Laparoscopic Small Bowel Resection Research Articles

Ileoileal intussusception due to metastatic melanoma

Introduction: Intussusception in adults is rare, and can be classified into intussusception with a pathological lead point, or intussusception without a lead point. Case Report: This case report describes a 63-year-old male with a history of metastatic melanoma who presented with a two-month history of abdominal pain, which was due to an ileoileal intussusception with metastatic melanoma deposit at the lead point. He was managed with laparoscopic small bowel resection, leading to resolution of his symptoms. Conclusion: A low threshold for surgical exploration is recommended in adults with intussusception for definitive diagnosis of the cause and for symptom management.

Bleeding Meckelʼs Diverticulum: An Alternative Diagnostic Approach

Gastrointestinal bleeding secondary to Meckel's diverticulum in adulthood can be diagnosed by multiple methods but advanced endoscopic techniques are not routinely used. We described a case of Meckel's diverticulum diagnosed after retrograde double ballon enteroscopy (DBE). A 33-year-old female with a history of peptic ulcer disease (PUD) presented with melena. Her PUD was diagnosed 13 years ago in another country by EGD, without recurrence. The melena started 1 day prior to admission with sharp epigastric abdominal pain. She denied additional risk factors for PUD and had completed recent urea breath testing that was negative for Helicobacter pylori. On admission her labs were significant for a hemoglobin of 11 g/dL, MCV 82.4. Physical exam demonstrated mild diffuse abdominal tenderness. She underwent an inpatient EGD which was normal. Outpatient colonoscopy was unremarkable with a normal terminal ileum, followed by a capsule endoscopy that was significant only for a focal proximal jejunal erosion. The following month she developed recurrent melena with a hemoglobin of 10.2 g/dL. She completed antegrade DBE to the mid jejunum that was normal. She subsequently underwent a retrograde DBE, revealing blood throughout the colon, and a Meckel's diverticulum in the mild ileum with short distal ulceration and a visible vessel. The area was tattooed, and general surgery performed a laparoscopic small bowel resection of the Meckel's diverticulum without complications. She has remained asymptomatic since her surgery. Meckel's diverticulum that presents with bleeding is typically diagnosed via mesenteric arteriography or Meckel's scan. The endoscopic and radiographic evaluation varies for adult patients. The role of DBE in Meckel's diverticulum has been reported in small cases series but can be a reliable means of diagnosis.

A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism

BackgroundCholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis.Case presentationA 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake.Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE.ConclusionThis appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.

Surgical management of complicated and medically refractory inflammatory bowel disease during pregnancy.

The medical management of inflammatory bowel disease (IBD) in pregnancy and the puerperium is well defined. Data on surgical management of complicated IBD in this setting are lacking. This study aimed to determine the optimal surgical strategy for medically refractory IBD during pregnancy and the puerperium. Three databases were systematically reviewed to identify all published series or case reports of women undergoing surgery for Crohn's disease (CD) or ulcerative colitis (UC) while pregnant or during the puerperium. Thirty-two papers were identified, including 86 patients. Nearly one-fifth (18%) of cases were de novo presentations and intervention was required at all stages of pregnancy. UC refractory to medical treatment and perforated small bowel CD were the commonest indications for surgery. Operations used included colectomy, colectomy with mucous fistula and Turnbull-blowhole colostomy for complicated UC and open or laparoscopic small bowel resection with stoma formation for CD. Surgical intervention during the third trimester universally resulted in the onset of labour. Endoscopic and radiological interventions were rarely employed. In studies after 1980 there was no maternal or foetal mortality but there was an almost 50% preterm delivery rate. Surgical management of complicated IBD during pregnancy and the puerperium needs to be tailored to disease severity, the type of complications and foetal status. It should involve gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists in a multidisciplinary manner within a single unit.

貧血が契機となり発見された空腸海綿状血管腫の1例

A 30-year-old male came to the hospital because of unsteady walking. Blood examination revealed severe anemia. Esophagogastroduodenoscopy (EGD) revealed no lesion. Colonoscopy revealed no lesion, but blood was present in the ascending colon. Double-balloon enteroscopy revealed a 50-mm elevated lesion in the jejunum. The surface of the lesion had a white and red granular pattern, which indicated cavernous lymphangioma. A laparoscopic small bowel resection was performed. The resected specimen showed a 75×50 mm-sized tumor. Pathological findings showed proliferation of blood vessels in the submucosa and lymphatic hyperplasia in the lamina propria mucosae. The main pathological finding was proliferation of blood vessels in the submucosa. Therefore, the lesion was diagnosed as cavernous hemangioma.

Intraoperative fluorescence-based enhanced reality laparoscopic real-time imaging to assess bowel perfusion at the anastomotic site in an experimental model.

Fluorescence videography is a promising technique for assessing bowel perfusion. Fluorescence-based enhanced reality (FLER) is a novel concept, in which a dynamic perfusion cartogram, generated by computer analysis, is superimposed on to real-time laparoscopic images. The aim of this experimental study was to assess the accuracy of FLER in detecting differences in perfusion in a small bowel resection-anastomosis model. A small bowel ischaemic segment was created laparoscopically in 13 pigs. Animals were allocated to having anastomoses performed at either low perfusion (25 per cent; n = 7) or high perfusion (75 per cent; n = 6), as determined by FLER analysis. Capillary lactate levels were measured in blood samples obtained by serosal puncturing in the ischaemic area, resection lines and vascularized areas. Pathological inflammation scoring of the anastomosis was carried out. Lactate levels in the ischaemic area (mean(s.d.) 5·6(2·8) mmol/l) were higher than those in resection lines at 25 per cent perfusion (3·7(1·7) mmol/l; P = 0·010) and 75 per cent perfusion (2·9(1·3) mmol/l; P < 0·001), and higher than levels in vascular zones (2·5(1·0) mmol/l; P < 0·001). Lactate levels in resection lines with 75 per cent perfusion were lower than those in lines with 25 per cent perfusion (P < 0·001), and similar to those in vascular zones (P = 0·188). Levels at resection lines with 25 per cent perfusion were higher than those in vascular zones (P = 0·001). Mean(s.d.) global inflammation scores were higher in the 25 per cent perfusion group compared with the 75 per cent perfusion group for mucosa/submucosa (2·1(0·4) versus 1·2(0·4); P = 0·003) and serosa (1·8(0·4) versus 0·8(0·8); P = 0·014). A ratio of preanastomotic lactate levels in the ischaemic area relative to the resection lines of 2 or less was predictive of a more severe inflammation score. In an experimental model, FLER appeared accurate in discriminating bowel perfusion levels. Surgical relevance Clinical assessment has limited accuracy in evaluating bowel perfusion before anastomosis. Fluorescence videography estimates intestinal perfusion based on the fluorescence intensity of injected fluorophores, which is proportional to bowel vascularization. However, evaluation of fluorescence intensity remains a static and subjective measure. Fluorescence-based enhanced reality (FLER) is a dynamic fluorescence videography technique integrating near-infrared endoscopy and specific software. The software generates a virtual perfusion cartogram based on time to peak fluorescence, which can be superimposed on to real-time laparoscopic images. This experimental study demonstrates the accuracy of FLER in detecting differences in bowel perfusion in a survival model of laparoscopic small bowel resection-anastomosis, based on biochemical and histopathological data. It is concluded that real-time imaging of bowel perfusion is easy to use and accurate, and should be translated into clinical use.

Acute Portomesenteric Venous Thrombosis following Laparoscopic Small Bowel Resection and Ventral Hernia Repair.

Acute portomesenteric venous thrombosis is a rare but life-threatening complication of laparoscopic surgery that has been described in literature. Prompt diagnosis and early initiation of treatment are vital to prevent life-threatening complications such as mesenteric ischemia and infarction. A 51-year-old lady had laparoscopic small bowel resection and primary anastomosis with ventral hernia repair 4 weeks earlier for partial small bowel obstruction. Her postoperative period was uneventful and she was discharged home. Four weeks after surgery she developed watery diarrhea and generalized abdominal pain for four-day duration. A computed tomography of the abdomen revealed portomesenteric venous thrombosis although a computed tomography of abdomen before surgery 4 weeks back did not show any portomesenteric venous thrombosis. We are reporting a case of acute portomesenteric venous thrombosis as a complication of laparoscopic surgery.

Large Primary Jejunal Adenocarcinoma Presenting as Bilateral Ovarian Carcinomatosis: Not Always a Krukenberg Tumor

Introduction: Adenocarcinoma of the small intestine (ASI) accounts for less than 2% of all gastrointestinal (GI) cancers. Metastatic ovarian neoplasm accounts for 3-8% of all ovarian tumors; however, metastasis from jejunal origin is extremely rare. Involvement of both ovaries, mainly originating from gastric cancer, is widely characterized as Krukenberg tumor, with classic signet-ring cell morphology and ovarian stromal sarcomatoid proliferation. We present a rare case of a woman with bilateral ovarian carcinomatosis of intestinal-type adenocarcinoma, without histologic features of Krukenberg tumor. A 37-year-old woman with recent bilateral oophorectomy and hysterectomy due to intestinal type carcinomatosis of the ovaries presented with dull epigastric pain associated with nausea and relieved by self-induced bilious, nonbloody vomiting. She denied changes in bowel habits or blood in the stool and was not anemic. Abdominal computed tomography showed a mildly dilated loop of small intestine in the left upper quadrant measuring 3.6 cm in diameter, with a distal mass-like transition. Push enteroscopy revealed a near-obstructing jejunal mass located 60 cm distal to the duodenal bulb. Colonoscopy was unremarkable. Biopsy of this mass showed invasive, moderately differentiated ASI. The patient underwent laparoscopic small bowel resection with primary anastomosis and omental biopsy. Final pathology report revealed a moderately differentiated, infiltrating ASI, invading the pericolonic adipose tissue with lymph node involvement. There were no histologic features of Krukenberg tumor in either the ovarian or intestinal adenocarcinoma. Primary jejunal adenocarcinoma (PJA) with involvement of both ovaries without histologic features of Krukenberg tumor is extremely rare. Lymphatic or direct spread is considered to be the main route of metastasis. Unless the tumor is causing intestinal obstruction, the diagnosis is frequently evasive until late in the course of the disease. Physicians should have a high index of suspicion for PJA in patients who present with vague symptoms of abdominal pain, vomiting, GI bleeding, unexplained weight loss, or other signs of small intestinal obstruction and bilateral ovarian carcinomatosis.Figure 1: Jejunal tumor.

Laparoscopic treatment of ileal intussusception due to heterotopic gastric mucosa in an adult patient.

Adult intussusception, which is a rare condition, generally requires surgical treatment. A 25-year-old-male with abdominal pain was diagnosed as ileal intussusception with computerized tomography. The patient underwent diagnostic laparoscopy, laparoscopic small bowel resection and anastomosis. The pathologic evaluation revealed heterotopic gastric mucosa. Heterotopic gastric mucosa is rarely seen in ileum and is difficult to diagnose preoperatively. Excision is the choice of treatment. Laparoscopic treatment can be preferred in adult intussusception even in urgent cases.

Polypoid arteriovenous malformation presenting with jejunojejunal intussusceptions in an adult.

Jejunal polypoid arteriovenous malformations (AVMs) and jejunojejunal intussusceptions are both rare. Here, we present the case of a 61-year-old woman who suffered intermittent episodes of abdominal pain over the course of 13 years. A computed tomography scan of her abdomen and pelvis revealed a distal jejunojejunal intussusception. A suspected low density mass was observed at the tip of the intussusception. Treatment comprised laparoscopic small bowel resection with end-to-end jejunostomy. The final diagnosis was a polypoid AVM measuring 5×3.5×3 cm. We suggest that polypoid AVM should be considered as a differential diagnosis in patients presenting with small intestinal neoplasms.

Small Bowel Hemangioblastoma Presenting as Acute GI Bleed

Introduction: A hemangioblastoma is an uncommon central nervous system (CNS) tumor. It is typically slow-growing and sporadic in occurrence, but up to 25% of cases are associated with von Hippel-Lindau disease. Generally found in the cerebellum, brainstem, or in the spinal cord, there are only a few reported cases of hemangiomablastomas outside the CNS, and these appear to be limited to the kidney, colon, and the retroperitoneum. Hemangiomablastomas are highly vascular lesions and in this presentation we summarize a unique case of acute GI bleeding secondary to hemangiomablastoma in the small bowel. Case Report: A 35-year-old Caucasian male with an unremarkable past medical history presented with syncopal episodes that began after having multiple bowel movements with black stools and subsequent hematochezia. He denied previous episodes of GI bleeding or anemia. He had no complaints of abdominal pain, heartburn, dysphasia, or weight loss. He had recently taken amoxicillin for a URI, and he had taken ibuprofen for several days leading up to his hospitalization. He denied sick contacts or recent travel. The family history was unremarkable. The patient's physical exam was essentially benign. Specifically, he had no abdominal tenderness. His laboratory tests included a hemoglobin level of 11.0 g/DL, and a BUN/creatinine of 25/1.2 mg/DL. The CT scan of the abdomen/pelvis found no abnormalities. The patient subsequently underwent an EGD and colonoscopy, which were both unremarkable. A Meckel's scan was negative, with no evidence for focal abnormal radiotracer activity. A video capsule endoscopy was then performed, and an ulcerated lesion was noted in the distal jejunum. The patient was referred to surgery and underwent an uneventful laparoscopic small bowel resection of the lesion. The surgical pathology results identified an extracerebellar hemangioblastoma. This diagnosis was supported by immunohistochemistry that showed that the stromal cells between the capillaries were negative for CD34, yet clearly positive for inhibin. The neooplastic cells also showed cytoplastic brachyuric expression consistent with hemangioblastoma. The patient has since done well, without recurrence of GI bleeding or other negative sequelae. Conclusion: To our knowledge, this appears to be the first reported case of a hemangioblastoma presenting in the small bowel. While extraordinarily rare, a hemangioblastoma should be considered in the differential for small bowel pathology associated with GI bleeding.

An Unusual Cause of Gastrointestinal Bleeding: There Is More Than Meets the Eye

Question: A 39-year-old man was admitted to the hospital with a 3-week history of intermittent episodes of melena and normocytic anemia with a hemoglobin of 7.0 and mean corpuscular volume of 86. His pre-endoscopic Rockall score was 0 and a Glasgow Blatchford of 10. His past medical history included diagnoses of schizophrenia and hypothyroidism. His medications included levothyroxine and risperidone and there was no history of nonsteroidal anti-inflammatory drug use use. He was transfused to a target hemoglobin of 9 and underwent gastroscopy with duodenal biopsies and colonoscopy with no stigmata of recent hemorrhage to explain his presentation. An urgent capsule endoscopy (SBCE) was performed in view of negative investigations. Figure A and the Supplementary Video show the capsule (SBCE) image and video clip of the abnormality. Magnetic resonance imaging (MRI) of the small bowel was performed following his SBCE findings (Figure B). Figure C reveals the histopathology specimen of the abnormality. What is the likely diagnosis? Look on page 915 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The images reveal the presence of an inverted Meckel's diverticulum, although this diagnosis was not recognized preoperatively in this case. Although rare, inverted Meckel’s diverticulum has been reported in the literature.1Rashid O.M. Ku J.K. Nagahashi M. et al.Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage.World J Gastroenterol. 2012; 18: 6155-6159Crossref PubMed Scopus (20) Google Scholar It can present as bleeding because of the presence of either ectopic gastric mucosa, trauma, or inversion-induced ischaemia.1Rashid O.M. Ku J.K. Nagahashi M. et al.Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage.World J Gastroenterol. 2012; 18: 6155-6159Crossref PubMed Scopus (20) Google Scholar Abdominal radiographic imaging including computed tomography is usually nonspecific unless the patient has intestinal obstruction or intussusception; however, 1 case reported a positive preoperative diagnosis using MRI.2Dujardin M. Op de Beek B. Osteaux M. Inverted Meckel’s diverticulum as a leading point ileoileal intussusception in an adult: case report.Abdominal Imaging. 2002; 27: 563-565Crossref PubMed Scopus (31) Google Scholar It can appear as a smooth intraluminal mass or a pedunculated polyp.3Levy A.D. Hobbs C.M. Meckel diverticulum: radiologic features with pathologic correlation.Radiographs. 2004; 24: 565-587Crossref PubMed Scopus (211) Google Scholar Treatment is surgical excision and is curative. It was initially felt that the findings at MRI (Figure B, arrow) and SBCE (Figure A) were consistent with a small bowel tumor and he underwent a laparoscopic small bowel resection of the lesion (midileum). The histology, however, confirmed the presence of an inverted Meckel’s diverticulum. Figure C shows a transverse cross-section through the Meckel’s diverticulum demonstrating peri-intestinal fat and covering inverted bowel wall. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjMjMwMGY1ZWNkYjEzYWUyNzFkZTIwYzZjMzQ0ZjA5OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgwNjU5NTMyfQ.EFQ_UMkZSyU_Qgct6T2FNPXIiKhzroL7et6zvesAcBMbqMxeRIwYZtiktjvCfvHRyX66uE5S4beCyVkzcBFiPxp7QtBVWEPncVZBb6wS18Lsyb_3Y5vrCHN9cP6vMObvtIgOf9N8D-x1K-PR19FLr5X5sYl8Kckp97bH837Sw49kFnitVW-0pi9O4BsUQCjehLMqQkHkFyZ_7-KZY9mjcbzWEFXY9kyvGD07F1-Xlp_4oKrHCFD1FOX_uV5MrKvwGFLwz27pCfVoRmdyc-0Ns58P89Mxi9IQRIrOujbTAvHHY9cT0xKlJ4XQqvP5wSoMyO56OxF-Mi0630A5YYz5Eg Download .mp4 (5.01 MB) Help with .mp4 files Supplementary Video

SMALL BOWEL LAPAROSCOPIC RESECTION FOR STRANGULATED UMBILICAL HERNIA

BMI of 51.3 kg/m 2 . A laparoscopic approach was performed; the exploration confirmed the strangulated umbilical hernia containing small bowel. Kelotomy was necessary to reduce the small bowel. Given the ischemic injuries of the herniated small bowel segment, the resection with side-to-side stapled anastomosis was then performed. The hernia sac was also resected. The parietal defect was then closed by conventional non absorbable running suture. The postoperative course was uneventful and the patient was discharged in the 4 th postoperative day. CONCLUSION: Even the laparoscopic small bowel resection for strangulated hernia is controversial the technique is feasible and safe in obese patients and could avoid operative site infection.

Laparoscopic Resection of Small Bowel for Endometriosis: A Retrospective Analysis of Demographics, Clinical Presentation, Prevalence, Procedure and Short and Long Term Follow Up

Study Objective: 1) To assess the correlation between the diagnosis by clinical presentation, laparoscopic observation and histopathological findings. 2) To assess efficacy and safety of laparoscopic small bowel resection in short and long term. Design: Retrospective study. Duration of follow up - 1 month to 96 months. Setting: Center for Endometriosis Care, a tertiary referral center for endometriosis, Atlanta, GA. Patients: Fourteen consecutive patients with small bowel endometriosis from year 2003 to 2010. Intervention: 1)Laparoscopic small bowel resection and reanastomosis. 2)Short and long term follow up with a standard questionnaire. Measurements and Main Results: At this referral center we have 144 cases of gastrointestinal endometriosis from year 2003 to 2010 and 14 small bowel endometriosis cases. Assessment included standard pre and post operative questionnaire for subjective symptoms and severity. Objective measurements were obtained by standard laparoscopic exploration of pelvis and abdomen. The disease was confirmed by histopathology report. Majority of patients were Caucasian in our study and age ranged from 25 to 49 years with an average of 35.1 years. Preoperative bowel symptoms included intestinal cramping in 85.7%, painful bowel movement in 78.5%, and constipation in 64.2% of patients. Major postoperative complication was seen only in one patient (7.1%). We found 93% positive correlation between the laparoscopic diagnosis and histopathological findings. Preliminary long term results show 100% symptom relief which is very promising. Conclusion: In our study small bowel endometriosis accounts for 9.7% of gastrointestinal endometriosis so we recommend laparoscopic exploration and management of small bowel in addition to large bowel in patients with bowel symptoms. In literature most small bowel endometriosis cases are diagnosed after emergent surgery for bowel obstruction. In order to avoid associated morbidity and mortality, we strongly advise resection of small bowel as plan of treatment after the diagnosis is made. Our data suggest that laparoscopic small bowel resection is a safe and effective procedure in hands of experienced team of laparoscopic gynecologist and surgeons.

Laparoscopic small bowel resection in the treatment of small intestinal tumors

腹腔镜技术已成为未来外科的发展方向之一，并已广泛地运用于普外科的各种手术中。但腹腔镜小肠切除术在小肠肿瘤，特别是恶性肿瘤方面的应用报道较少。我院从2003年4月至2010年3月间共施行了8例腹腔镜辅助下小肠切除术治疗小肠肿瘤，现将结果报告如下。

Midgut pain due to an intussuscepting terminal ileal lipoma: a case report

IntroductionThe occurrence of intussusception in adults is rare. The condition is found in 1 in 1300 abdominal operations and 1 in 100 patients operated for intestinal obstruction. The child to adult ratio is 20:1.Case presentationA 52-year-old Irish Caucasian woman was investigated for a 3-month history of intermittent episodes of colicky midgut pain and associated constipation. Ileocolonoscopy revealed a pedunculated lesion in the terminal ileum prolapsing into the caecum. Computed tomography confirmed a smooth-walled, nonobstructing, low density intramural lesion in the terminal ileum with secondary intussusception. A laparoscopic small bowel resection was performed. Histology revealed a large pedunculated polypoidal mass measuring 4 × 2.5 × 2 cm consistent with a submucosal lipoma. She had complete resolution of her symptoms and remained well at 12-month follow-up.ConclusionThis case highlights an unusual cause of incomplete small bowel obstruction successfully treated through interdisciplinary cooperation. Ileal lipomas are not typically amenable to endoscopic removal and require resection. This can be successfully achieved via a laparoscopic approach with early restoration of premorbid functioning.