Nasogastric Tube Decompression Research Articles

7783 Pheochromocytoma Unusually Presenting As Intestinal Pseudo-Obstruction: A Case Report

Abstract Disclosure: J.V. Chua: None. E.C. Cunanan: None. J.G. Sazon: None. J.L. Reyes: None. Introduction: Pheochromocytoma is a rare neuroendocrine tumor that arises from the adrenal medulla. It may present with a variety of symptoms that can resemble other diseases as a result of the effects of catecholamine overproduction on the different organ systems of the body, occasionally making diagnosis difficult and delaying appropriate treatment.Intestinal pseudo-obstruction is an unusual presentation of pheochromocytoma from the effects of excessive catecholamines on the gastrointestinal system, resulting in decreased peristalsis with constriction of the sphincter muscles, consequently prolonging intestinal transit time. Currently, there is no available data on its incidence or prevalence rate. Clinical Case: This is a case of a 50-year-old Filipino male initially presenting with abdominal pain and enlargement with inability to pass stool and flatus, not relieved by laxatives, enemas, and nasogastric and rectal tube decompression. Abdominal radiograph revealed segmental ileus versus partial large bowel obstruction, while abdominal CT scan showed fecal impaction and an incidental finding of an enhancing adrenal mass on the left adrenal gland. Colonoscopy findings were unremarkable. Laboratory workup demonstrated elevated 24-hour urine metanephrine levels with a value of 44.62 mg/24 hours (normal value: 0-1.0 mg/24 hours). The patient was initially managed conservatively, but no improvement in symptoms was noted. Pre-operative preparation was done with terazosin and intravenous saline infusion, and the patient then underwent left open adrenalectomy with bowel decompression, which provided resolution of symptoms and resumption of regular bowel movement post-operatively. The final result of the histopathologic examination confirmed the diagnosis of pheochromocytoma. Conclusion: Gastrointestinal symptoms such as ileus and pseudo-intestinal obstruction are uncommon presentations of pheochromocytoma. A high index of suspicion is necessary among patients presenting with these symptoms, and pheochromocytoma should be considered as part of the differential diagnosis. Presentation: 6/1/2024

ThP6.9 - Endoluminal vacuum-assisted closure (EndoVAC) therapy in spontaneous duodenal perforation: a novel approach to an undertreated problem

Abstract Introduction Duodenal perforation is a rare but critical condition, with management ranging from conservative to surgical depending on timing of presentation, patient status, and clinician preference. In recent years, minimally invasive techniques have been emerging alternatives for their safety and efficacy. Notably, there have been cases promoting endoluminal vacuum-assisted closure (EndoVAC) therapy as a viable alternative for use among patients with iatrogenic oesophageal perforations. To our knowledge, there has been no reported use of this novel approach specifically in spontaneous duodenal perforations. Case presentation A 55-year-old female with no history of trauma, surgery, NSAID use, or gastrointestinal conditions presented with epigastric pain and vomiting. A CT scan revealed a contained duodenal perforation at the D2/3 junction, accompanied by a complex retroperitoneal collection unsuitable for imaging-guided drainage. Initial management was conservative with intravenous hydration, antibiotics, proton pump inhibitors, and nasogastric tube decompression. She underwent oesophagoduodenoscopy and EndoVAC therapy resulting in complete resolution of collection and a small diverticulum on repeat CT. Discussion Current standard of care for duodenal perforations would be conservative management, though this carries the risk of deterioration due to biliopancreatic leakage and slow resolution of sepsis. Surgical management, when needed, is often technically challenging with high morbidity. EndoVAC gives the benefit of providing targeted drainage and negative pressure therapy to the site of perforation, reducing ongoing contamination, and promoting wound granulation. Conclusion EndoVAC therapy offers a minimally invasive alternative to treatment of duodenal perforations and has the potential for broader application in specialist and tertiary healthcare settings.

Cervical gastric decompression tube: safety and efficacy outcomes for inoperable malignant bowel obstruction.

Inoperable malignant bowel obstruction, which results in chronic nausea, vomiting and abdominal pain, often requires nasogastric tube decompression. However, these tubes are often uncomfortable for patients and require hospitalization during the end-of-life care. Cervical esophago-gastric (CEG) decompression tubes are a potential palliative solution. The objective of this study is to present the outcomes of CEG tubes in 11 patients with malignant bowel obstruction. We performed a retrospective review of patients requiring nasogastric tube decompression who received CEG decompression tubes for inoperable malignant bowel obstructions between 2016-2022. CEG tube placement was performed percutaneously through the left neck using a guidewire and an endoscopic technique. The average age of patients was 58 years (31-72 years), with metastatic colorectal cancer (36.4%) and ovarian cancer (27.3%) being the most common causes of malignant bowel obstruction. All procedures were completed percutaneously, without requiring conversion to open procedures. The morbidity of the procedure was 27%, which included tube dislodgement, local cellulitis, or bleeding at the insertion site. None of the patients required reoperation, with most of the patients successfully treated conservatively. Most patients were discharged home after the procedure (82%); however, 45% were readmitted (mostly due to abdominal pain). Most patients (73%) were able to continue additional chemotherapy after tube placement. The average survival from cancer diagnosis was approximately six months, whereas the average survival after the procedure was about four months. No mortalities occurred due to CEG tube placement. A CEG decompression tube is safe for patients with malignant bowel obstruction. The procedure allows patients to undergo additional chemotherapy and be discharged home with a more comfortable tube.

Acute gastric dilatation with segmented abdominal paresis as a rare manifestation of herpes zoster: a case report and review of the literature

BackgroundHerpes zoster is a common disease that can affect men and women at any age. Sensory neuropathy is the most common complication while motor neuropathy of the abdominal muscles is rare complication appearing in ~ 0.7% of patients. Furthermore, visceral nerve involvement causing gastroparesis is an extremely rare postherpetic complication. We present an extremely rare case of acute gastric dilatation with segmented abdominal paresis as a rare manifestation of herpes zoster infection.Case presentationA 91-year-old Asian man was admitted to hospital with 2-day history of vomiting and left abdominal protrusion. He was previously treated for a rash on the left abdominal wall as herpes zoster infection with oral valaciclovir 2 weeks prior. On physical examination, characteristic herpes zoster rash scars and an ipsilateral abdominal bulge were observed on the left side. Computed tomography revealed no abdominal wall defect, mass, or stenosis. Remarkable distension of the stomach, asymmetrical left flank wall bulge, and a thinner abdominal wall on the left compared with the right side were shown. He was diagnosed as acute gastric dilatation owing to gastroparesis and segmental paresis of the abdominal musculature associated with herpes zoster infection. The patient showed significant improvement in symptoms and abdominal paresis within a month of conservative treatment, including nasogastric tube decompression and mosapride administration.ConclusionAcute gastric dilatation with abdominal paresis is an extremely rare complication of herpes zoster infection, and to date there have been no reports in the literature. It alerts us that, when examining patients with abdominal bulge, we should be conscious of this rare pathology for the optical diagnosis, avoiding unnecessary invasive examination or surgical exploration.

A119 ACUTE COLONOC PSEUDO-OBSTRUCTION AFTER ENDOSCOPIC RESECTION OF A FULLY CIRCUMFERENTIAL LARGE NON-PEDUNCULATED COLORECTAL POLYP

Abstract Background Complex large non-pedunculated colorectal polyps (LNPCPs), including those involving the full circumference of the bowel, are now readily managed by minimally invasive endoscopic resection techniques. Established procedure-related adverse events include sedation related adverse events, deep mural injury, clinically significant post-resection bleeding, delayed perforation and serositis. An appreciation for potential procedure-related adverse events is critical to the effective implementation of these techniques. Aims To describe a case of acute colonic pseudo-obstruction after endoscopic resection of a fully circumferential LNPCP. Methods Case report and review of the literature Results A 91-year-old male with a history of atrial fibrillation, chronic kidney disease and suspected McKittrick-Wheelock syndrome underwent successful endoscopic mucosal resection (EMR) of a 100mm fully circumferential LNPCP in the sigmoid colon. Histopathology diagnosed a tubulovillous adenoma with high-grade dysplasia. After elective admission, he suffered from clinically significant post-EMR bleeding requiring 2 units of packed red blood cells. On post-operative day 1 he began to suffer from nausea, abdominal pain and obstipation. On examination, he was visibly distended. Abdominal X-ray revealed extensive gas-filled loops of small and large bowel with the absence of gas in the rectum. He was managed conservatively with nasogastric tube decompression. Total duration of hospital stay was 9 days. Conclusions Critical to the continued expansion of minimally invasive endoscopic resection techniques is an awareness for potential procedure-related adverse events. To our knowledge this is the first description of acute colonic pseudo-obstruction after endoscopic resection Funding Agencies None

1214 Wilkie's Syndrome - a Case Report

Abstract Aortomesenteric duodenal compression syndrome (Wilkie’s syndrome) describes compression of the third duodenal segment between the superior mesenteric artery and aorta, causing upper gastrointestinal (UGI) obstruction. Wilkie’s syndrome typically presents with significant weight loss and features of UGI obstruction. It can initially be treated conservatively with decompression and appropriate re-feeding, but occasionally requires surgical correction. In this presentation, we describe a case of Wilkie’s syndrome in a non-English speaking foreign national, disengaged from healthcare. Case Presentation A 47-year-old Romanian national presented with two months of severe epigastric pain, vomiting, inability to tolerate food intake and severe weight loss, with a background of five years of similar symptoms. On examination, the patient was tachycardic (130), severely dehydrated with skin tenting, and cachexic with a distended abdomen and palpable mass in the epigastrium. Computed tomography imaging was performed, excluding an obstructing malignancy, instead demonstrating significant stomach distension (∼50% of the peritoneal cavity), from Wilkie's Syndrome. The patient underwent oesophagogastroduodenoscopy which demonstrated oesophagitis, gastritis and a duodenal ulcer. Biopsies were negative for H pylori and malignancy. Management involved nasogastric tube decompression, intravenous electrolyte collection, fluid resuscitation and high dose PPI. The patient was discharged on day 6 with planned follow-up in one month and assessment for requirement of surgical management for Wilkie’s syndrome. Discussion We present a rare case of Wilkie’s syndrome and discuss conservative and surgical management. We also use this case of late presentation to highlight the challenges of management, and the importance of clearly communicated follow-up plans in vulnerable populations.

Readmission and Disposition in Patients With Malignant Bowel Obstructions Following Gastrostomy Tube.

Patients with peritoneal carcinomatosis (PC) can develop malignant bowel obstructions (MBOs) requiring inpatient admission and nasogastric tube decompression. Palliative decompressive gastrostomy tubes (G-tubes) may affect patient disposition, allowing for self-management and reduction in inpatient services. Therefore, we sought to assess disposition and inpatient readmission rates in patients admitted with PC and MBO following G-tube placement. The Vizient® Clinical Data Base was queried for inpatient admissions from October 2018 to May 2022 utilizing ICD-10 codes to identify patients admitted with PC and bowel obstruction, with or without G-tube placement. Demographics and hospital outcomes were recorded. Descriptive statistics and multivariate logistic regression analysis were performed. From 750 patients, 59 (7.9%) had a G-tube placed. Compared to patients without G-tubes, those with G-tubes had lower rates of disposition to home (32.2% vs 70.0%, P < .001) and higher rates of disposition to hospice (home: 30.5% vs 7.8%, P < .001, facility: 10.2% vs 3.9%, P = .02). There was no significant difference in the rate (17.3% vs 22.3%, P = .40) or risk (OR = 1.44, 95% CI .69-3.01) of 30-day readmissions with G-tubes. However, palliative care consultation (OR 33.77, 95% CI 19.16-59.52) and G-tube placement (OR 5.82, 95% CI 2.56-13.25) were independent predictors for hospice. Placement of G-tubes in patients with PC and MBO was associated with higher rates of disposition to hospice but there is no difference in 30-day readmission rates compared to those without G-tubes. Further prospective studies are needed to understand the role of G-tube placement in patients with MBO in relation to outcomes and disposition.

Gastric Outlet Obstruction Secondary to Incarcerated Stomach in Parastomal Hernia

Gastric outlet obstruction due to an incarcerated stomach in a parastomal hernia is extremely rare. Here, we present the management of such a case with a review of the literature. A 79-year-old woman presented with a 3-week history of postprandial vomiting and associated parastomal and epigastric pain. She had a loop colostomy created for severe fecal incontinence secondary to anal stenosis. Imaging revealed a large parastomal hernia with an incarcerated gastric antrum. She was initially managed nonoperatively with a nasogastric tube. She underwent a semi-elective open Sugarbaker mesh repair of the parastomal hernia with good results. Gastric outlet obstruction secondary to incarceration of the stomach in a parastomal hernia is uncommon. A conservative approach with nasogastric tube decompression is a reasonable initial approach in a patient who is not critically unwell, which allows time for consideration of different parastomal hernia repair techniques.

S3409 Features of Recurrent Mechanical Obstruction With Nonobstructive Duodenal Neuroendocrine Tumor

Introduction: Neuroendocrine tumors (NET) are a rare cause of bowel obstruction which is usually mechanical in nature. We present an unusual case of bowel obstruction in a patient with NET where no mechanical obstruction was found despite extensive work up. Case Description/Methods: A 56-year-old male was admitted after 9-10 admissions to another facility with bowel obstruction and 50-pound weight loss over 10 months. His symptoms included abdominal pain, distention, and vomiting. He had no prior abdominal surgeries. Previous CT abdomen revealed small bowel obstruction with transition point in the terminal ileum. Current CT showed gastric outlet obstruction (Figure A). Formerly he was managed nonoperatively with nasogastric tube (NGT) decompression. Prior esophagogastroduodenoscopy and colonoscopy did not reveal an obstruction. NGT output was 2.5 L. Push enteroscopy, video capsule endoscopy did not reveal any mechanical obstruction. MR enterography showed two right mesenteric nodules, larger of which was 2.1 x 2.3 cm in size. These were moderately FDG avid on PET-CT. Endoscopic ultrasound biopsy revealed a well differentiated NET. The lesions were intensely somatostatin receptor positive on Gallium-68 DOTATOC PETCT (Figure 1B). Pancreatic polypeptide was 2145 pg/mL (0-435), chromogranin A 1458 ng/ml (0-103), serotonin 278 ng/mL (50-200), and gastrin 208 ng/mL (0-100). He underwent partial duodenal resection with primary repair and peripancreatic lymph node resection. No obstructive pathology was found intraoperatively. Histopathology confirmed well differentiated NET with metastatic peripancreatic nodes. He has had no admissions over the past 3 months and has gained 33 pounds. Discussion: NET are rare tumors and use of appropriate diagnostic modalities are key to timely diagnosis. Despite improvement and availability of diagnostic modalities, most patients have metastatic disease at diagnosis. NET presenting with bowel obstruction usually have an obstructing tumor. We wish to bring to light the unusual presentation of NET with mechanical obstruction on imaging but extensive negative work up for an actual obstructing lesion. It is possible that mesenteric inflammation and edema secondary to NET may have caused recurrent obstruction in this case. NET can present with mechanical obstruction and are often missed on conventional imaging. Gallium-68 DOTATOC PETCT may be a reasonable investigation in a patient with unexplained recurrent gastrointestinal obstruction.Figure 1.: A, CT abdomen with dilated stomach and duodenum and decompressed distal small bowel suggestive of gastric outlet obstruction (arrow) (B) Ga-68 DOTATOC PET/CT scan showing somatostatin receptor positive peripancreatic nodules consistent with metastatic neuroendocrine tumor (chevron).

257. DIFFERENCES IN PERIOPERATIVE STRATEGIES IN ESOPHAGEAL CANCER TREATMENT IN 13 NORDIC UNIVERSITY HOSPITALS CALL FOR HIGH-LEVEL EVIDENCE REGARDING THESE PRACTICES

Abstract The Nordic countries have similar health care systems and registries simplifying epidemiological research and the treatment of esophageal cancer is largely centralized. However, differences in treatment traditions can hamper the possibility to assess results and harmonize control arms in joint randomized trials. In setting up a Nordic multi-center randomized trial regarding the use of nasogastric tube (NG-tube) decompression, we aimed to investigate differences in perioperative routines after esophageal resection at Nordic University hospitals. All Nordic University Hospitals with an upper gastrointestinal cancer center (UGC) were contacted regarding a Nordic randomized controlled trial exploring the effects and complications associated with the use of NG-tube after esophagectomy for cancer. Those who chose to join the trial were sent a questionnaire regarding surgical volumes and practices including mean annual number of esophagectomies, surgical method/access, and routine use of pyloric drainage and jejunostomy. In addition, the current standard postoperative use of NG-tube and routine X-ray/CT evaluation, along with postoperative traditions regarding the start of liquid diet was enquired. High volume centers were defined as performing &amp;gt;20 procedures/year. Thirteen of 17 centers with a combined catchment area of 16 million inhabitants and an annual volume of 445 esophagectomies joined the trial network. All, but one center used a total minimally invasive- or hybrid surgical approach but otherwise, the routine use of pyloric drainage and jejunostomy varied widely without being statistically different. All 13 centers reported routine use of NG-tube and 4 employed continuous suction. The NG-tube was removed between 3 and 7 days postoperatively, but also strategies between the centers (suction on NG-tube, start of liquid diet, routine X-ray/CT evaluation) varied without being statistically significant Firm adherence to standardized operations and safety protocols are implemented in Nordic UGCs to reduce the potential consequences of complications. However, the results find the differences in perioperative care after esophagectomy apparent, highlighting the need for high-level evidence regarding these practices. A unified approach may facilitate clinical trial initiatives. There is a paucity of evidence regarding optimal NG-tube use after esophagectomy for cancer and a randomized trial (kiNETiC ISRCTN39935085) investigating this issue is underway.

58 The Unfolding Situation of Caecal Volvulus: A Review of 36 Cases

Abstract Aim Caecal Volvulus is a rare cause of bowel obstruction. However, there has been a steady rise in the number of cases over the decades. The demographic profile of patients developing Caecal Volvulus has changed to a much older population. We conducted a retrospective review to find the incidence, demographic profile, management, and outcomes of Caecal Volvulus patients in our institution during the last nine years. Method A total of 38 patients were diagnosed with Caecal Volvulus at Worcestershire Acute Hospitals NHS Trust between 01.01.2011 to 31.03.2020. Results Most of our patients were females (78%) with a median age was 76 years. The majority (86%) had at least one medical comorbidity, and 36% had a previous abdominal operation. Abdominal pain was the main complaint in 94% of patients. All patients had a CT scan to confirm their diagnosis. Most of our patients (84%) underwent surgery. Open right hemicolectomy was the most commonly performed operation (87%). Out of the six patients who did not undergo surgery, three responded to bowel rest and nasogastric tube decompression; one patient underwent successful colonoscopic decompression. In contrast, two patients, unfortunately, passed away. The median length of hospital stay was 9 days, with a 30-day mortality of 3%. Conclusion Caecal Volvulus remains a rare cause of bowel obstruction. Most of our patients were old, frail and had medical comorbidities. More than a third of them had undergone previous abdominal surgery. Early CT scan followed by surgery was associated with low mortality.

Delayed gastric emptying after surgery for transverse colon cancer: diagnosis, management and prevention

Delayed gastric emptying is a syndrome of gastric motility disorder with slow gastric emptying as the main sign, provided that mechanical factors such as intestinal obstruction and anastomotic stricture are excluded. The incidence of delayed gastric emptying after colon cancer surgery is 1.4%, mainly after transverse colon cancer surgery. Most of the studies on delayed gastric emptying are case reports, lacking systematic studies. The diagnoses and treatments can be draw on the experience of delayed gastric emptying after pancreatic surgery. Our retrospective study indicated that the incidence of delayed gastric emptying after surgery for transverse colon cancer was 4.0%, higher than that for other colon cancer. Patients who underwent gastrocolic ligament lymph node dissection were at higher risk than those who did not (3.6% vs. 0.8%). Gastrocolic ligament lymph node dissection and stress are causative factors for delayed gastric emptying after surgery for transverse colon cancer. We add the gastrografin test upon the diagnostic criteria of the International Study Group for Pancreatic Surgery, which is simple and practical. Nasogastric tube decompression, enteral nutrition combined with parenteral nutrition, glucocorticoids, and prokinetic agents can cure most patients with postoperative delayed gastric emptying. All the patients with postoperative delayed gastric emptying were cured in our studies. Strict indications for gastrocolic ligament lymph node dissection (patients with cT3-4 and cN+) may decrease the occurrence of delayed gastric emptying after surgery for transverse colon cancer.

104: PERIOPERATIVE STRATEGIES IN ESOPHAGEAL CANCER RESECTION IN 12 NORDIC UNIVERSITY HOSPITALS

Abstract Background and aim The Nordic countries have similar health care systems and registries simplifying epidemiological research. Differences in treatment traditions can, however, hamper the possibility to assess results and to harmonize control arms in joint randomized trials. In the process to set up a Nordic multi-center randomized trial regarding use of nasogastric tube (NG-tube) decompression after esophagectomy, we aimed to investigate perioperative routines in 12 University Hospitals in Sweden, Denmark, Norway and Finland. Methods All Nordic University Hospitals were contacted regarding a Nordic randomized controlled trial exploring effects and complications associated with the use of nasogastric tube use after esophagectomy for cancer. Those who chose to join the trial were sent a questionnaire regarding surgical and perioperative routines. Results Twelve centers with a combined catchment area of 16 million inhabitants and an annual volume of 400 esophagectomies joined the trial network. All but one used totally minimally invasive or hybrid surgical approach. All 12 centers reported routine use of NG-tube and 5 employed continuous suction. The NG-tube was removed between 3 and 7 days postoperatively. A routine pylorus drainage procedure was reported from two centers. Jejunostomy was used universally in 5 centers and selectively in 6 centers. One center did not use jejunostomy. Conclusion Differences in perioperative care after esophagectomy is apparent in the Nordic countries, highlighting the need for high-level evidence regarding these practices. A unified approach may facilitate clinical trial initiatives. There is a paucity of evidence regarding optimal NG-tube use after esophagectomy for cancer and a randomized trial investigating this issue is under way.

The Unfolding Situation of Caecal Volvulus: A Retrospective Analysis of 36 Cases From a Single Center.

BackgroundCaecal volvulus (CV) is a rare cause of bowel obstruction. However, there has been a steady rise in the number of cases over the decades. The demographic profile of patients developing CV has changed to a much older population. We conducted a retrospective review to determine the incidence, demographic profile, management, and outcomes of CV patients in our institution during the last nine years.MethodologyA retrospective audit of all patients diagnosed with CV at Worcestershire Acute Hospitals NHS Trust between 01 January 2011 and 31 March 2020 was performed. Patients admitted with any other type of volvuli such as sigmoid volvulus, small bowel volvulus, and gastric volvulus were excluded.A systematic search of the electronic medical records for all patients admitted under the International Classification of Diseases, Tenth Revision code K562: volvulus was performed for the study duration. It yielded a total of 1,019 patients. After excluding all patients who did not have either a CV or caecal bascule, we included 36 patients in the final analysis.ResultsMost of our patients were females (78%) with a median age was 76 years. The majority (86%) had at least one medical comorbidity, and 36% had a previous abdominal operation. Abdominal pain was the main complaint in 94% of patients. All patients had undergone a computed tomography (CT) scan to confirm their diagnosis. Most of our patients (84%) underwent surgery. Open right hemicolectomy was the most commonly performed operation (87%). Out of the six patients who did not undergo surgery, three responded to bowel rest and nasogastric tube decompression; one patient underwent successful colonoscopic decompression. In contrast, two patients, unfortunately, passed away. The median length of hospital stay was nine days, with a 30-day mortality of 3%.ConclusionsCV remains a rare cause of bowel obstruction. Most of our patients were old, frail, and had medical comorbidities. More than one-third of patients had undergone previous abdominal surgery. Early CT scan followed by right hemicolectomy was associated with low mortality.

A rare case of Wernicke encephalopathy in stage IV gastric cancer

ABSTRACT A 38-year-old male with stage IV gastric adenocarcinoma presented with abdominal pain, nausea, bilious non-bloody vomiting, and lethargy. He was found to have an ileus and was treated appropriately with bowel rest and nasogastric tube decompression. However, the patient was also noted to have confusion and nystagmus. While he was abstinent from alcohol for 20 years, he was found to have Wernicke Encephalopathy (WE) as a result of malnutrition from the underlying malignancy.

Intramural Duodenal Abscess Secondary to Cholecystitis of Remnant Gallbladder: A Case Report

Introduction: Gastric outlet obstruction (GOO) has various causes, commonly related to malignancy and peptic ulcer disease. Intramural duodenal abscess is a rare cause of GOO and sparsely reported in literature. Case Presentation: 88-year-old female presented with clinical symptoms of GOO. Surgical history included open partial cholecystectomy. Medical management was initiated with proton pump inhibitors (PPI) and nasogastric tube decompression. Initial labs revealed anemia (11.8), leukocytosis (14.6) and normal liver function tests. Computer tomography identified inflammatory versus neoplastic mass involving gallbladder, duodenum and antrum (Figure 1). Magnetic resonance cholangiopancreatography denoted irregular mass of duodenum abutting the gallbladder. Esophagogastroduodenoscopy revealed polypoid duodenal mass partially obstructing the duodenal bulb. Biopsies discovered inflammation. Hepatobiliary surgery recommended completion cholecystectomy, transduodenal mass resection, and possible biliary reconstruction. Given age and nutritional status, pancreaticoduodenectomy was not entertained. Intraoperatively, remnant gallbladder was adhered to first portion of duodenum. The pylorus and proximal duodenum were firm concerning for malignancy compared to duodenal polyp. Frank purulence was noted during completion cholecystectomy. Proximal duodenum was thin requiring resection, along with pylorus and distal gastrectomy followed by Billroth II gastrojejunostomy. Surgical pathology revealed chronic intramural duodenal abscess causing GOO. Patient recovered to independent living after brief LTAC stay. Conclusion: PPIs have decreased surgical intervention necessity and benign causes of GOO. However, intramural duodenal abscess needs consideration in patients with subtotal cholecystectomy history superposed with acute cholecystitis and presentation of GOO. Surgical resection is beneficial in this clinical scenario.

P-P03 Impact of routine nasogastric decompression versus no nasogastric decompression after pancreatoduodenectomy on perioperative outcomes: A meta-analysis of available evidence

Abstract Background This meta-analysis reviewed the current evidence on the impact of routine Nasogastric decompression (NGD) versus no NGD after pancreatoduodenectomy on perioperative outcomes. Methods PubMed, Medline, Scopus, Embase and Cochrane databases were searched for studies reporting the role of nasogastric tube decompression after pancreatoduodenectomy on perioperative outcomes were retrieved and analysed up to January 2021. Results Eight studies with total of 1301 patients were enrolled of which 668 patients had routine NGD. Routine NGD was associated with a higher incidence of overall delayed gastric emptying (DGE) and clinically relevant DGE (OR = 2.51, 95% CI; 1.12 - 5.63, I2= 83%, P = 0.03, and OR = 3.64, 95% CI: 1.83 – 7.25, I2 = 54%, P &amp;lt; 0.01, respectively). Routine NGD was also associated with a higher rate of Clavien-Dindo ≥ 2 complications (OR = 3.12, 95% CI: 1.05 – 9.28, I2 = 88%, P = 0.04), and increased length of hospital stay (MD = 2.67, 95% CI: 0.60 – 4.75, I2 = 97%, P = 0.02). There were no significant differences in overall complications (OR = 1.07, 95% CI: 0.79 – 1.46, I2 0%, P = 0.66), or postoperative pancreatic fistula (OR = 1.21, 95% CI: 0.86 – 1.72, I2 = 0%, P = 0.28) between the two groups. Conclusions Routine NGD may be associated with increased rates of DGE, major complications and longer length of stay after pancreatoduodenectomy.

Nonoperative management without nasogastric tube decompression for adhesive small bowel obstruction

BackgroundAlthough nasogastric tube (NGT) decompression is widely used in nonoperative management for adhesive small bowel obstruction (SBO), robust evidence is lacking to support this routine practice. MethodsPatients who received nonoperative management with a diagnosis of adhesive SBO were retrospectively reviewed. Those who received NGT or long-tube decompression at admission were categorized into the NGT group, while those who initially had no NGT placement were categorized into the non-NGT group. The incidence of vomiting after admission, pneumonia after admission, and the need for surgery were compared. ResultsAmong 288 patients, 148 (51.3%) had non-NGT conservative treatment. There were no significant differences in the incidence of vomiting (NGT vs non-NGT: 12.9% vs 18.9%, p = 0.16), pneumonia (1.4% vs 0%, p = 0.235), or need for surgery (12.9% vs 7.4%, p = 0.126). ConclusionsWhile NGT decompression is a standard of care for adhesive SBO, selective NGT insertion for patients with persistent nausea or vomiting can become an option.

Two case series of Chiladiti syndrome and a review of literature

Introduction: Chilaiditi’s syndrome was repeatedly an unforgettable case in Emergency Department due to its various symptoms. Methods: This case report consisted two reported cases of Chilaiditi syndrome. Then, we followed the methods of PRISMA for systematic review. Results: In this report, two cases of Chilaiditi syndrome with the different chief of complaint when admitted to the hospital. A 35-yearold woman presented to the Emergency ward with abdominal pain, while the older subject, a 67-year-old man complained of shortness of breath. Plain radiograph showed an elevated right hemidiaphragm and the presence of subphrenic air, making the diagnosis of Chilaiditi syndrome. Both patients were managed conservatively with nasogastric tube decompression and intravenous fluid. The follow up showed favorable results and symptoms resolved. Discussion: Chilaiditi syndrome might not be a rare entity, but a difficult syndrome to identify clinically due to its various unspecific symptoms. The radiological examination was needed to be carried out for the diagnosis. Conservative management led to favorable results. Conclusion: Clinicians should be more aware of the diagnosis of Chilaidity syndrome with its various symptoms. Radiological evidence should be obtained for the confirmed diagnosis, and conservative management was the modality choice. Keywords: Chilaiditi syndrome; radiology; conservative.

S1917 Complicated Diverticulitis of the Sigmoid Flexure in a Patient with Left Nephrolithiasis

Introduction: Complicated diverticulitis is defined as diverticular inflammation associated with hemorrhage, abscess, phlegmon, perforation or obstruction. There are currently no reported cases of complicated diverticulitis occurring secondary to obstructive nephrolithiasis. We report a patient admitted for a left ureteral stone, whose significant perinephric inflammation was suspected to play a role in the development of complicated diverticulitis. Case description/methods: A 76 year old woman with history of recurrent nephrolithiasis presented with acute left flank pain. On arrival, she was mildly tachycardic. Physical exam was notable for left costovertebral angle tenderness. Labs were notable for an elevated blood urea nitrogen of 25 mg/dL. Computed tomography (CT) abdomen showed a 6 mm obstructing calculus within the left proximal ureter causing moderate hydronephrosis and significant peri-nephric inflammation. The patient was started on ceftriaxone. The next day, she had a worsening leukocytosis and an acute kidney injury, so she was taken urgently for left ureteral stent placement. Postoperatively, she had significant abdominal pain, so a repeat CT abdomen was obtained. It revealed inflamed diverticulum at the splenic flexure with an associated abscess abutting the spleen, consistent with complicated diverticulitis. She was managed supportively with nasogastric tube decompression, pain control, and broadened antibiotics. On hospital day 8, her abdominal pain worsened. Repeat CT abdomen showed enlargement of the perisplenic abscess and multiple new small abscesses anterior to the spleen. The patient was taken for laparoscopic splenectomy, which was complicated by iatrogenic perforation of the stomach, peritonitis, and septic shock. After a prolonged and complicated hospital stay in the surgical intensive care unit, the patient was discharged to a long term care facility. Discussion: Our patient's complicated diverticulitis was suspected to be secondary to her left ureteral stone. While most cases of diverticulitis occur at the sigmoid colon, our patient’s was at the splenic flexure, in close proximity to the left renal fossa where significant inflammation was noted on initial imaging. It is also possible that her diverticulitis was a consequence of iatrogenic ureteral injury during cystoscopy. Clinicians should be aware that complicated diverticulitis may occur in relation to nephrolithiasis.Figure 1.: a: Synaptophysin positive tumor cells b: Chromogranin A positive tumor cells c: Colonoscopy showing 2 cm mass at Hepatic flexure. d: High grade adenocarcinoma arising in a background of sessile serrated adenoma e: CK7 positive immunohistochemical staining.