Left Mid Abdomen Research Articles

Jejunal Cavernous Hemangioma Mimicking Malignancy With Increased Activity on 18F-FDG PET/CT.

A 50-year-old woman underwent 18F-FDG PET/CT to evaluate possible abdominal malignancy, which was revealed by CT. The images showed a large cystic-solid lesion with peripherally increased FDG activity in the left mid-abdomen. Histopathology of the excised lesion confirmed a jejunal cavernous hemangioma. We reported a rare case of jejunal cavernous hemangioma with FDG accumulation on PET/CT, mimicking malignancy.

A case report of encapsulating peritoneal sclerosis followed by cesarean section: Clinical diagnosis and treatment experience

Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon syndrome, is an uncommon condition that typically presents with features of bowel obstruction. EPS followed by cesarean section is extremely rare. Intestinal obstruction caused by EPS lacks specificity and poses clinical difficulties for diagnosis and treatment. We present the case of a patient with recurrent intestinal obstruction followed by cesarean section, and the diagnosis of EPS was confirmed intraoperatively. The patient recovered well postoperatively, and achieved satisfactory therapeutic results. Management of this condition tests the surgeon's knowledge and experience of the disease. A 27-year-old woman with recurrent abdominal pain and distention accompanied by reduced anal discharge and defecation there months. The patient had a history of cesarean section 4 months earlier and recovered well after operation. She had no other history of abdominal surgery or diseases. On examination, a 10-cm long transverse incision was made in the lower abdomen, and marking on the intestinal movements were observed in the left mid-abdomen. A long, soft lump with good mobility was touched in the left lower abdomen. The abdominal computed tomography and small bowel barium meal examination revealed incomplete intestinal obstruction. Incomplete small bowel obstruction due to abdominal adhesions after the cesarean section was initially considered. After conservative treatment, the symptom of intestinal obstruction still recurred. Thus, we decided to perform a surgery of repeated decortication of fibrous peritoneal membranes. The operation successfully released the intestinal obstruction and abdominal pain, postoperative course recovered smoothly. After cesarean section could develop EPS. Intestinal obstruction caused by EPS lacks specificity and poses clinical difficulty in diagnosis and treatment. The management of this condition tests the surgeon's knowledge and experience, and surgery is an effective treatment measure.

The Limiting Reagent for Peristalsis

Question: A 62-year-old woman with a history of renal cell carcinoma surgically managed via left nephrectomy and small bowel obstructions treated surgically presented with 4 days of oral intolerance and abdominal distention. Her last bowel movement and flatus were 3 days prior. She was afebrile, vital signs stable, with a white blood cell count of 12.9 × 103/μL. Computed tomography findings were significant for marked distension of the stomach and proximal duodenum, with a transition point in the left midabdomen and distal collapsed loops of small bowel and colon.

Laparoscopic Technique for Extraction of Large Abdominopelvic Masses

<h3>Study Objective</h3> To review preoperative evaluation of a patient presenting with an abdominopelvic mass. To discuss methods of drainage and spill prevention during surgical management of large abdominopelvic masses and to demonstrate an efficient laparoscopic method for extraction of large adnexal masses. <h3>Design</h3> N/A <h3>Setting</h3> In the operating room with patient in dorsal lithotomy position with both arms tucked. Five-millimeter ports were placed in the umbilicus, the right lower quadrant and the left mid-abdomen. The specimen was extracted through an 8 mm port in the left lower quadrant. <h3>Patients or Participants</h3> 27-year-old female with a 15 × 13 cm abdominopelvic mass who presented with right lower quadrant and low back pain and mild right hydronephrosis. She had a benign appearing cyst on ultrasound and her tumor markers were negative. <h3>Interventions</h3> We employ a morcellation method we refer to as apple-peeling to cut the cyst into a long strip of 1 inch width to allow easy removal through an 8 mm laparoscopic port without spill or struggle. <h3>Measurements and Main Results</h3> N/A <h3>Conclusion</h3> Large abdominopelvic masses can be managed via laparoscopic approach with proper pre-operative work-up to ensure benign status. The apple-peeling morcellation technique demonstrated in this video allows efficient extraction of abominopelvic masses > 10 cm through small laparoscopic ports (8mm)

S3689 Small Bowel Obstruction in COVID-19 Patient Without Risk Factors

Introduction: The documented gastrointestinal associations of COVID-19 infection include enteritis, colitis, ileus, and mesenteric thrombosis from associated coagulopathy. A direct link to small bowel obstruction (SBO) has yet to be proposed. Aside from isolated cases of bacterial enteritis, infection is not a widely accepted cause of SBO. SBO is mostly caused by adhesions formed after intra-abdominal surgery. Other causes include congenital adhesions, neoplasms, hernias, and stenosis from inflammatory bowel disease (IBD) or bowel ischemia. We report a unique case of acute SBO in a patient with COVID-19 symptoms but no known risk factors of SBO. Case Description/Methods: A 67-year-old man with history of HTN and TURP for BPH presented with intermittent fever and dry cough for 1 week. He had no history of abdominal surgery, hernia, malignancy, IBD, or bowel ischemia. He was febrile to 102.6F and O2 saturation was 100% on room air without respiratory distress. SARS-CoV-2 PCR assay was positive. After two days of remdesivir, he was hypoxic requiring nasal cannula and had abdominal pain with loose stool. On exam, abdomen was distended with guarding. CT abdomen showed 2 transition points, multiple dilated bowel loops, and fluid and stool in distal bowel consistent with partial SBO. Nasogastric tube drained gastric contents with bile. He was intubated for ex-lap which showed no transition points or congenital adhesions. Proximal two-thirds of bowel were dilated, thickened, and hyperemic but the distal third was normal caliber. Creeping fat and friable mesentery with ecchymosis were noted throughout. Abdomen was left open with plan for closure the following day. Closure was delayed by 4 days due to worsening hypoxia and new pressor requirements. Oxygen and pressor requirements improved after starting steroid and antibiotic treatment. Abdomen was then closed as bowel remained viable. He was extubated, weaned to room air, and able to tolerate food within 1 week followed by discharge to rehab. Discussion: In our patient who developed partial SBO in the setting of worsening COVID-19 respiratory symptoms with no history of intra-abdominal surgery or other risk factors of SBO, COVID-19 should be considered as a possible etiology. Ex-lap findings were non-specific and could indicate inflammatory or ischemic evidence of COVID-19 gut involvement. Further research is required to better understand this patient’s diagnosis and a possible relationship between COVID-19 enteritis and acute development of SBO.Figure 1:: CT Abdomen Showing Two Transition Points Image A: Transition point in left mid abdomen. Image B: Transition point in right mid abdomen.

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.

Left Mid Abdomen: An Initial Trocar Entry Site (for complex surgical cases)

Study Objective To demonstrate technique and safety of initial trocar entry into the left mid abdominal wall. Design Video. Setting Small Tertiary Academic University Hospital Center. Patients or Participants N/A Interventions Outline anatomical point on abdomen. Show with video how entry can be accomplished in safe manner. Measurements and Main Results N/A Conclusion Left mid abdomen can be utilized as an initial site for trocar entry with the proper knowledge and setup.

S2862 Bowel Within the Bowel; A Case of Metastatic Melanoma Presenting as Small Bowel Intussusception

INTRODUCTION: Melanoma is notorious for metastasizing to almost any part of the body. Metastasis to the gastrointestinal tract is most commonly diagnosed on autopsy. A clinical diagnosis is rare and occurs in approximately 2% of cases. We present a rare case of metastatic melanoma to the small bowel that presented as melena and ultimately caused small bowel intussusception. CASE DESCRIPTION/METHODS: 84-year-old male was admitted to the hospital with one-week history of melena and worsening abdominal pain. Past medical history was significant for stage IIB metastatic melanoma. Melanoma was first diagnosed on bottom of right foot 10 years prior to admission and was treated with surgical excision and adjuvant pegylated interferon. Patient had recurrence of melanoma on his back 1 year prior to presentation and underwent surgical excision and was treated with nivolumab. Physical examination revealed two new dermal nodules on the left chest. Laboratory investigations showed a decrease in hemoglobin from 11.5 g/dl three months prior to 9.5 g/dl. Esophagogastroduodenoscopy (EGD) was remarkable for a large, purplish, smooth mass in the third portion of the duodenum which was biopsied. Colonoscopy was unremarkable. Histologic examination revealed neoplastic cells positive for MART-1 and negative for CD3 and CD20. Immunohistochemical staining demonstrated that the malignant cells were positive for S100 which confirmed the diagnosis of metastatic melanoma. The patient was discharged however again presented to the Emergency Department with severe abdominal pain. Computed tomography with contrast showed small bowel intussusception within the left mid abdomen with dilated loops of small bowel proximally and collapsed loops of small bowel distally. Patient was taken for an emergent laparoscopic small bowel resection due to concern of ischemia. He was found to have multiple intra-abdominal lesions studding the small bowel and mesentery. Further metastatic workup revealed lesions in the lungs and the brain suggestive of advanced disease. Decision was made to proceed with palliative ipilimumab chemotherapy and radiation. DISCUSSION: Small bowel tumors are rare, accounting for only 3–6% of all GI tumors. Small bowel melanomas can be primary or metastatic lesions. Clinical presentation of GI metastases includes abdominal pain, overt bleeding, anemia, intestinal obstruction or rarely intussusception. Surgery may not be curative, however is the treatment of choice as it is effective in palliating symptoms and may prolong survival.Figure 1Figure 2

SUN-902 Bradycardia as a Presentation of Malignant Pheochromocytoma

IntroductionPheochromocytoma usually presents with tachycardia, hypertension and other symptoms related to catecholamine release. Bradycardia has been reported in up to 10% of patients and is due to an unusual reflex to cathecolamine surge.Case Report:57-year-old morbidly obese female with a history of COPD, hypertension, paroxysmal bradycardia, and urinary incontinence was referred to endocrinology clinic after an adrenal mass was found incidentally as part of a work-up for microscopic hematuria and urinary incontinence. CT abdomen showed unilateral 3.3 x 3.9 cm left lobular adrenal mass. Family history was negative for malignancies or pheochomocytoma. Patient denied substance abuse or ethanol use. Her medications include amlodipine, hydrochlorothiazide and albuterol. Physical exam was remarkable for a BMI of 51.6 and bradycardia of 50 bpm and well controlled blood pressure. On further review of her history, patient had prior visits to outpatient and emergency department for chronic headaches, insomnia, palpitations and sweating. Patient had a previous admission 13 years prior for chest pain and hypertensive urgency associated with headache and junctional bradycardia.Laboratory workup was significant for serum metanephrine levels of 749 pg/ml (normal <42), serum normetanephrine 185 pg/ml(normal <145), serum chromogranin A 130 ng/L(normal <39) and 24hr urine metanephrine of 1340 ug/24hr (normal <96) and urine normetanephrine of 357 ug/24hr (normal <80). Previous ECG showed sinus bradycardia. Echo-cardiogram revealed normal ejection fraction with left atrial enlargement.MIBG showed large focal area of intense radio-tracer accumulation in left mid abdomen and small focal lesions in the liver. Diagnosis of malignant pheochromocytoma was made and patient was referred to another institution for further management.Conclusion:Malignant pheochromocytoma is a rare neuroendocrine tumor that usually presents with tachycardia and hypertension. 10% of patients with malignant pheochromocytoma can debut with bradycardia due to sinus arrest. Although malignant and benign pheochromocytoma share the same clinical and histological features, the presence of metastasis is the main clue to differentiate them. Surgery remains the main treatment option even if complete debulking cannot be achieved. Nuclear radiation therapy or chemotherapy are two other therapeutic options that can be considered alone or in combination with surgery depending on the patients’ comorbidities. Lifetime surveillance is recommended as recurrence can occur up to 40 years after original resection. References-Chen H, Sippel RS, O’Dorisio MS, Vinik AI, Lloyd RV, Pacak K. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Pancreas. 2010 Aug;39(6):775-83.

Aortic anastomotic pseudoaneurysm repaired with iliac branched endoprosthesis

A 75-year-old man undergoing surveillance imaging for a known pseudoaneurysm of the aortic anastomosis of an aortobifemoral bypass graft placed 20 years prior for occlusive disease was found to have increase in pseudoaneurysm size to 6 cm (A/Cover). The patient has a history of chronic obstructive pulmonary disease and non-small cell lung cancer with right upper lobectomy. He is of very thin habitus, and a pulsatile mass was visible in his left mid abdomen. Previously, the patient had undergone multiple cutdowns to the right and left groin for graft thrombectomies, pseudoaneurysm repair, as well as distal bypass and revision of the distal bypass with the last intervention 5 years previously.

2650 Severe Celiac Disease Presenting With Intussusception Without Lead-Point in an Adult Male

INTRODUCTION: Adult celiac disease is an autoimmune disorder that usually presents with abdominal pain and diarrhea. We present the case of an adult man who presents with chronic diarrhea and intussusception, who was diagnosed with severe celiac disease. CASE DESCRIPTION/METHODS: 38 year old male with history of depression, presents with three months of abdominal pain and intermittent watery diarrhea, associated with thirty-pound weight loss, fatigue, nausea, diffuse joint stiffness and mild swelling, and tingling and numbness that started two weeks prior. Physical exam was remarkable for thin body habitus, hyperactive bowel sounds and diffuse abdominal tenderness with guarding. Laboratory testing was significant for microcytic anemia and INR 2.7, work up for infectious causes of diarrhea was negative. Liver and renal function tests were normal. CT of the abdomen showed fluid filled colon as well as entero-enteric intussusception of approximately 10 cm in left mid abdomen. Further investigation included tissue transglutaminase (TTG) antibodies of more than 100 U/mL and IgA 227. Colonoscopy with random biopsies was performed, pathology revealed partial villous atrophy negative for increased intraepithelial lymphocytes, suggestive of celiac disease. Patient was diagnosed with severe celiac disease, associated with multiple vitamin deficiencies secondary to malabsorption and peripheral neuropathy. Patient was managed conservatively and eventually discharged with follow up of Gastroenterology and Rheumatology practices. DISCUSSION: Intussusception is well described in patients with previously diagnosed celiac disease, in which small intestinal lymphoma or adenocarcinoma may represent the “lead point” causing the intussusception. Much rarely seen is intussusception as the presenting symptom of previously undiagnosed celiac disease, particularly in the absence of a lead point. Theories of its development include presence of flaccid, dilated small bowel, fold abnormalities, lymphadenopathies and fluid excess. Intussusception in celiac disease is often multiple, transient and repetitive, so surgical intervention should be avoided. In our case, the presence of intussusception without a lead point was suggestive of celiac disease, confirmed by serologic and histologic testing. Intussusception without a lead point should prompt investigation for celiac disease as it may represent initial presentation, in order to avoid unnecessary surgical intervention.

Intussusception in an Adult With Chronic Cannabis Use: A Case Report

Intussusception is a rare finding in adults presenting with abdominal pain. In the absence of obstruction, environmental factors should be investigated. Cannabinoid Hyperemesis Syndrome (CHS) and its relationship to intussusception in adults has not been established but should be considered if the clinical course matches the criteria and an obstruction has been ruled out. A recent article in The New York Times identified the syndrome as a commonly missed diagnosis that may affect an estimated 2.7 million Americans that are known to smoke marijuana. Patients present to the emergency department (ED) an average of 7 times before a diagnosis is made, expending up to $100,000 in medical resources. With the recent legalization of marijuana by many states, more patients are suspected to present with this syndrome. This case represents an example of how a delay in making a clinical diagnosis correlates to overtesting and rising medical costs. A 30-year-old female with a history of inhaled cannabis use since adolescence presented to the ED with abdominal pain, nausea, and vomiting. She has a history of multiple visits with similar symptoms in the last 3 years. Symptomatic relief at home was previously achieved with hot showers. The patient was managed for nausea and discharged home. The following day, she returned to the ED with severe abdominal pain and intractable vomiting. Abdominal CT revealed 3 jejunal intussusceptions:1 on the right and 2 on the left. Previous imaging on past presentations showed multiple intussusceptions along the small bowel, but a pathological lead point was never identified. She was admitted to the surgical unit and managed conservatively. On day 3, the abdominal pain subsided and repeat imaging showed resolution of all intussusceptions. Cannabinoid Hyperemesis Syndrome (CHS) is a phenomenon associated with long-term cannabis use. It can be diagnosed clinically by the following criteria: cannabis use, abdominal pain, nausea and vomiting, and symptom relief with hot showers and cannabis cessation. Our patient meets all of the criteria but the correlation to CHS was not previously considered, leading to repeat diagnostic testing and unnecessary hospital admission. In an economy where healthcare costs account for 17.9% of the GDP, reducing medical interventions that add low value to healthcare outcome is critical for the financial sustainability of our health systems. One solution lies in restoring the confidence of making a clinical judgment.3072_A Figure 1. Axial contrast enhanced CT scan of the abdomen showing a target-like mass in the small bowel, pathognomonic of intussusception.3072_B Figure 2. Ring-like configurations in the right and left mid abdomen showing evidence of additional intussusceptions (arrow).3072_C Figure 3. Sagittal contrast enhanced CT scan of the abdomen demonstrating a sausage-like mass, typical of a small bowel intussusception. No obstruction or lead point is identified.

Recurrent Jejunal Intussusception From Heterotopic Pancreas

Introduction Heterotopic or ectopic pancreas is usually asymptomatic. We present a unique case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Case description A 39-year-old male presented locally with a one-year history of recurrent left mid abdominal discomfort. Prior contrast-enhanced computed tomography (Figure 1) was reviewed and showed two areas of jejunal intussusception (arrows). Subsequent diagnostic laparoscopy done at his local hospital was unrevealing. Given ongoing recurrent pain, he came for further evaluation. On examination at our institution, the patient did have pain to palpation in the left mid abdomen without an appreciated mass. Laboratory evaluation revealed a normal complete blood count, liver test and chromogranin A. Capsule endoscopy did visualize a submucosal jejunal lesion. Double balloon enteroscopy showed a 3-centimeter distal jejunal submucosal umbilicated mass (Figure 2). The biopsy of the lesion showed normal jejunal mucosa without dysplasia. Small bowel resection was recommended for definitive diagnosis and to treat the probable recurrent intussusception. Pathologically, a solid 1.2 x 0.8 x 0.6 cm submucosal mass was found. The biopsy result showed benign jejunum with pancreatic glands and ducts extending from the mucosal surface to the muscularis propria consistent with heterotopic pancreatic glands (Figure 3, HE, x10). He has had no further episode following the surgery.FigureFigureFigureDiscussion We present a rare case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Heterotopic (or ectopic) pancreas is a rare congenital anomaly defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. It is usually found in the stomach, duodenum and jejunum. It generally has a diameter of 1-4 cm and is commonly submucosal in nature. Heterotopic pancreas is commonly asymptomatic but can cause pancreatitis, abscess, pseudocyst, malignant transformation, or local complications such as obstruction or intussusception. The diagnosis of this lesion can be challenging. Endoscopic features include umbilication and duct opening, but these findings are non-specific. Endoscopic biopsies are generally superficial and not diagnostic. As the diagnosis is challenging, surgical or endoscopic excision is recommended for both diagnosis and treatment.

Transient Intussusception

Intussusception is the invagination of a bowel segment into the contiguous intestinal tract. It can be further classified according to their location as enteroenteric, colocolonic and enterocolonic, being ileocecal the most common. On CT images, we can recognize three different patterns like target, reniform and sausage shaped. This is a 33-year-old man with a PMH of heroin abuse. Patient was brought to the ER complaining of a right lower abdominal pain. This pain started 2 hours prior arrival to ER and it was described as sharp, stabbing, and radiating to the entire abdomen with associated nausea and vomiting. He denied Any fever. Vital signs showed a BP of 139/80 mmHg, pulse of 80 bpm, RR of 20 and temperature of 99.4 F. On physical exam, the abdomen was soft with tenderness to palpation of RLQ but without rebound. A CT abdomen was done diagnosing short segment of jejunal-jejunal intussusception in the left mid abdomen. Fifteen hours later a repeated CT showed a resolved intussusception, after which the patient underwent a diagnostic laparoscopy where a normal appearing jejunum and ileum without was seen, without any evidence of intussusception. There were no bleeding points or tumors noted on the external surface of both the jejunum and ileum and the appendix appeared grossly normal. Procedure was terminated and the patient was discharged, without any further workup. It is interesting to mention that the mechanism of any intussusception seems to be related to a bowel lesion that serves as a lead point. Although rare, cases of transient episodes have been seen in patients with celiac or Crohn's disease. Unfortunately, our patient was discharge without any further evaluation of the etiology of this episode. Moreover, other diagnostic methods like intraoperative enteroscopy, push-enteroscopy or MR enterography could have been appropriate in this case to find any intraluminal tumors and/or inflammatory process. We report this case to encourage physicians to perform a deeper assessment of the etiology of an episode of intussusception, regardless of its transient nature, since patients can have reoccurring events in the future.Figure: CT abdomen at admission showing intussusception.Figure: CT abdomen- coronal view at admision: intussusception measuring about 5.5 cm in length in the left abdomen.Figure: CT abdomen 15 hours after: where previously seen intussusception has resolved.

Unique Obstructive Intestinal Manifestations of Metastatic Melanoma: A Case Series

Introduction: Though rare in adults, intussusception can occur anywhere in the gastrointestinal (GI) tract causing variable symptoms. 90% of cases may be due to disorders like neoplasm or postoperative status and may cause 1% of small bowel obstructions (SBO). Metastatic melanoma (MM) may involve the GI tract, and its various manifestations accentuate the need for astute awareness when treating patients with MM for GI symptoms.We report the cases of 3 women with MM diagnosed with partial SBO (pSBO) of varying types due to metastases.Figure: A) Axial fused PET/CT of the pelvis reveals a hypermetabolic focus in the ileum. B) Axial contrast-enhanced CT of the pelvis reveals ileal bowel wall thickening and associated intussusception caused by melanoma metastatic mass functioning as a lead-point (orange arrow). Oral contrast reveals distended small bowel proximal to intussusception indicating secondary partial SBO (yellow arrows).Figure: C) Enhancing partially obstructing mass (orange arrow) within the bowel lumen which expands the small bowel at that level. There is an adjacent distended loop of proximal small bowel which is partially filled with gas.Figure: D) Axial contrast CT with right lower quadrant intussusception, likely ileocolonic. E) Axial contrast CT with small bowel intussusception of the left mid-abdomen.Case Presentations: Case 1: A 55-year-old woman with MM (right inguinal primary lesion) to right axillary lymph nodes post excision and radiation underwent positron emission tomography/computed tomography (PET/CT) to address mild abdominal pain and for surveillance. PET/CT detected hypermetabolic activity in the small bowel (A) concerning for a soft tissue mass acting as a lead-point for intussusception and pSBO (B). Surgical excision of the mass confirmed MM. She received chemotherapy, but CT showed new mesenteric and hepatic masses. Case 2: A 75-year-old woman with MM (right heel primary lesion) throughout her abdomen was admitted for SBO causing left lower quadrant pain and constipation. She underwent prior excisions (several intra-abdominal surgeries) and several courses of chemotherapy. CT showed a left lower quadrant intraluminal enteric mass with proximal bowel distention consistent with a metastatic mass causing intermittent or pSBO (C). She improved with nonsurgical therapy. She was too ill for a novel chemotherapy trial and pursued hospice. Case 3: A 58-year-old woman with MM (periumbilical primary lesion) to the shoulder, lung, kidney, spleen, mesentery and brain presented with bilateral upper quadrant pain, postprandial emesis and decreased stool output. 2 months prior, a SBO resolved with conservative therapy. She had no prior abdominal surgery. In addition to intra-abdominal metastases, CT showed 2 areas of small bowel intussusception (D-E) with likely MM lead points causing pSBO. She improved without surgery and resumed chemotherapy. Discussion: These cases highlight the importance of maintaining high clinical suspicion of metastatic GI masses as culprits for SBO. When GI symptoms exist in patients with known malignancy such as MM, attempting to identify a soft tissue mass on imaging as a lead-point in intussusception or transition point in SBO for timely and accurate diagnosis is imperative to optimize management.

Non-communicating small intestinal duplication in a dog: a case report

Enteric duplication is rare in dogs. Here, we report the rarest form of duplication in which two segments are parallel and share a wall for most of their lengths. A nine-year-old spayed female Yorkshire terrier was referred to the Veterinary Medical Teaching Hospital at Gyeongsang National University due to anorexia and diarrhoea. Physical examination, haematological examination, radiography, and ultrasonography were performed. On physical examination, dry, pale mucous membrane was identified. Moderate anaemia with decreased packed cell volume was detected in complete blood count. Serum urea nitrogen and creatinine levels were mildly increased. Radiographic images revealed no significant findings. On ultrasonographic examination, a multi-layered appearance of a focal small intestinal segment was identified in the left mid abdomen. Following the lesion, it was divided into two small intestinal segments. Based on imaging findings, intussusceptions or enteric duplication were suspected. To resect the abnormal small intestinal segment, enterectomy was performed. Follow-up was not performed because the patient expired during the postoperative recovery time. The histopathological diagnosis was non-communicating small intestinal duplication. Non-communicating intestinal duplication is related to embryologic abnormalities and is usually concurrent with other anomalies such as vertebral malformations and urogenital duplications. However, this case had no other anomalies associated with the malformation of the intestine.

Trocar Site Hernia after Use of an 8-mm Bladeless Trocar in Robotic Colorectal Surgery

Port site hernias are a rare complication after laparoscopic and robotic surgery. The current case is an 8-㎜ port site hernia which occurred after robot-assisted colorectal surgery. A 70-year-old female with a BMI (body mass index) of 25.7 was diagnosed as rectosigmoid colon cancer. She underwent a robot-assisted low anterior resection with double-stapled anastomosis for AJCC (American Joint Committee on Cancer) stage IIIB. After the main procedure, fascial defects in the supra-pubic and the supra-umbilical site were closed with a routine procedure (12 ㎜). Thirty two months after surgery, she developed an incisional hernia in the left mid abdomen (8-㎜ port). Recognition of the potential for a port site hernia using an 8-mm bladeless trocar port as well as a 12-㎜ port is essential in robotic surgery. Patients with risk factors for a port site hernia may require complete port site closure.

The Case of the Wandering Spleen

Wandering spleen is a condition that describes the movement of the spleen to an ectopic location inside the abdomen/pelvis as a result of weakened peritoneal ligaments. Wandering spleens are rare, with a less than 0.2% incidence being reported. Diagnosing a wandering spleen can be challenging because of the wide range of findings and the oftentimes vagueness of the patient’s symptoms. The most common ectopic location of the spleen is the left mid-abdomen. The most frequent treatment for wandering spleen includes splenopexy or splenectomy, depending on the complications associated with the condition.

A novel application for single-incision laparoscopic surgery (SILS): SIL jejunostomy feeding tube placement

Single-incision laparoscopic surgery (SILS) is rapidly gaining popularity as the practical alternative to natural orifice transluminal endoscopic surgery (NOTES). Although SILS achieves essentially the same goal as NOTES (a nearly invisible scar in the umbilicus), it does not carry the significant potential risks of a transluminal approach. The SILS approach has been most commonly described for cholecystectomy and appendectomy. The authors describe a novel application for this approach in the placement of a feeding jejunostomy tube. The described application for this technique is the first to be reported. The authors describe use of the technique for two intensive care unit (ICU) patients requiring long-term postpyloric tube feeds. Access was obtained through the umbilicus with the SILS port. The selected loop of the jejunum was exteriorized through this incision, and the feeding tube was placed. The loop was returned into the abdomen, and the SILS port was replaced in the incision. Under laparoscopic visualization and guidance, the feeding tube was brought externally through a predetermined site in the left midabdomen. Two patients underwent SILS jejunostomy tube placement. The average operating time was 42.5 min. No intraoperative or immediate postoperative complications occurred. Tube feedings were started on postoperative day 1 for both patients, with good bowel function. The SILS technique for jejunostomy placement is a promising and feasible alternative to the current methods. It is less invasive than the open approach while providing complete intraabdominal visualization. It is less technically demanding than the direct percutaneous endoscopic jejunostomy (PEJ) approach and avoids the risks and difficulties associated with it. The same benefits of other SILS procedures are evident in this application. The authors believe a series study will further highlight long-term benefits and any potential complications.

Gastrointestinal: A retroperitoneal liposarcoma that formed a fistula into the descending colon

Liposarcoma frequently occurs in the retroperitoneum and lower extremities, accounting for 9.8–16% of all soft tissue sarcomas. Liposaromas vary by histology and can be classified into four types. Those four types are well differentiated, myxoid/round cell, pleomorphic and dedifferentiated. This classification corresponds to the clinical aspect and prognosis of patients. Dedifferentiated liposarcoma (DDL) has both a well differentiated liposarcoma and a high grade nonlipogenic sarcoma within the tumor. It is difficult to diagnose DDL histologically. DDL can show a variety of histological appearances. The most common phenotype is malignant fibrous histiocytoma. Other phenotypes include leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and angiosarcoma. For DDL, prognosis is generally poor compared with the other types of liposarcoma. It shows high recurrence rate of 40-83%, metastasis rate of 15–30%, and the overall 5-year survival rate of 20%. DDLs often originate in the retroperitoneum, extremities, trunk, testis, and spermatic cord. A 61-year-old man was admitted to our hospital with 38.8°C of fever and general weakness. He had a history of a 20 × 10 cm well-differentiated retroperitoneal liposarcoma and underwent debulking surgery and intraoperative radiotherapy eight years previously. After surgery, there was no remnant mass visible on the abdominal computed tomography (CT) scan. On the current admission, physical examination revealed a palpable mass in the left mid abdomen. CT scan revealed a 8.5 × 8.3 cm sized large mass abutting the descending colon and left kidney in the left retroperitoneal cavity. The tumor encased a segment of the bowel loop and there was air density suspicious of tumor fistulization into the colonic lumen. Colonoscopy showed a fistula into the descending colon 30 cm from the anal verge (Figure 1). A yellowish mass was seen through the fistula with erythematous and edematous mucosal changes around the fistula. We suspected that the liposarcoma had recurred, and the patient underwent left colon segmental resection. The specimen showed a 9.5 × 8.5 cm sized, well-demarcated, yellowish-gray, lobulated, glistening, and firm mass. Microscopic findings showed a dedifferentiated liposarcoma containing a well-differentiated component with fat lobules and a nonlipogenic hypercellular area. There were scattered atypical lipocytes (Figure 2, upper panel) and pleomorphic spindle cells (Figure 2, lower panel, H&E, orig. mag. ×200) consistent with a subtype of malignant fibrous histiocytoma. Contributed by