cameroon. Following a procedure of termination of her pregnancy, the patient noted the presence of bowel at the vaginal introitus associated with signs of intestinal obstruction. She was transferred to a specialized center was after 4 days later of the onset of the evisceration. Considering the gangrened eviscerated terminal ileum, a right hemicolectomy with anastomosis was performed, as well as a suture of the uterine perforation. The second patient was an 18-year-old African living as a refugee in Cameroon. She was referred for abdominal pain in the context of intestinal obstruction with a viable jejunal loop extruding through the vagina. A simple jejunal resection was performed with end-to-end anastomosis and suture of the uterine perforation. In both cases, the postoperative course was uneventful.ConclusionsUterine perforation is a serious complication of intrauterine gynecological procedures and instrumental abortion in particular. It can lead to evisceration of the intra-abdominal viscera through the uterine perforation. It is therefore a real surgical emergency with multiple and fatal consequences.

A case of jejunal loop varices caused by portal vein occlusion after pancreatoduodenectomy for duodenal cancer successfully treated with interventional radiology via laparotomy

症例は76歳女性．2年前に他院で十二指腸癌に対して亜全胃温存膵頭十二指腸切除術を施行された．術後に急性膵炎を発症し，それに伴う門脈閉塞により側副血行路が発達した．その後，胆管空腸吻合部の挙上空腸静脈瘤からの出血を繰り返したため静脈瘤治療目的で当院紹介．小腸ダブルバルーン内視鏡検査では，肝管空腸吻合部に静脈瘤を認めたが，細い新生血管の拡張を主体としており内視鏡的治療は困難と判断した．また門脈閉塞のため経門脈的治療も困難と考え，全身麻酔下・開腹下に経回結腸静脈的静脈瘤塞栓術を施行した．術後のCTで挙上空腸静脈瘤の造影効果は消失し，塞栓物質の良好な停滞を認めた．本症例では術後再出血なく経過しているが，新たな側副血行路発達や再出血のリスクがあるため慎重な経過観察が必要である．

Water-filled technique for therapeutic pancreato-biliary EUS in patients with surgically altered anatomy.

One of the main challenges encountered by endosonographers is performing diagnostic and interventional pancreato-biliary endoscopic ultrasound (EUS) procedures in the presence of surgically altered upper gastrointestinal anatomy. We describe the water-filled technique (WFT) for EUS examination and treatment of the pancreato-biliary region in patients with surgically altered upper gastrointestinal anatomy. Using the WFT, the scope is advanced up to the gastro-jejunal anastomosis and, after placing the tip of the scope 2 cm beyond it, enlargement of the jejunal lumen is obtained by water instillation of the jejunal loop. An enlargement of more than 1.5 cm allows advancement of the tip of the scope under EUSguidance up to the duodenum, in a retrograde way. The WFT is useful for reaching the ampullary area and performing diagnostic and therapeutic EUS in patients with surgically altered anatomy. The technique is also reproducible and can be easily used by endoscopists who regularly perform EUS.

Gastrojejunal fistula caused by magnet beads ingestion in a 2 -year-old boy

Abstract Foreign body (FB) ingestions are common events in infants and toddlers. Magnet ingestion increases in the last decades among children and it may be catastrophic if not detected. A 2-year-old-boy was brought to an emergency department for bilious vomiting for five days associated with abdominal pain and constipation. An erect abdominal X-ray showed a radiopaque chain of beads in the upper abdomen, gastric and duodenal gas bubbles with air fluids levels, and a gasless abdomen. Exploratory laparotomy through upper midline incision was performed. In our case, the magnet beads were just beyond the ligament of Treitz and made the jejunal loop as an omega shape that fistulized to the posterior wall of the stomach through the mesentery of the transverse colon. All magnet beads were extracted and the perforations in the jejunum and posterior wall of the stomach were both closed primarily. Conclusion It is crucial to intervene early in symptomatic patients with multiple magnets ingestion, especially if it is located beyond the stomach, to prevent future complications like hollow viscus perforations, fistula formation, and even short bowel syndrome.

Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience.

Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions. It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted. We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8days (range 2-10). During the follow-up interval, no leak recurrences were observed. Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.

EUS-guided gastroenterostomy in a COVID-19-infected patient with duodenal stenosing lymphoma (with videos).

EUS-guided gastroenterostomy (GE) was alternative treatment with respect to conventional therapies for oncological gastric outlet obstruction (GOO) during the COVID-19 pandemic in Italy. This is the case of a patient with obstructing duodenal diffuse large B-cell lymphoma (DLBCL) causing GOO. Malignant duodenal stenosis was treated by the wireless EUS-GE simplified technique: in a single step, EUS-GE was performed, directly puncturing with a hot-cautery device the jejunal loop and using a fully-covered lumen-apposing metal stent (LAMS). A pneumatic stent dilation was finally performed to consolidate the newly-created fistula. The patient was able to tolerate oral feeding and discharged 2 days after. An adequate nutritional state persists after 8 months, with patency of the stent. In the context of the COVID-19 crisis in Italy, EUS-GE was preferred to surgery for GOO with a rapid hospital discharge and prompt oncological treatment resumption. COVID-19 outbreak dramatically changed patients' management in Italy, especially for oncological patients, due to their higher risk of becoming critically ill contracting the virus. Oncologists have to reassess the surgical procedures need, considering nonsurgical management whenever possible.[1] In this period, a 53-year-old male presented with GOO. Upper-GI endoscopy revealed a large duodenal bulb Forrest 3 ulcer [Figure 1], with second duodenum stenosis [Figure 2], positive for DLBCL. Two cycles of specific chemotherapy were given. Finished second cycle, the patient developed a mild form of COVID-19 disease with pharyngeal swabs positive for 90 days. Given GOO presence in COVID-19 patient, EUS-GE was considered. The procedure was performed in a negative-pressure endoscopic room under oro-tracheal intubation. Under endoscopic and fluoroscopic control a guide-wire was advanced through the duodenal stenosis to the first jejunal loop; a 7-French pig-tail nasojejunal tube (N-JT) was advanced through the guidewire and left in situ. A linear echoendoscope (EG38-J10UT-Pentax, Hamburg, Germany) was used and 500 mL of saline was injected into N-JT under continuous EUS-control, to distend the first jejunal loop at Treitz ligament. With adequate loop distension and clear lumen evidence, methylene blue dye was injected through the N-JT for subsequent GE patency assessment. EUS-GE was performed in a single step directly puncturing with a hot-cautery device jejunal loop, positioning a fully-covered LAMS (LAMS; HotAxios-Boston Scientific) 2 cm in caliber, 1 cm length, to connect gastric wall with first jejunal loop [Figure 3].[2] Methylene blue dye outlet was immediately seen; iodinate contrast injection into N-JT confirmed stomach-jejunum connection [Video 1]. Pneumatic stent dilation up to 18 mm was performed [Video 2]. 24 h contrast X-ray confirmed LAMS correct positioning and patency [Figure 4]. Two days after, the patient was able to tolerate oral feeding and was discharged. An adequate nutritional state persists after 8 months, with patency of the stent [Figures 5, 6 and Video 3]. Being the lymphoma in complete remission, a surgical/more definitive strategy will be discussed.Figure 1: Endoscopic aspect of duodenal bulb ulcer, resulted at histology diffuse large B cell-lymphomaFigure 2: Computed tomography-scan view of second duodenum stenosis due to the lymphoma (with naso-gastric tube inserted)Figure 3: Endoscopic view just after second flange positioning of lumen apposing metal stent between the stomach and the first jejunal loopFigure 4: 24-h contrast X-ray after EUS-gastroenterostomy: Lumen apposing metal stent correct positioning and patencyFigure 5: 8-month endoscopic control after EUS-gastroenterostomy: Complete duodenal bulb ulcer regressionFigure 6: 8-month endoscopic control after EUS-gastroenterostomy: Lumen apposing metal stent correct positioning and patencyLumen apposing metal stent correct positioning and patencyGOO increases malnutrition risk and significantly impacts on life quality and oncological regimens adherence. In the context of the COVID-19 crisis in Italy, EUS-GE was preferred to surgery for GOO with a rapid hospital discharge and prompt oncological treatment resumption. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.