Ligament Of Treitz Research Articles

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications.

Сlinical case of pancreatic cancer

Description of a rare case of pancreas body tumor, which was grown into celiac trunk, is presented. The patient was saved due toanftomy of right hepatic artery, which was a branch of superior mesenteric artery.
 Patient Z.V, 60 years old, came to the clinic with such complaints as pain, heaviness in abdomen and waist area,weakness.4–5 cm tumor of pancreas body was detectedduring surgery. The tumor had grown into celiac trunk and into left adrenal gland.
 The friable tissue of hepato-duodenal ligament was dissected duringthe surgery.Thesurgeons mobilized duodenum usingKoxertechnique. As a result of this manipulation, the followingblood vesselswere visualized:inferior vena cava and abdominal aorta, celiac trunk, superior mesentericartery. Surgical team opened ligament of Treitz and excisedpancreas body2.5 cm away from thetumor proximally. The stump was sewed with “mattress stich”, celiac trunk was sectioned and entangled, surgeons also dissected common hepatic artery. After section they checked blood supply of liver. The pressure of blood flowing from gastro-duodenal and pancreato-duodenal artery was enough for providing normal blood flow in the left hepatic artery.
 Morphological result of the excisedtissue — Ductal adenocarcinoma (No 672).
 The patient’sstate was satisfactory when he left the clinic. He underwent medical check-up three times next year. He feels well, his state of health is normal. Patient is capable of working.
 This case is interesting due to the anatomy of right hepatic artery (which was a branch of superior mesenteric artery) that saved patient’s life.

Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding: New Frontiers.

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to blood loss from the gastrointestinal tract proximal to the ligament of Treitz due to lesions that are non-variceal in origin. The distinction of the bleeding source as non-variceal is important in numerous aspects, but none more so than endoscopic approaches for successful hemostasis. When a patient presents with acute overt blood loss, NVUGIB is a medical emergency, which requires immediate intervention. There have been major strides in pharmacologic and endoscopic interventions for successful induction and remission of hemostasis in the last two decades. Despite achieving tangible improvements, the burden of the disease and the consequent mortality remain high. To address endoscopic outcomes better, several new technologies have emerged and have been subsequently incorporated to the armamentarium of hemostatic tools. This study aims to provide a succinct review on novel technologies for endoscopic hemostasis.

P2.52: Complete Jejunal Exclusion: A novel method to manage Enterocutaneous Fistulas in the background of short bowel syndrome

Introduction: Management of enterocutaneous fistulas (ECF) in patients with short bowel syndrome (SBS) is challenging. High output fistulas are unlikely to close spontaneously; however, the success rate of surgical intervention is limited due to poor nutrition, inflammation, limited bowel length and lack of abdominal wall integrity. Here, we describe 8 cases of utilizing complete jejunal exclusion at the ligament of Treitz with a gastrostomy tube drainage to manage the ECF as a temporary measure for subsequent bowel reconstruction or transplant. To our knowledge, this is the first report of this approach. Methods: Eight patients who underwent jejunal exclusion at our institution were retrospectively reviewed. In all cases, the jejunum was divided 1–2 inches distal to the ligament of Treitz. Both ends were oversewn. A gastrostomy tube was placed for retrograde decompression of proximal enteric secretions without pyloroplasty. In 4 cases of active ECF’s, we accessed the ligament of Treitz via a left subcostal incision to avoid the fistula. Results: The procedure was done for active ECFs (n=4), impending fistulas (n=1), bridge to transplant following desmoid tumor resection in Gardner’s syndrome (n=2), and after graft enterectomy (n=1). Four cases of active ECFs were managed elsewhere without success. All patients were discharged home on TPN. Of the 4 ECF cases, the fistula output decreased substantially in all patients and closed entirely in 2 cases. Two underwent successful reconstruction and 2 are awaiting reconstruction. One who had secondary biliary cirrhosis due to biliary obstruction and TPN induced liver disease died while waiting for multivisceral transplant (MVT). Of the desmoid tumor cases, one underwent MVT, is alive and well 8 years after transplant, while the other refused to undergo MVT and is living with TPN and g-tube decompression 6 years after the procedure. The patient who underwent graft enterectomy is listed for MVT-this patient developed acute pancreatitis after the jejunal exclusion and required G-J tube decompression. Conclusions: Jejunal exclusion is an effective and generally well tolerated option in the management of intractable ECF in patients with SBS. Associated complications include pancreatitis and liver failure. This procedure should be considered as a bridge to intestinal rehabilitation or transplantation in patients with ECFs that fail to close with medical or traditional surgical management. Table:Picture:

P1.52: EXTENDED HIRSCHSPRUNG’S DISEASE: OUR EXPERIENCE AND LITERATURE REVIEW

Introduction: Extended Hirschsprung’s disease (EHD) is a rare condition leading to intestinal failure (IF). Its impact in Latin America (LATAM) is unknown. The aim of this study is to review our experience and published evidence. Methods: Case series. Inclusion criteria: patients < 18 ys. with EHD diagnosis, confirmed by full thickness biopsies during laparotomy, between 2009–2018. Residual intestinal length (RIL): measured from ligament of Treitz to enterostomy. Medical records and patients data base review, in addition to PubMed, Cochrane, Embase, Lilacs and Medline research, using “Hirschsprung’s disease”, “intestinal failure” and “total intestinal aganglionosis” as keywords, 1993–2018. Results: N=5. Median age 42.2 m (r:4–108). Mean RIL: 54.6 cm (r:30–80). It took 3.2 surgical procedures (r:2–4) to perform a functional enterostomy. The distal aganglionic bowel was preserved in all cases. 5/5 with IF and mean parenteral nutrition (PN) dependance time of 46 months (r:10–114). All received enteral nutrition by oral feeds and gastroclisis in 2 cases. 3 patients were listed for intestinal transplantation (ITx), 2 have already received an ITx. Follow up: 2.16 years (r: 0.75–4.25). 80% (4/5) overall survival on home PN, 1 death 9 months after ITx due to PTLD (off PN). Literature review: 127 articles. No publications from LATAM. 120 excluded: 6 duplications, 114 do not fulfill inclusion criteria. 7 remaining articles, N 47: 0.49 mo.; mean 4.9 years follow up (r:2.67–7.3); 3.57 procedures (r:1.4–5.75) until reaching an accurate diagnosis; RIL: 44.7 cm (32.2–60); 7 had aganglionic bowel resection; 66% survival; causes of death: 3 after ITx, 1 listed for ITx, 11 due to PN complications. 18/47 patients received an ITx. Discussion: EHD is an uncommon disorder leading to IF, and its prevalence in our continent is unknown. Our outcomes are similar to those published elsewhere. Home PN provides acceptable medium-term survival, although most patients will need an ITx in the long term.

To Determine the Frequency of the Common Causes of Lower Gastrointestinal Bleeding after Colonoscopy

Introduction: Lower Gastrointestinal Bleeding (LGIB) is defined as bleeding from distal to the ligament of Treitz at the duodeno-jejunal flexure and it accounts for 30-40% of all gastrointestinal bleeding. Although it is less common than the upper gastrointestinal bleeding yet considered as medical and surgical emergency particularly when massive. The leading causes of LGIB are hemorrhoids, rectal ulcers, rectal polyps and colitis; while less frequent causes include ulcerative colitis, Crohn's disease and diverticulitis. This is apparently in contrast to the western literature where inflammatory bowel diseases and diverticulitis are the common cause of LGIB. Presently Colonoscopy is the diagnostic and therapeutic procedure of choice in LGIB.&#x0D; Objective: To determine the frequency of the common causes of lower gastrointestinal bleeding (LGIB) after Colonoscopic examination in a tertiary care hospital of Lahore.&#x0D; Methodology: This cross-sectional descriptive study was conducted at Department of Gastroenterology, Services institute of Medical Sciences Lahore (SIMS) from April 2016 to March 2017.&#x0D; Results: A total of 277 patients were included in this study, 181(65.34%) were males and 96(34.65%) were females. The average age oi the patients was 45.5 years. Colonoscopy showed abnormal findings in 219 (79.06%) patients. The internal hemorrhoids were the most common cause of LGIB while least common cause of LGIB after Colonoscopic examination was malignant lesions of colon and rectum.&#x0D; Conclusion: In our study bleeding from internal hemorrhoids was the leading cause of lower gastrointestinal bleeding followed by rectal ulcers and polyps.&#x0D; &#x0D; Keywords: Lower GI Bleeding, Hemorrhoids, Rectal Ulcer, Rectal polyps, Colonoscopy.

Conventional Versus Distal Laparoscopic One-Anastomosis Gastric Bypass: a Randomized Controlled Trial with 1-Year Follow-up.

There is no consensus on the ideal small bowel length that should be bypassed in laparoscopic one-anastomosis gastric bypass (OAGB). This study aimed to compare the safety and efficacy of conventional versus distal techniques of laparoscopic OAGB. This randomized controlled trial involved 60 adults with morbid obesity scheduled for laparoscopic OAGB randomly assigned to one of the two techniques; conventional technique (fixed anastomosis 200cm from the ligament of Treitz) and distal technique (anastomosis 400cm from the ileocecal valve). Total small bowel length (TSBL) was measured in all cases. Quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI). Outcome measures were excess body weight loss percentage (EBWL%), resolution of associated comorbidities, frequency of nutritional deficiencies, and quality of life. No patients were lost to follow-up. The two groups were comparable in TSBL, EBWL%, and complete resolution of comorbidities up to 12months. The percentage of afferent loop length to TSBL was significantly higher in the distal group (p < 0.001) but was not correlated with EBWL%. The levels of hemoglobin, cholesterol, triglycerides, iron, and albumin were significantly lower and parathormone hormone was higher in the distal group. The GIQLI score was significantly higher in the conventional group during follow-up. OAGB achieves optimum results when the afferent loop length is 200cm; bypassing more than 200cm does not improve weight loss or comorbidity resolution. Measuring TSBL is recommended to avoid excessive small bowel shortening that increases the risk of nutritional consequences.

A MODIFIED TECHNIQUE FOR SURGICAL REMOVAL OF THE CONGENITAL DUODENAL OBSTRUCTION

Purpose. To improve the duodenum function after Kimura surgery which is performed for the congenital duodenal obstruction by restoring the horseshoe-shaped duodenum. Material and methods. A comparative analysis of two groups of patients was made: In Group 1 (n = 31) , patients were operated with the mobilization of lower horizontal duodenal branch and duodenoduodenal anastomosis by Kimura without restoring the horseshoe-shape of the duodenum. In Group 2 (n = 11), children had similar surgeries but the horseshoe-shaped configuration of the duodenum was restored by fixing the initial part of the jejunum to the Treitz ligament. After surgery, the researchers radiographically compared time of barium suspension passage through the duodenum in patients of both groups. Results. In children from Group 1, passage of the contrast suspension via duodenum lasted for 43.9 ± 3.9 sec., what is approximately 2 times faster than in the norm. In patients from Group 2, this indicator was 3-4 times larger than in patients from Group 1 and was 158.2 ± 18.2 sec. Such a slowdown in the chyme passage along the duodenum prolongs exposure of food masses to pancreatic juice, bile and intestinal juice and, consequently, improves the duodenal function. Conclusion. The authors recommend to end the surgical intervention for eliminating congenital duodenal obstruction by Kimura technique with the restoration of horseshoe-shaped duodenum by fixing the initial part of the jejunum to the Treitz ligament.

Colonoscopic Findings of Patients with Lower Gastrointestinal Bleeding in Erbil City

Background and objectives: Rectal bleeding is a frequent symptom in young people and often over- investigated.Rectal bleeding is defined as bleeding from lower gastrointestinal tract, which means bleeding from a place distal to ligament of Treitz. This study was conducted to determine the frequency of different causes of rectal bleeding in young patients. Methods: Four hundred and seventy patients with rectal bleeding were selected in out-patient department were referred to gastroenterology units of Hawler and Rizgary Hospital in Erbil. Patients with suspected upper GI source of bleeding excluded from the study. All patients were subjected to colonoscopy after preparation of the gut and the findings were recorded. When it was necessary, biopsy samples were also taken. Diagnosis was based on colonoscop- ic findings. Results: The total number of patients was 470. Their mean age + SD were 31.96 + 7.65 years, the median was 32 years, ranging from 12 to 46 years, more than one third of patients had hemorrhoids, either alone (35.7%), or with other finding, (45%) of patients had hemorrhoid with or without other diseases, (8.3%) had inflammatory bowel disease and colorectal tumor (4.7%), also 21.3% of patients found to be normal. Conclusions:Haemorrhoids were the main cause of bleeding per rectum, followed by evidence of inflammatory bowel disease. The incidence of colorectal tumor was low (4.7%). Though most findings were benign, colonoscopy should be strongly considered for this patient group with non urgent rectal bleeding.

Technique and outcome of percutaneous endoscopic transgastric jejunostomy for continuous infusion of levodopa-carbidopa intestinal gel for treatment of Parkinson’s disease

Objective: A new method of drug delivery via the small bowel, continuous infusion of levodopa-carbidopa intestinal gel (LCIG), for patients with advanced Parkinson’s disease (PD) has been developed and shown to improve patients’ quality of life. Levodopa is infused directly and continuously into the proximal jejunum via a percutaneous endoscopic transgastric jejunostomy (PEG-J) tube that is connected to a portable infusion pump. The aim of this study was to evaluate the safety and outcomes of our PEG-J technique performed in advance of LCIG therapy in patients with advanced PD.Material and methods: We reviewed the cases of 37 patients who underwent PEG-J for LCIG therapy at our hospital between November 2016 and May 2018. Pull-through percutaneous endoscopic gastrostomy (PEG) and gastropexy were performed in all patients. The J-tube was inserted through the PEG tube and placed beyond the ligament of Treitz endoscopically under fluoroscopic guidance. After two weeks, the gastropexy sutures were removed.Results: PEG-J with placement of the tube beyond the ligament of Treitz was successful in all 37 patients. Median procedure time was 26.4 min. Median hospital stay after the procedure was 16 days. Median follow-up with the PEG-J tube in place was 11 months. There were five procedure-related complications (13.5%) and 13 device-related complications (35.1%). There was no death related to the procedure.Conclusions: Our PEG-J technique can be performed safely in patients with advanced PD, and favorable outcomes have been achieved to date.

Procedure-specific postoperative gastrointestinal hemorrhage

Gastrointestinal bleeding (GIB) can occur as a complicating issue in the postoperative course after visceral surgery. It can be of varying clinical extent ranging from mild anemia to fatal hemorrhagic shock. Symptomatic manifestations of aGIB are hematemesis, melena and hematochezia. The GIB are fundamentally differentiated into upper and lower GIB. While upper GIB is defined as the occurrence of endoluminal hemorrhage above the ligament of Treitz, correspondingly the definition of lower GIB is intraluminal bleeding distal to the duodenojejunal flexure. Knowledge of their procedure-related incidence during the postoperative course enables abetter assessment of the necessary intervention.

Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report

BackgroundTotal colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung’s disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations.Case presentationWe present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment.ConclusionsTCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.

Laparoscopic distal gastrectomy for gastric cancer patient with intestinal malrotation: report of a case

BackgroundIntestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer.Case presentationA 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma.Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I.Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes.Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation.Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was non-rotation (90°). She was discharged from our hospital without any complications.ConclusionWe encountered a case of adult asymptomatic intestinal malrotation with gastric cancer. Even when encountering such a case during laparoscopic gastrectomy, reviewing CT images carefully to reconsider the anatomical anomalies, and tracing the dissectible layer accurately with adequate countertraction can facilitate safe and successful surgery.

A case with mesenteric desmoid tumor after laparoscopic resection of stage I sigmoid colon cancer

BackgroundIntra-abdominal desmoid tumors are rare and generally occur in some patients with familial adenomatous polyposis or secondary to an external stimulus such as surgical trauma. We report herein a case of intra-abdominal desmoid tumor in the jejunal mesentery after laparoscopic colectomy for sigmoid colon cancer.Case presentationA 74-year-old woman underwent laparoscopic sigmoid colectomy for colon cancer with pathological stage I. Follow-up computed tomography (CT) 18 months after primary surgery showed a nodular and enhanced soft tissue density mass, 20 mm in size, in the mesentery at the left side of the abdomen. Serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were within the normal range. Fluorodeoxyglucose positron emission tomography did not suggest cancer recurrence. Another CT scan, done 1 month later, revealed that the tumor had enlarged to 25 mm in size. Although the pathological diagnosis was not obtained, we suspected recurrence of the sigmoid colon cancer and applied chemotherapy using capecitabine, oxaliplatin, and bevacizumab. After 3 cycles of chemotherapy, however, the tumor had enlarged further. Therefore, the surgical resection of the tumor was performed to determine the diagnosis and to achieve possible curative resection of the tumor. The tumor existed in the mesentery of the jejunum, 100 cm from the ligament of Treitz, and showed invasive growth. We resected 40 cm of the jejunal segment together with the tumor. Microscopically, the tumor was composed of fibroblast, myofibroblast, and infiltrating the inflammatory cell and diagnosed as desmoid tumor by immunostaining (desmin+/−, β-catenin+, CD117−, vimentin+). At 33 months after the resection of the desmoid tumor, neither the sigmoid colon cancer nor desmoid tumor has had a recurrence.ConclusionsAfter surgery for gastrointestinal cancer, it is difficult to differentiate between intra-abdominal desmoid tumor and recurrence. The possibility of intra-abdominal desmoid should be considered along with tumor recurrence during postoperative surveillance after resection of gastrointestinal cancer, especially when the risk of recurrence is low.

Jejunal MALT (Mucosa Associated Lymphoid Tissue) Lymphoma: A Case Report

Background: MALT (Mucosa Associated Lymphoid Tissue) Lymphoma is an uncommon condition. It is an involvement of extranodal site in hematologic malignancy, Non-Hodgkin Lymphoma.Case Presentation: Pondok Indah, Puri Indah Hospital Jakarta treated a 38-year-old female with acute abdomen due to jejunal MALT Lymphoma perforation, one meter from treitz ligament. Emergency laparotomy was performed, the patient had a resection and end to end anastomose. She was hospitalized in intensive care unit for 4 days after the surgery and died because of prolonged septic shock.Conclusions: MALT lymphoma is an uncommon condition which is often encountered in emergency conditions due to acute abdominal pain caused by intra-abdominal perforation of the hollow viscus. Late diagnosis and treatment may cause severe outcome such as perforation and hypovolemic shock. This case report is expected to provide insight and to increase the awareness of the incidence of jejunal MALT lymphoma in Indonesia.

Proximal Jejunal Bypass Improves the Outcome of Gastric Clip in Patients with Obesity and Type 2 Diabetes Mellitus.

Laparoscopic gastric clip (GC), a novel pure restrictive procedure, is a safe and effective treatment for morbid obesity. However, whether adding a proximal jejunal bypass (PJB) to this procedure might increase the efficacy is unknown. Outcomes of 74 (43 women and 31male) obese patients who had undergone PJB-GC (41) or GC (33) for the treatment of type 2 diabetes mellitus (T2D) with 1year follow-up were assessed. GC consists of creating a transverse gastric partition with a metallic clip. PJB consists of a jejuno-ileostomy between 20 and 320cm distal to the ligament of Treitz. Postoperative body mass index (BMI) reduction, total weight loss (TWL), and remission rates of T2D were evaluated. The preoperative clinical characters in both groups were similar. The mean operative time was significantly longer in the PJB-GC group than in the GC group. At 24months after surgery, the BMI was lower (32.5 ± 6.2 vs. 37.0 ± 5.9kg/m2, p = 0.002) and weight loss higher in PJB-GC than GC (TWL 31.3 ± 14.8 vs. 23.5 ± 10.4%, p = 0.011). Remission of T2D was greater in the PJB-GC group (90.2 vs. 57.2%; p < 0.001). In this study, PJB-GC was superior to GC in weight loss and T2D remission at 1 and 2years after surgery. Adding PJB to GC increased the effect of weight loss and diabetic control.

P306 Double balloon enteroscopy in paediatric Crohn’s disease and 10 years follow-up

Crohn’s disease can occur throughout the entire gastrointestinal tract, often discontinuously, with the ileum and colon being the most common site. However, CD may involve any region of the small bowel (SB) other than the ileum and colon and isolated SB CD can present a diagnostic challenge. Double Balloon Enteroscopy (DBE) is an endoscopic modality for children that allow the diagnostic and therapeutic procedures of SB disease. Our aim was to evaluate the SB by DBE in children refractory to CD treatment Between 2007 and 2010, 20 paediatric patients (age 2–17 years) with CD diagnosis, refractory to treatment were selected to undergo SB by DBE. The main objective was to evaluate SB inflammation-related, narrowing, malignancy or other diseases. Previously, all had performed radiological imaging to exclude stricturing. Only one experienced endoscopist performed all the DBE. In addition, 10 years follow-up with therapy was analysed The mean patient age was 12 years (range 2–17 years). Four patients (5%) had SB CD solely in jejunum, which was not detected by either colonoscopy or radiological examination (Table) Sociodemographic data. Sociodemographic data. DBE lesions were: Active duodenojejunal ulcers, mucosal healing and/or pseudo polyps and mucosal granularity. General anaesthesia was performed in 6 children from 2 to 7 years and deep sedation with propofol in 14 patients. Mean length of SB examined was 220 cm beyond the ligament of Treitz (range 120 to 360 cm). Mean duration of the procedure: 48 min (range 30 to 60). No significant complications were related to the procedure. One patient had a malignancy diagnosis extra-intestinal; one had IL-10 and/or IL-10R gene mutation and one change the diagnosis to ulcerative colitis. Currently, 14 patients are in follow-up, 5 children in paediatric GI clinic and the other 9 at adult GI clinic. Curiously, the proportion of patients free of long-term therapy has decreased. We conclude DBE is a safe and useful tool to clarify SB pathologies in paediatric patients like CD. DBE can provide additional information in patients who require therapeutic decision or to make differential diagnosis. In addition is allows biopsy sampling. General anaesthesia or sedation and should be considered

Jejunal diverticulosis complicated with perforation: A rare acute abdomen etiology

IntroductionJejunal diverticulosis is a rare intestinal pathology with an incidence of 0.5–1%. While most cases are asymptomatic, 30–40% of the cases may become symptomatic with chronic abdominal pain, malabsorption, hemorrhage, diverticulitis, obstruction, abscess formation and, rarely, diverticula perforation. It is generally localized on the mesenteric side and it develops from the entry points of the vessels into the jejunum. Case presentationCase 1 – A 36-year Case 2 a 75 old female patient patient was admitted to the emergency department with the complaint of widespread abdominal pain, Case 1 8 diverticules, one with diverticule perforation, was observed in the jejunum segment between the 50th and 90th centimeters after the Treitz Ligament. Case 2 – In the diverticulum 100 cm distal from the Treitz ligament, mesenteric perforation area of 4–5 mm were observed. ResultsSegmentary small bowel resection and side-by-side anastomosis were performed in these cases. In the histopathological examination, the Diverticula were seen to be pseudodiverticullar lesions including herniation of the mucosa and submucosa. ConclusionJejunoileal diverticulosis is a rare disease with life-threatening complications such as perforation, obstruction and bleeding, it is usually asymptomatic or presents with nonspecific symptoms. It should be considered in the differential diagnosis of acute abdomen.

Left-sided mesocolic hernia presenting as internal Maydl's hernia, complicated by jejunal volvulus

Left mesocolic hernia (syn – left paraduodenal hernia/hernia of Landzert) is a type of internal hernia which occurs due to malrotation of the midgut and forms a potential space near the ligament of trietz. Prompt diagnosis is crucial to prevent strangulation. We report a rare case of left mesocolic hernia presenting as internal Maydl's hernia complicated by jejunal volulus, presenting as acute abdomen. An emergency derotation and reduction of small bowel was done with repair of the defect.

Safe zone for left renal vein exposure during laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic cancer

Introduction: The left renal vein (LRV) is an important landmark for the posterior dissection in laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) for pancreatic ductal adenocarcinoma (PDAC). However, it is technically difficult to safely expose the LRV during L-RAMPS because of complex anatomy of the renal vessels. We show our surgical method to safely expose the LRV in L-RAMPS. Method: In L-RAMPS, the anterior surface of the left kidney was first exposed to avoid disorientation. The ligament of Treitz was retracted to the ventral side to secure the surgical field. The LRV was initially exposed on the left posterior side of the superior mesenteric artery (SMA), followed by exposure toward the left kidney. To evaluate this surgical technique, we retrospectively examined i) the surgical outcomes of 47 patients who underwent L-RAMPS, and ii) the anatomical structure of the renal vessels in these patients using multidetector computed tomography (MDCT). Result: i) The LRV was exposed without intraoperative injury. The median operative time and blood loss were 265 min (range 154 - 410 min) and 31 ml (range 0-1712), respectively. The morbidity rate (Clavien-Dindo IIIa) was 10.6% and the mortality rate was none. R0 resection rate was 95.7%. ii) MDCT showed that one (80.9%) or two (19.1%) left renal arteries (LRAs) originated from the abdominal aorta. LRVs were classified into two types depending on their positions (primarily caudal, 72.4%; cranial, 27.6%) in relation to the inferior border of the pancreas. Notably, the LRA branch ventrally traversed the LRV at the left renal hilum in more than 40% of the patients, thus risking arterial injury. Although the common pattern is that all the LRA branches run at the dorsal side of the LRV. Conclusion: The safe zone for the initial exposure of the LRV is near the left posterior side of the SMA.