Partial Small Bowel Resection Research Articles

Single-stage laparoscopic treatment of a cholecystoduodenal fistula with perforated small bowel ileus and fibrinous purulent peritonitis. A single case study

Gallstone ileus is a rare complication of recurrent cholecystitis and one of the rarest causes of mechanical bowel obstruction, with an increasing incidence in the elderly. We present a case of multiple small bowel perforations of the jejunum due to gallstone obstruction and the incidental finding of high‑grade appendiceal mucinous neoplasia of the appendix. To our knowledge, this is the first such case to be described and completely resolved by a laparoscopic approach.
 An 83‑year‑old woman presented to our emergency department with severe vomiting, constipation, and deterioration of her general condition. A computed tomography scan revealed thickening of the gallbladder with a continuous aerobe to the duodenum, a mechanical obstruction of the small intestine at the transition to the ileum, and a thickened and calcified appendix. Due to a high suspicion of gallbladder perforation with the formation of a bilio‑duodenal fistula, the patient underwent an emergency exploratory laparoscopy, which revealed a small bowel perforation in three segments with marked local fibrinous, purulent, and stercoral peritonitis of the left hemiabdomen. The gallstone was retrieved through the perforated small bowel, and a partial small bowel resection and a cecal wedge resection were performed laparoscopically. Small bowel continuity was restored with an anisoperistaltic side‑to‑side jejuno‑jejunostomy. The patient was discharged on postoperative day eight.
 Despite advances in imaging, gallstone ileus remains a diagnostic challenge. Because the disease occurs predominantly in elderly patients, gallstone ileus remains associated with high morbidity and mortality. It remains unclear from the literature whether the optimal surgical management of bilioenteric fistula is best resolved by a single‑stage or a two‑stage approach.

Intraductal papillary mucinous neoplasm originating from a jejunal heterotopic pancreas: A case report

Intraductal papillary mucinous neoplasm (IPMN) is a rare pancreatic tumor and has the potential to become malignant. Surgery is the most effective treatment at present, but there is no consensus on the site of resection. Heterotopic pancreas occurs in the gastrointestinal tract, especially the stomach and duodenum but is asymptomatic and rare. We report a case of ectopic pancreas with IPMN located in the jejunum. A 56-year-old male patient suffered from severe pain, nausea and vomiting due to a traffic accident and sought emergency treatment at our hospital. Contrast-enhanced computed tomography of the whole abdomen suggested splenic congestion, which was considered to be splenic rupture. Emergency laparotomy was performed, and the ruptured spleen was removed during the operation. Unexpectedly, a cauliflower-like mass of about 2.5 cm × 2.5 cm in size was incidentally found about 80 cm from the ligament of Treitz during the operation. A partial small bowel resection was performed, and postoperative pathology confirmed the small bowel mass as heterotopic pancreas with low-grade IPMN. Ectopic pancreas occurs in the jejunum and is pathologically confirmed as IPMN after surgical resection.

Robotic-assisted Laparoscopic Bilateral Ileal Ureter Replacement With Extracorporeal Ileal Segment Preparation for Bilateral Extensive Ureteral Strictures: The Initial Experience

ObjectiveTo present our initial experience and evaluate perioperative, and follow-up outcomes following the novel technique of robot-assisted laparoscopic bilateral ileal ureter replacement (IUR) with extracorporeal ileal segment preparation for bilateral extensive ureteral strictures (BEUS). MethodsWe prospectively enrolled 4 consecutive patients with BEUS undergoing robot-assisted laparoscopic bilateral IUR with extracorporeal ileal segment preparation between June 2021 and October 2021. A 4-arm technique was used. The demographic characteristics, perioperative data, and follow-up outcomes as well as the description of surgical technique were reported. ResultsAll the patients had BEUS, and the length of strictures was over 10.ßcm in both sides. All procedures were performed effectively with a median operative time of 312.5.ßminutes (range 227-433) and a median estimated blood loss of 75.ßmL (range 50-200). In one patient, additional partial small bowel resection procedure was performed. No case was converted to open surgery. The median length of the ileal graft was 29.ßcm (range 15-32). The median postoperative hospitalization was 10 days (range 6-13). Two patients developed metabolic acidosis, and no major complications during the perioperative and follow-up period were reported. All patients presented symptom-free, with no signs of restenosis and improved/stabilized hydronephrosis, during the median follow-up of 12 months (range 12-15). ConclusionWe present the details and initial experience of robot-assisted laparoscopic bilateral IUR with extracorporeal ileal segment preparation. According to the median follow-up of 12 months, this minimally invasive procedure is a safe, feasible, and effective approach in the management of BEUS.

Generalized Infantile Myofibromatosis with Extensive Small Bowel Involvement in a Neonate.

Infantile myofibromatosis is a rare benign congenital tumour that often regresses spontaneously but may pose therapeutic challenges in its widespread visceral form. We present the case of a full-term neonate with generalized infantile myofibromatosis including ubiquitous subcutaneous and muscular nodules, a tumour in the mastoid and disseminated intestinal involvement. The intestinal tumours led to a mechanical ileus with intestinal perforation within the first days of life. After partial small bowel resection and necessary proximal jejunostomy the boy was dependent on total parenteral nutrition. Chemotherapy with vinblastine and methotrexate was started and was temporarily supplemented with imatinib. Feeding stayed impossible despite tumour shrinkage. At the age of 4.5 months, restoration of intestinal continuity with further stricturoplasties was performed which - for the first time - allowed complete oral feeding. Chemotherapy was continued for further two months. Currently, the child is in good general condition with growth and further disease regression. This report suggests that massive visceral involvement of infantile myofibromatosis may require extensive intestinal surgery, as conservative therapy cannot resolve the disease and its sequelae.

50-Year-Old Man With Hematochezia and Fatigue

A 50-year-old man, originally from southern Mexico, presented to primary care clinic for evaluation of intermittent bright red blood per rectum (BRBPR). His medical comorbidities included type 2 diabetes, hypothyroidism, and well-controlled hypertension. He had a history of cholecystectomy in Mexico many years ago, with an unspecified complication requiring laparotomy and partial small-bowel resection. His medications included metformin, glimepiride, lisinopril, levothyroxine, atorvastatin, and low-dose aspirin.

To Evaluate The Efficacy Of Bioresorbable Seprafilm Membrane In Avoiding Abdominal Adhesions

Aim: To evaluate the efficacy of bioresorbable Seprafilm membrane in avoiding abdominal adhesions.
 Material and methods: After obtaining approval from the appropriate institutional review board, this research was conducted within the department of General Surgery. Patients who needed a Hartmann procedure for diverticulitis or rectosigmoid blockage were randomly assigned to receive Seprafilm or to act as a control patient.
 Results: This research covered 100 patients in total. 50 patients were randomly assigned to receive Seprafilm while the other 50 served as controls. There were no significant variations in medical history or preoperative physical examination. At the midline incision, five patients got three Seprafilm membranes, 35 patients received two membranes, and ten patients received one membrane. In 40 patients, additional surgical operations were performed during the Hartmann procedure. In the Seprafilm group, 8 patients had appendectomy, 6 had surgical decompression of the small intestine, 3 had his peritoneal dialysis catheter removed, and 3 had ovarian cyst resection and partial small intestinal resection for unintentional bowel perforation. In the control group, 8 patients had further appendectomy, 6 patients had splenectomy, 3 patients had suturing for an iatrogenic bladder damage, and 3 patients had partial small bowel resection for a mesentery abscess. The median blood loss in the Seprafilm group was 352mL and 420mL in the control group. Postoperative wound healing was abnormal in 18 of the Seprafilm patients and 14 of the control patients. The time between the original operation and the follow-up surgery was not statistically different across groups. The median interval in the Seprafilm group was 6 months (range 2-17) and 4 months in the control group (range 1–31).
 Conclusion: we concluded a decrease in the degree of adhesion development following the application of Seprafilm in Hartmann procedure patients compared to controls.

S3488 Symptomatic Meckel’s Diverticulum in an Adult Presenting With Recurrent Gastrointestinal Bleeding

Introduction: Meckel’s diverticulum is a gastrointestinal congenital malformation that results due to persistence of the vitelline duct, and is commonly diagnosed in children before the age of two. Rarely, symptomatic Meckel’s diverticulum can present in adults, as in this case with recurrent gastrointestinal bleeding. Case Description/Methods: A 51-year-old male with a history of iron deficiency anemia presented to the hospital with hematochezia associated with mild epigastric tenderness. He had a similar presentation one year ago with unrevealing EGD, colonoscopy, and video capsule endoscopy. Three months ago, repeat colonoscopy was notable for a single nonbleeding diverticulum in the terminal ileum and outpatient double balloon endoscopy was recommended, however not yet done due to current hospitalization. He presented with tachycardia and hypotension as well as a hemoglobin 10.6g/dL (previously 11.4g/dL few weeks prior) and mildly elevated BUN. CT abdomen and pelvis was negative for any active bleeding. Repeat EGD and colonoscopy was unremarkable except for blood-tinged fluid interspersed in the colon but again the source of bleeding remained obscure. Given the history of a previous finding of a terminal ileum diverticulum and persistence of hematochezia, a Meckel’s scan was performed revealing abnormal uptake in the right mid to lower abdomen suspicious for Meckel’s diverticulum containing ectopic gastric mucosa. Patient was taken to the operation room; a large Meckel’s diverticulum was noted at approximately two feet proximal to the ileo-cecal valve along with hemorrhagic inflammatory changes within the local mesentery. Patient underwent partial small bowel resection and appendectomy with pathology revealing a Meckel’s diverticulum of the ileum with gastric heterotopia. Patient had an uncomplicated recovery postoperatively along with resolution of hematochezia. Discussion: A finding of Meckel’s diverticulum is common in the pediatric population; however, it is a rare diagnosis in adults. This case highlights the importance of considering Meckel’s diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. It is also important to notice that Meckel's diverticulum can be missed on video capsule study.

Lipid absorption and overall intestinal lymphatic transport are impaired following partial small bowel resection in mice

Short bowel syndrome (SBS) is associated with diminished levels of serum fats caused by unknown mechanisms. We have shown that mesenteric lymphatics remodel to a more primitive state one week after small bowel resection (SBR); therefore, this study focuses on the effect of chronic lymphatic remodeling and magnitude of resection on intestinal lipid uptake and transport. C57BL6 and Prox1 creER-Rosa26LSLTdTomato (lymphatic reporter) mice underwent 50% or 75% proximal SBR or sham operations. Functional transport of lipids and fecal fat content was measured and lymphatic vasculature was compared via imaging. There was a significant reduction in functional transport of cholesterol and triglyceride after SBR with increasing loss of bowel, mirrored by a progressive increase in fecal fat content. We also describe significant morphological changes in the lymphatic vasculature in both the lamina propria and mesentery. Intestinal lymphatic drainage assay in vivo demonstrated a marked reduction of systemic absorption after resection. Intestinal lymphatic vessels significantly remodel in the setting of chronic SBS. This remodeling may account at least in part for impaired intestinal uptake and transport of fat via the compromised lymphatic architecture. We believe that these changes may contribute to the development of intestinal failure associated liver disease (IFALD), a major morbidity in patients with SBS.

Small Bowel Perforation Secondary to Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a heterogeneous entity often described as either an acute or chronic occlusion of the portal vein or its tributaries. The clinical presentation is highly variable, and it often mimics other more common causes of abdominal pain. In most patients, imaging studies such as doppler ultrasound, computed tomography, or magnetic resonance imaging are adequate for diagnosis. Occasionally imaging studies may be inadequate, and the diagnosis may not be made until complications such as bowel necrosis and perforation have occurred. We present a case of a morbidly obese 45-year-old female who was initially treated for suspected small bowel enteritis and discharged home on several occasions after nonspecific findings on abdominal imaging were seen and interval improvement in symptoms occurred with intravenous fluids and antibiotics. She then presented with worsening symptoms and was found on abdominal imaging to have a large fluid collection in the peritoneal cavity requiring exploratory laparotomy with peritoneal washout and partial small bowel resection due to perforation. She was diagnosed with PVT with mesenteric extension after samples of the resected mesentery were evaluated in the pathology laboratory. Her treatment included a prolonged course of antibiotics, total parenteral nutrition, and anticoagulation.

小腸壊死を合併した新型コロナウイルス感染患者に対して緊急小腸部分切除術を施行した1例

小腸壊死を合併した新型コロナウイルス感染患者に対して緊急小腸部分切除術を施行した1例

A Retrospective Study of Patients Undergoing Gastrointestinal Surgery with or without Receiving Alvimopan: Comparing Length of Stay and Total Direct Cost

Objective: Alvimopan (Entereg®) has been shown to accelerate the recovery time of upper and lower gastrointestinal (GI) system following partial large or small bowel resection with primary anastomosis. Alvimopan acquisition cost can increase health care costs. The purpose of this study is to assess the effectiveness of alvimopan reducing the length of stay (LOS) and total direct cost in patients undergoing gastrointestinal surgery. Materials and methods: Data was collected using the Crimson Clinical Advantage software. The software identified 64 patients who underwent major small and large bowel surgical procedures from July 2018 to February 2019. Patients’ demographics, comorbidities, and treatment details were collected. Two groups where analyzed, patients that received alvimopan 12mg twice daily for up to 15 doses or until patients discharged, which ever occur first, with controls (patients who did not receive alvimopan). The data was retrospectively collected from patient records at Hialeah Hospital. The primary endpoints included reduction in both length of stay and total direct cost. Results: The study reviewed 64 patients that met the inclusion criteria, 33 (51.5%) of these patients received alvimopan. When comparing both groups, alvimopan treatment was associated with a reduced duration mean of hospitalization (4.48 vs 7.39 days, P < 0.01). In addition, almivopan was also associated with a significant reduction of the average total direct cost for treatment group ($7,965 vs $9,100), a difference of 12.4%. Conclusion: Patients who undergo segmental bowel resection with primary anastomosis and received alvimopan had a reduction of the length of stay and total direct costs compared with control group.

Ileal Dieulafoy lesion arose 15\u2009years after partial small bowel resection for meconium obstruction of the neonate: a case report

BackgroundAnastomotic or perianastomotic ulcers present with symptoms such as chronic anaemia and occult bleeding as long-term complications of bowel resection performed in infancy.Case presentationHerein, we describe a 15-year-old girl with a history of surgery for meconium obstruction without mucoviscidosis in infancy who was hospitalized with chief complaints of presyncope and convulsions. Seven hours after admission, she developed melena and went into shock. An emergency laparotomy was performed, and a Dieulafoy lesion was detected near the site of ileal anastomosis from the surgery that had been performed during infancy.ConclusionsAlthough overt massive lower gastrointestinal bleeding necessitating emergency care is rare in the long term after infant bowel resection, Dieulafoy lesions can cause serious bleeding, requiring rapid life-saving haemostatic procedures.

S3131 An Unusual Case of Postprandial Diarrhea: Gastrocolic Fistula from Gastric Band Erosion

Introduction: Bariatric surgery is increasingly performed nowadays. Gastroenterologists may encounter patients with its complications. Known complication of laparoscopic adjustable gastric banding (LAGB) include reflux, band slippage, erosion, pouch enlargement, and port breakage. We report a case with an unusual complication of LAGB. Case Description/Methods: A 45-year-old male with LAGB and atrial fibrillation presented with chronic diarrhea. Symptoms onset was 3 years ago after his partial small bowel resection when he presented with peritonitis. The patient reported loose stool within 15 minutes after each meal, abdominal pain, and 13-lbs weight loss. Physical exam was unremarkable. Laboratory data were within normal limits except mild anemia (Hgb of 12.9 g/dL) and mild renal impairment (Cr of 1.55 mg/dL). Upper GI study with small bowel follow through showed two separate channels arising from the proximal stomach with one connecting to the mid-transverse colon, suggesting a gastrocolic fistula (GCF) (figure 1A). CT scan of chest/abdomen/pelvis that was performed prior to barium studies was reviewed and demonstrated gastric erosion of the LAGB, with tethering of gastric cardia to the transverse colon with prolapse of the tubing into the distal transverse colon (figure 1B). Subsequent upper endoscopy showed an eroded gastric band in the gastric cardia and appeared to be extending through the gastric wall (figure 1C). Colonoscopy noted gastric band was entering transverse colon and extended distally (figure 1D). Surgical specimen of previous small bowel resection was reviewed and didn't show small bowel ischemia nor small bowel Crohn’s disease. The patient is currently evaluated by a bariatric surgeon for the definite treatment. Discussion: GCF is an uncommon manifestation of certain malignancies, pancreatitis, Crohn’s disease, peptic ulcer disease, and few cases related to other bariatric surgeries, usually with sleeve gastrectomy. LAGB related erosions of stomach, colon, and small bowel have been reported. To best of our knowledge, there are only 3 other cases of GCF related to LAGB. We report a rare complication of LAGB. Mechanism of GCF from LAGB is not fully understood, and is likely related to erosion of gastric wall from band pressure or foreign body reaction. Symptoms includes abdominal pain, weight loss, diarrhea, and sepsis. Diagnosis is made with upper GI series, contrast enhanced CT and endoscopic visualization. Surgery is the mainstay of treatment with removal of band and closure of fistula.Figure 1.: Endoscopic image of gastric ulcer in first case (A). Microscopic image H&E stained 400x of lymphoepithelial lesion with surrounding lymphocyte mucosal invasion (B). Endoscopic image of polypoid lesion in second case (C). Microscopic image H&E stained 200x of diffuse lymphocyte invasion into the lamina propria and muscularis mucosa (D).

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report

BackgroundSuture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.Case presentationA 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer.ConclusionsSuture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative.

CRS/HIPEC is thought to confer a survival advantage for patients with malignant peritoneal mesothelioma (MPM). However, the impact of nonperitoneal organ resection is not clearly defined. We evaluated the impact of major organ resection (MOR) on postoperative outcomes and overall survival (OS). The US HIPEC collaborative database (2000-2017) was reviewed for MPM patients who underwent CRS/HIPEC. MOR was defined as total or partial resection of diaphragm, stomach, spleen, pancreas, small bowel, colon, rectum, kidney, ureter, bladder, and/or uterus. MOR was categorized as 0, 1, or 2+ organs. A total of 174 patients were identified. Median PCI was 16 (3-39). The distribution of patients with MOR-0, MOR-1, and MOR-2+ was 94, 45, and 35 patients, respectively. MOR-1 and MOR-2+ groups had a higher frequency of any complication compared with MOR-0 (57.8%, 74.3%, and 48.9%, respectively, p = 0.035), but Clavien 3/4 complications were similar. Median length of stay was slightly higher in the MOR-1 and MOR-2+ groups (10 and 11days) compared with the MOR-0 cohort (9days, p = 0.005). Incomplete cytoreduction, ASA class 4, and male gender were associated with increased mortality on unadjusted analysis; however, their impact on OS was attenuated on multivariable analysis. MOR was not associated with OS based on these data (MOR-1: HR 1.67, 95% CI 0.59-4.74; MOR-2+ : HR 0.77, 95% CI 0.22-2.69). MOR was not associated with an increase in major complications or worse OS in patients undergoing CRS/HIPEC for MPM and should be considered, if necessary, to achieve complete cytoreduction for MPM patients.

Imaging features and clinical analysis of diffuse uterine leiomyomatosis cases

Objective: To discuss the imaging, clinical features and management of diffuse uterine leiomyomatosis (DUL). Methods: Six cases of DUL confirmed in Peking Union Medical College Hospital from August 2009 to September 2019 were reviewed on their image and clinical data. Retrospective analysis was conducted on their perioperative and postoperative follow-up data. Results: The average age of the first diagnosis of DUL was (27±3) years old. All of the patients complained menorrhagia and three patients suffered moderate to severe anemia. Three patients were diagnosed infertility. Pelvic ultrasound and MRI showed symmetrical enlarged uterus with complete replacement of the myometrium by innumerable, confluent leiomyomas.Four patients were treated with GnRH-a before operation to reduce the volume of myoma and correct anemia. Among the six patients, five had undergone myomectomy because of DUL before visiting Peking Union Medical College Hospital. Three patients underwent open myomectomy. The number of resected myoma was 188-300 and the bleeding volume was 1 200-2 500 ml. Two of them suffered recurrence at 51 and 40 months after operation. One received sirolimus for 20 months without recurrence until now. Other three patients underwent hysterectomy. One patient underwent partial small bowel resection and partial omentum resection because of severe pelvic adhesion during hysterectomy, and the blood loss was 2 000 ml. Conclusions: Pelvic imaging especially MRI is helpful for early recognition and preoperative evaluation for DUL. Fertility preservation is a great challenge for DUL patients. The risk of recurrence after myomectomy is high. Hysterectomy is the last choice to completely cure DUL at present.

P801 Treatment patterns of complex perianal fistula in Crohn’s disease in five European countries: the PREFACE study, a retrospective chart review

Abstract Background Presence of fistulas in Crohn’s disease (CD) is an indicator of poor prognosis; 22.1% of CD patients suffer from fistulising disease1 with high variability in complex perianal fistula (CPF) prevalence2. There is limited information available about the management of CPF in a real-world setting. This study describes the treatment patterns of patients with CPF in CD in Europe. Methods Retrospective medical chart review of consecutive patients with CD receiving treatment for a new episode of CPF during the period (September 2011 to September 2014), in Belgium, France, Germany, Italy and Spain. Index date was defined as the date of treatment initiation for a new episode of CPF during the eligibility period. Data was collected from CD diagnosis to at least 3 years after index date (except for deceased or lost to follow-up patients) to describe patient characteristics and treatments used for all CPFs episodes since CD diagnosis. Results A total of 386 patients (51% female) were included with a mean (SD) age of 38 (13) and 10 (9) years since CD diagnosis. At CD diagnosis, 28% of patients had ileal, 29% colonic and 39% ileocolonic involvement; 24% of study patients had anal or perianal fistula. Prior to index date, 42% of patients had at least one surgery, being partial resection of small bowel the most common one. ASA-5, anti-TNFs and immunosuppressants were used for CD or complications in 47%, 48% and 42% of patients. Patients presented 584 CPFs during the study period. More than half of these CPFs were trans-sphincteric (60%). Out of the 584 CPFs, 92% were treated with at least one surgical intervention (most frequent: 56% long-term seton placement, 46% surgical drainage), and 86.6% with at least one medical treatment. Medical treatments most frequently used for CPFs or CD and complications (overlapping a CPF episode) were anti-TNFs (49%), antibiotics (44%) and immunosuppressants (26%). Conclusion Almost one fourth of the patients with CPF already had anal or perianal fistulas at CD diagnosis. Based on ECCO guidelines it was expected that almost all CPFs in CD patients should be treated with anti-TNF with or without surgical intervention. However, the use of anti-TNF during CPF episodes was lower than expected. Surgical drainage and seton placement were performed in a majority of patients in at least 3 years following treatment intensification, with a low rate of other types of surgery. Almost two third of CPFs were trans-sphincteric and if inadequately treated, sphincter function may be compromised.

A Case of Primary Jejunal Cancer Located Near the Treitz Ligament Treated by Laparoscopic-Assisted Partial Small Bowel Resection

A Case of Primary Jejunal Cancer Located Near the Treitz Ligament Treated by Laparoscopic-Assisted Partial Small Bowel Resection

2641 Duodenal Crohn’s Disease Presenting as Gastric Outlet Obstruction Requiring Partial Gastrectomy

INTRODUCTION: Crohn’s disease (CD) is a chronic relapsing inflammatory disease which mainly affects the gastrointestinal tract. Although about 30–50% of these patients develop proximal disease, only about 0.5–4% of patients have clinically significant disease involving the stomach and/or duodenum. We present a case of isolated duodenal CD presenting as gastric outlet obstruction (GOO) requiring gastrectomy. CASE DESCRIPTION/METHODS: An 18-year-old woman without medical history presented to clinic with a 4-year history of postprandial abdominal pain, nausea, nonbloody emesis, decreased appetite, and unintentional weight loss. EGD demonstrated pyloric stenosis confirmed with upper GI series. Due to persistent symptoms with worsening weight loss on follow up, patient underwent repeat EGD that showed pyloric stenosis and erosive duodenitis. Duodenal biopsy showed active duodenitis with mucosal ulceration and granulation tissue. Pertinent labs were positive for ASCA IgA and ASCA IgG but negative for ANCA. As C-reactive protein was normal, patient was not begun on therapy. One month later, she underwent subtotal gastrectomy with partial small bowel resection with pathology showing marked active and chronic enteritis with ulceration and granulomas consistent with CD. On follow up, patient’s symptoms had resolved and she had largely returned to her baseline weight gaining about 30lbs. DISCUSSION: Published cases of proximal CD typically present with a several years history of progressively worsening gastritis-like epigastric pain. GOO developed in several cases, however, usually after numerous years. GOO symptoms frequently included bloating, vomiting, postprandial pain, and weight loss with inability to tolerate oral intake similar to our patient. Like other few published cases, our patient’s initial presentation of CD was GOO, though weight loss was quite severe in our patient. To our knowledge, rapidly progressive obstructive symptoms developed in two published cases. Duodenal CD treatment includes medical and endoscopic therapy. Medical therapy includes acid suppression with a proton-pump inhibitor and anti-TNF therapy. Endoscopic dilation may be possible if a stricture is present. Surgical intervention is undertaken when conservative therapy fails which includes resection, bypass, or strictureplasty. Duodenal CD causing GOO poses a diagnostic challenge and often requires a combination of endoscopic, radiological, histologic, and biochemical findings for accurate diagnosis and treatment.

2523 A Rare Location for a Rare Gastrointestinal Tumor With a Classical Presentation of Abdominal Pain, and Gastrointestinal Bleeding

INTRODUCTION: Yolk sac tumors belong to the class of nonseminomatous germ cell tumor (NSGCT), which rarely present as extragonadal germ cell tumors (GCT) of the retroperitoneum. Patients present with small bowel obstruction or gastrointestinal bleeding. Most commonly, these retroperitoneal tumors affect the ileum or jejunum, but here we present a case of a 31-year-old man who presented with a retroperitoneal yolk sac tumor with associated fistulization to the duodenum, jejunum, and ileum. CASE DESCRIPTION/METHODS: A 31 year-old man with no medical or surgical history was admitted with abdominal pain and melena. He underwent contrast-enhanced abdominal computed tomography (CT) showing an enlarging mass with central necrosis, and small bowel fistulization. Gastroenterology was consulted and upper endoscopy was performed, showing evidence of a duodenal mass and fistula, which was biopsied. Initial biopsies were inconclusive. Surgical oncology was consulted, and the patient underwent attempted surgical resection but the majority of the small intestine, colon, and associated mesentery were tethered and resection was not possible. A repeat EGD-guided biopsy was performed and pathology had the histological and immunohistochemical features of a yolk sac tumor. Laboratory studies revealed elevated serum alpha-fetoprotein (AFP) of 992 ng/mL [<6.0 ng/mL], normal serum beta-human chorionic gonadotropin (beta-hCG), and elevated serum lactic acid dehydrogenase (LDH) of 421 U/L [122-222 U/L]. Testicular ultrasound was negative for any abnormalities. Oncology initiated the patient on neoadjuvant cisplatin, etoposide, and bleomycin (BEP) every three weeks for three cycles. Two weeks after starting first cycle, AFP had dropped to 65 ng/mL, and thereafter to 11 ng/mL. Repeat imaging showed that the tumor had decreased in size. Approximately three months after completion of the last cycle of chemotherapy the patient underwent retroperitoneal tumor resection, along with partial small bowel resection. There was no evidence of malignancy in the final surgical pathology. One year later he is cancer free. DISCUSSION: This case highlights a successful collaboration between gastroenterology, radiology, surgery and oncology. There are no randomized trials in the treatment of retroperitoneal GCTs, thus case reports such as this provide much needed guidance in the treatment of this rare condition. It also illustrates the importance of tissue diagnosis via EGD in order to provide prompt diagnosis without invasive surgical biopsy.