Resection Of Duodenum Research Articles

Which style of duodenojejunostomy is better after resection of distal duodenum

BackgroundDistal duodenal resections are sometimes necessary for radical surgery, but how to restore duodenal continuity is still unclear. This study aimed at determining which style of anastomosis was more suitable for the duodenojejunostomy after resection of distal duodenum.Patients and methodsWe retrospectively identified 34 patients who underwent distal duodenum resection at our center between January 2014 and December 2021. According to whether the end or the side of the proximal duodenum was involved in reconstruction, duodenojejunostomy were classified as End style (E-style) and Side style (S-style). Demographic data, clinicopathological details, and postoperative complications were analyzed between two groups.ResultsThirteen patients (38.2%) received E-style duodenojejunostomy, and 21 patients (62.8%) received S-style duodenojejunostomy. Comparative analysis showed that in group of E-style, patients had a lower rate of multivisceral resection(5/13 vs 18/21; P = 0.008), delayed gastric emptying (DGE) (1/13 vs 11/21; P = 0.011) and intraperitoneal infection (2/13 vs 12/21; P = 0.03). In this study, the incidence of major complications was up to 35.3% (12/34) and no patient died of complication in perioperative period. In two group, there was no difference in the incidence of major complications (E-style vs S-style: 3/13 vs 9/21; P = 0.292).ConclusionsThe E-style duodenojejunostomy for the reconstruction of distal duodenum resection is safe and feasible. The E-style anastomosis may have potential value in decreasing the occurrence of complications such as DGE and intraperitoneal infection, and the definitive advantages still need to be verified.

Intussusception of the third portion of the duodenum secondary to a primary duodenal malignancy: A case report.

Introduction and importanceIntussusception is invagination of the bowel and is rare in adults, representing only 5% of all cases of intussusception. Duodenal intussusception is also very rare. To the best of our knowledge, there is only one previous report of a malignant tumor in the fourth portion of the duodenum as the lead point of intussusception (Vaibhav et al., 2021 [1]). This reports a duodenal-duodenal intussusception caused by a malignant tumor in the third portion of the duodenum.Case presentationA 36-year-old woman with abdominal pain was diagnosed with duodenal intussusception by abdominal ultrasonography and computed tomography scan. Double balloon endoscopy showed that the intussusception had spontaneously reduced, and a tumor was found in the third portion of the duodenum. Open resection was performed because of the tumor location. Pathologic examination revealed adenocarcinoma with an adenoma of the duodenum. The patient had no evidence of recurrence for 4 years after resection.Clinical discussionThis patient had a primary duodenal malignancy and presented with intussusception, Duodenal intussusception is a rare condition requiring prompt intervention, usually requiring surgery. In this patient, since endoscopic resection was difficult, partial resection of duodenum was performed by open surgery assisted by double balloon enteroscopy. The pathological diagnosis of the resected specimen was primary duodenal malignancy.ConclusionThis is a report of adult duodenal intussusception caused by a primary duodenal malignancy. This rare condition posed an intriguing challenge for the optimal operative approach.

Cirugía radioguiada con análogos de somatostatina radiomarcados en tumores neuroendocrinos: reporte de caso

Introducción: el mejor tratamiento para los tumores neuroendocrinos es la resección completa del tumor, los ganglios, e inclusive en casos seleccionados, las metástasis a distancia. En ocasiones, el tumor primario es pequeño y de difícil localización preoperatoria o sus recaídas pueden ser difíciles de localizar en el terreno de fibrosis por cirugías o tratamientos previos. La cirugía radioguíada ofrece una opción adicional de localización intraoperatoria que hasta ahora no ha sido muy utilizada en tumores neuroendocrinos. Presentación del caso: paciente de 59 años con antecedente de resección atípica de duodeno y páncreas por tumor neuroendocrino grado 2 del duodeno un año antes. En la tomografía por emisión de positrones/tomografía computarizada (PET/CT) 68Ga-DOTANOC se encontró un ganglio con sobreexpresión de receptores de somatostatina en el mesenterio, sin otras lesiones a distancia. Por los antecedentes quirúrgicos y la dificultad de visualizar la lesión en las imágenes anatómicas (resonancia magnética [RM]) se decidió realizar la cirugía radioguíada. En el preoperatorio se administraron 15 mCi de tecnecio 99 metaestable-hidrazinonicotinilo-Tyr3-octreotida (99mTc-HYNIC-TOC) y se verificó la buena captación en el ganglio. En cirugía, luego de la disección inicial se utilizó la sonda gamma, que detectó una actividad 5 veces mayor en el ganglio, comparado con los tejidos vecinos, lo que permitió su localización y resección. La evolución fue adecuada y un año después no hay evidencia de recaídas. Conclusión: la cirugía radioguíada no ha sido muy utilizada en la localización intraoperatoria de tumores neuroendocrinos, pero es una buena alternativa en casos seleccionados, como el presentado en este artículo, y permite la detección intraoperatoria y su resección completa.

A case of gastric and duodenal mucosa-associated lymphoid tissue lymphoma with multiple gastric cancers: a case report

BackgroundGastric mucosa-associated lymphoid tissue (MALT) lymphoma is often caused by Helicobacter pylori and has a good prognosis. Rarely, patients with MALT lymphoma may have gastric cancer and have a poor prognosis.Case presentationWe herein report a case in which surgical treatment was achieved for a 72-year-old male patient with gastric and duodenal MALT lymphoma coexisting multiple gastric cancers. He underwent upper endoscopy for epigastric discomfort, which revealed mucosal erosion on the posterior wall of the middle body of the stomach, an elevated lesion on the duodenal bulb, and a raised tumor on the antrum of the stomach. He was diagnosed with gastric and duodenal MALT lymphoma with early gastric cancer. One month after H. pylori eradication, a second upper endoscopy revealed no improvement in the gastric or duodenal mucosa, and areas of strong redness with a shallow recess just below the cardia of the stomach. As a result, a diagnosis of gastric and duodenal MALT lymphoma with two gastric cancers was made. Total gastrectomy with proximal duodenum resection using intraoperative upper endoscopy and regional lymph node dissection was performed. Pathologically, gastric and duodenal MALT lymphoma and three gastric cancers were detected. Since one of them was an advanced cancer, he started taking S-1 after his general condition improved.ConclusionFor early detection of gastric and duodenal MALT lymphoma or gastric cancer, appropriate upper endoscopy and a biopsy are important. It is necessary to select a suitable treatment, such as H. pylori eradication, endoscopic treatment, surgery, chemotherapy, and irradiation, according to the disease state.

開腹手術で確定診断と治療を行った後腹膜膿瘍を合併した十二指腸水平脚潰瘍穿孔の1例(A case of perforated ulcer in third portion of duodenum with retroperitoneal abscess, which was diagnosed and treated by laparotomy)

要旨 60歳の男性。腹痛・下痢・嘔吐出現3日目に前医受診し原因不明のイレウスと診断され保存的加療が行われた。症状出現9日目のCT検査で後腹膜膿瘍形成を指摘され，加療目的で当院に転院となった。同日，虫垂穿孔または十二指腸穿孔による後腹膜膿瘍を疑い開腹手術を施行し，約1cm大の十二指腸水平脚後壁穿孔を認めた。十二指腸穿孔部位は炎症性に肥厚し脆弱で，単純縫合や被覆は困難と判断し，十二指腸水平脚部分切除および十二指腸下行脚−空腸吻合をOverlap法で行った。術後経過は良好で，約8か月後の上部消化管内視鏡検査で十二指腸に発赤・びらんのみ認め，切除検体の病理学的な特記所見はなく，十二指腸水平脚潰瘍穿孔と診断した。十二指腸水平脚穿孔は頻度が低く，特異的所見に乏しいが，後腹膜膿瘍形成前の発症早期に穿孔部位の縫合閉鎖手術を行うことが望ましい。後腹膜膿瘍を合併した症例では，ドレナージ・外科手術による治療を状況に応じて行うべきであると考えられた。

Therapeutic experience of type Ⅲ-b congenital intestinal atresia

To summarize the clinical characteristics and treatment of type Ⅲ-b congenital intestinal atresia (CIA). The clinical data of 12 type Ⅲ-b CIA treated in the Children's Hospital of Zhejiang University School of Medicine from January 2015 to December 2017 were analyzed retrospectively. Of the 12 patients diagnosed as type Ⅲ-b CIA in operation, treatment was refused during operation by their parents in 2 cases. For one child, only the proximal intestine was partly resected in the first operation, dilatation and dysplasia of the duodenum was diagnosed and total duodenum was resected and sutured in the second operation, as the child had postoperative intestinal obstruction. For one child, due to the long distal normal intestine, distal apple-peel like intestine was partly resected without mesenteric reformation. For the rest 8 children total duodenum resection and mesenteric reformation were performed. During the postoperative follow-up, one case was early rejected for further treatment by parents, one case died from complex congenital heart disease, 5 cases had the complication of short bowel syndrome. All 8 survival children received parenteral nutrition support after operation, 5 of whom received parenteral nutrition support for more than 42 days, and they were followed up for 1-3 years after discharge. The short-time efficacy was satisfactory. For children with type Ⅲ-b CIA, the distal apple-peel like intestine should be preserved as much as possible, the mesenteric reformation should be performed and the proximal dilated bowel should be partly resected and sutured. Postoperative nutritional support and early intestinal rehabilitation contribute to the compensation for rest intestines.

十二指腸切除5年後に発症したWernicke-Korsakoff 症候群を伴った脚気心の1例

十二指腸切除5年後に発症したWernicke-Korsakoff 症候群を伴った脚気心の1例

Surgical treatment of paraduodenal pancreatitis

Background: Cystic inflammatory transformation of duodenal wall described as a "paraduodenal pancreatitis" (PP). We evaluated the clinical efficacy of the surgical treatment of PP Methods: 90 patients with PP were retrospectively included over 12 years. Initially, all patients received conservative therapy. 80 patients required surgical treatment after conservative treatment with a median duration of 2 years. 37 patients underwent pancreaticoduodenectomy (PD), 21 -duodenum resection, 18 – duodenum-preserving pancreatic head resection (DPPHR), 4 - palliative operations. 10 non-operated patients remained under observation. 4 of them required various palliative endoscopic procedures.Long-term results were evaluated in 50 patients, the median follow-up was 47 months Results: PP was associated with chronic pancreatitis (CP) in 93%. Clinical course of PP consisted of the typical symptoms of CP: abdominal pain in 98.8% of patients, body weight loss - 65.5%, duodenal obstruction - 64%, biliary hypertension - 36%. The overall postoperative morbidity was 33.8%, mortality - 1.25%. After surgical treatment 66% of patients had no clinical symptoms, 32% - significant improvement and no clinical effect was in 2 % Conclusion: Typically PP occurs in patients with CP. The treatment of patients with PP should starts from conservative therapy. Surgery is indicated for patients with a persistent abdominal pain and a presence of a CP complications. Procedures of choice are PD and DPPHR

Superior Mesenteric Artery Syndrome: a Prospective Study in a Single Institution

BackgroundSuperior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, resulting from the compression of the duodenum between superior mesenteric artery and aorta. This prospective registry aims to describe demographic, clinical, and outcome features of patients suffering from SMAS and to point out the indications for surgery. MethodsBetween 2008 and 2016, patients with chronic gastrointestinal symptoms and diagnosis of SMAS were included. Demographics, clinical presentation, diagnosis, and surgical outcome were recorded. Symptoms were investigated with a standardized questionnaire. The diagnosis was achieved through barium swallow, CT/MR angiography (aortomesenteric angle ≤ 22°, distance ≤ 8 mm), endoscopy. All patients underwent duodenojejunostomy ± distal duodenum resection. At follow-up, symptom score and barium swallow were re-evaluated. ResultsThirty-nine patients (11 M/28 F, median age 38 years, median BMI 17.8 kg/m2) were included. Barium swallow showed a gastroduodenal dilation in 57% of patients, and a delayed gastroduodenal emptying in 38%. Median aortomesenteric angle was 11° and distance was 5 mm. All patients underwent duodenojejunostomy, and in 32 patients, a distal duodenum resection was also performed. At a median follow-up of 47 months, the overall symptom score significantly dropped (10 vs. 32, p < 0.0001) and BMI increased (19.5 vs. 17.8, p < 0.0001). Barium swallow at 2 months postoperatively showed an improvement in terms of gastroduodenal dilation and emptying in 38% of patients with preoperative pathological findings. ConclusionsSMAS is a rare condition that should be suspected in cases of chronic, refractory upper digestive symptoms, particularly in females with low BMIs. Surgical treatment may improve symptoms and quality of life, although it is not curative in all cases.ClinicalTrials.gov Identifier: NCT03416647

Gastric Outlet Obstruction as a Manifestation of Recurrent Crohnʼs Disease

Introduction The most common complications of Crohn's disease are the development of fistulas[1], abscess formation, malabsorption of bile acids, and adhesions. Rarely, Crohn's disease involves the stomach and the duodenum. We present a case of gastric outlet obstruction due to recurrent Crohn's disease. Case Report A 55-year-old male with a history of Crohn's disease in remission since 1990 presented with two weeks of nausea, vomiting, and 20 lbs. of weight loss. He had a remote history of antrectomy and ileocecectomy with no available details. In 2011, he had pyloric and postbulbar stenosis that required endoscopic dilatation. A computed tomography of the chest, abdomen and pelvis with contrast showed no acute findings. An outpatient esophagogastroduodenoscopy showed gastric outlet obstruction due to anastomotic stenosis of a previous antrectomy site and he was admitted. Initially, we treated the patient conservatively with intravenous fluids and proton pump inhibitors. However, he continued to have severe symptoms and eventually underwent duodenectomy with gastroduodenostomy. There were massive adhesions secondary to prior surgeries. The pathology report of the pylorus and duodenum resection (Figures 1 and 2) showed suppurative and granulomatous inflammation with focal abscess formation, adhesions, and stenosis consistent with Crohn's disease. On the tenth day of hospitalization, the patient recovered and was discharged home. Discussion While no controlled studies have been reported for the management of gastroduodenal Crohn's disease, the initial treatment typically includes corticosteroids and aggressive suppression of gastric acid using a proton pump inhibitor. Endoscopic balloon dilation can be used in short strictures. More severe strictures may require bypass via a gastrojejunostomy or gastroduodenostomy[2].2085_A Figure 1. Surface ulceration, crypt architecture distortion, and acute inflammation in the lamina propria with focal cryptitis.2085_B Figure 2. Granulomatous formation.

Experience in clinical diagnosis and treatment of duodenal tumors.

Small bowel tumors are rare tumors. Duodenal tumors occur more commonly compared with other small intestinal tumors. To summarize the clinicopathological features of duodenal tumors, in the present study 44 cases of duodenal tumors were collected, and the comparative clinicopathological characteristics between tumors of the ampulla and non-ampulla, the choice of treatment, and differences in the prognosis, were analyzed. The pathological type identified was predominantly adenocarcinoma; periampullary duodenal tumors were almost classifiable as adenocarcinoma in terms of their type. Non-ampulla duodenal tumors also included rare pathological types, such as stromal tumor and large B-cell lymphoma. The symptoms of duodenal tumors were non-specific, therefore rendering early diagnosis and treatment difficult. Due to jaundice, periampullary duodenal tumors were diagnosed earlier than non-ampulla duodenal tumors. Endoscopy and computed tomography (CT) examinations were valuable in terms of diagnosis, and were used as a means of screening. Carcinoembryonic antigen (CEA) and cancer antigen 199 (CA199) were revealed to be important as biomarkers. Radical surgery was the most effective treatment. Pancreaticoduodenectomy was revealed to be applicable in all cases of duodenal tumors. For non-ampulla duodenal tumors, partial duodenum resection and subtotal gastrectomy were appropriate for selection as methods of treatment. No survival benefits were identified for adjuvant chemotherapy. Duodenal tumors were shown to be a rare neoplasm with atypical symptoms; they should be diagnosed and treated as early as possible; CT and gastroscopy may be used for screening, radical surgery offers the best treatment; pancreatoduodenectomy is not the only surgery option available; and chemotherapy did not result in any survival benefits.

CYSTIC DEGENERATION OF THE DUODENUM ASSOCIATED WITH CHRONIC PANCREATITIS

Inflammatory cystic lesion of the descending part of the duodenum, mainly in the field of small duodenal papilla in chronic pancreatitis (CP) is described as “duodenal dystrophy” (DD). The pathogenesis of this condition has not been studied and treatment strategy is not defined. Purpose. Investigation of cystic inflammatory transformation of duodenal wall pathogenesis in patients with CP, described as a DD, and evaluate the clinical ef ficiency of surgical treatment. Material and methods . Eighty two patients with DD were retrospectively included over 12 years. The diagnosis of DD was established by transabdominal ultrasound, CT, MRI and endosonography. Initially, all patients were treated conservatively. 74 patients required surgical treatment subsequently after conservative treatment with a median duration of 2 years. 34 patients underwent pancreaticoduodenectomy (PD), 21 patients underwent duodenum resection, 15 – duodenum preserving pancreatic head resection of (DPPHR). 4 patients underwent palliative operations. Diagnosis of CP and DD was verified by histological study of surgical specimens. Not operated patients (8) are under observation. Long-term results of surgical treatment were evaluated in 47 patients with a median follow-up was 49.9 months. Results . Histological examination resulted that in 69.9% of DD was related with groove pancreatitis, with ectopic pancreatic tissue – in 30.1%. DD was associated with CP in 92.6% of cases. Clinical presentation of DD was not related with etiology and showed typical symptoms of CP: abdominal pain occurred in 98.8% of patients, body weight loss – 61.7%, duodenal obstruction – 35.8%, biliary hypertension – 34.1%. The overall morbidity was 35.1%. Overall postoperative mortality was 1.37% (1 patient). 66% of patients had no clinical symptoms postoperatively, a significant improvement – 32%, no effect – 2%. Conclusion. The most cases of DD is related with groove pancreatitis, less – with ectopic pancreatic tissue in the duodenal wall. Typically DD occurs in patients with CP. Treatment of patients with CP and DD should be started with conservative therapy. Surgery is indicated for persistent abdominal pain and presence of CP complications. Procedures of choice are PD and DPPHR.

Clinical characteristics and prognostic factors of primary duodenal carcinoma

Objective To summarize the clinical characteristics and investigate the prognostic factors of primary duodenal carcinoma. Methods The clinical data of 122 patients with primary duodenal carcinoma who were admitted to the Shengjing Hospital Affiliated to China Medical University from November 2007 to May 2013 were retrospectively analyzed. All the patients received different operations according to the characteristics of tumors. Primary duodenal carcinomas of patients were confirmed by the postoperative pathological diagnosis. All the patients were followed up by outpatient examination, telephone interview and correspondence till November 30, 2014. The treatment process, results of imaging examination and laboratory examination and postoperative survival were recorded. The clinical features, diagnostic criteria, therapeutic regimens and prognostic factors were analyzed. The survival rate and survival curve were analyzed and drawn by the Kaplan-Meier method. The univariate analysis was done using the Log-rank test, and multivariate analysis was done using the COX regression model. Results Among the 122 patients with primary duodenal carcinoma, jaundice as the first symptom was detected in 57 patients, abdominal pain and upper abdomen discomfort in 37 patients, gastrointestinal obstruction in 14 patients, anorexia and reduction of body weight in 4 patients, gastrointestinal hemorrhage in 3 patients, diarrhea in 3 patients, pyrexia in 3 patients and abdominal mass in 1 patient. The positive rates of CT examinations, endoscopic examinations, magnetic resonanced cholangio-pancreatography (MRCP), B-ultrasound examinations and upper gastrointestinal contrast examinations were 69.67%(85/122), 85.56%(77/90), 79.76%(67/84), 12.73%(7/55) and 75.00%(36/48), respectively. Among the 122 patients, anemia was detected in 48 patients, positive fecal occult blood test in 94 patients, increasing level of CA19-9 in 71 patients, increasing level of CEA in 22 patients and increasing level of AFP in 9 patients. The tumors located at the descending part of duodenum, duodenal bulb and horizontal part of duodenum were detected in patients of 86.07%(105/122), 7.37%(9/122) and 6.56%(8/122), respectively. The mean diameter of tumors was 2.3 cm (range, 1.0-15.0cm). All the 122 patients received operation. Pancreaticoduo-denectomy was performed in 100 patients, including combined with jejunostomy in 17 patients, pylorus-preserving pancreatoduodenectomy in 7 patients, segmental resection of duodenum and gastrojejunostomy in 5 patients, local resection of duodenal papilla in 6 patients and palliative gastrojejunostomy in 11 patients. Nineteen patients with complications were cured by symptomatic treatment. Of the 122 patients, adenocarcinoma, carcinoid tumor, lymphoma, small cell carcinoma, intraepithelial neoplasm combined with differentiated rhabdomyoma and with undifferentiated rhabdomyoma were detected in 116, 2, 1, 1, 1 and 1 patients, respectively. The Ⅰ, Ⅱ, Ⅲ and Ⅳ stage of tumors were detected in 10, 4, 74 and 34 patients. There were 100 patients without lymph node metastasis, 13 patients with 0 0.4. One-hundred and twelve of 122 patients were followed up for 1-70 months with a median follow-up time of 20 months. The postoperative survival time, a median of survival time, postoperative 3- and 5-year survival rates were 1-70 months, 18 months, 36.6% and 13.5%, respectively. The results of univariate analysis showed that the lymph node metastasis, differentiated grade of tumor, MLR and with invasion of pancreas were risk factors affecting the prognosis of patients (χ2=8.465, 57.355, 16.232, 20.112, P 0.4 were independent risk factors affecting the prognosis of patients (RR=3.330, 3.718, 2.623, 95% confidence interval: 1.861-5.956, 1.292-10.696, 1.624-4.236, P<0.05). Conclusions Most of the primary duodenal carcinomas are located at the descending part of duodenum without specific clinical symptoms in the early stage. The joint usage of assistant examinations can improve the diagnostic rate of primary duodenal carcinoma, and surgery is mainly therapeutic method. The low-differentiation of tumor, MLR>0.4 and invasion of pancreas are independent risk factors affecting the prognosis of patients. Key words: Primary duodenal neoplasms; Diagnosis; Therapy; Prognosis

Duodenal Gastrointestinal Stromal Tumor: A Rare Cause of Massive Upper GI Bleed managed with Segmental Resection of Duodenum

ABSTRACT Duodenal gastrointestinal stromal tumors (GIST) are relatively rare tumors and account for less than 5% of all cases of GIST, but still represents approximately 30% of primary duodenal tumors. Surgery is the only curative approach for duodenal GIST, but the optimal surgical procedure for duodenal GIST is not yet established. At present, there are no established guidelines regarding management of duodenal GIST. Various procedures including pancreaticoduodenectomy, pancreas-sparing duodenectomy, segmental duodenectomy, or wedge local resection have been described, but oncologic outcomes have not been evaluated. Buchs et al evaluated the role of segmental duodenal resection in the management of duodenal GIST and concluded that segmental resection is adequate for localized tumor where negative resection margins are obtainable. Here we present a case of duodenal GIST with massive upper GI bleed which was treated with segmental resection of the duodenum. How to cite this article Umapathi L, Bagaria D, Attri V, Kaman L. Duodenal Gastrointestinal Stromal Tumor: A Rare Cause of Massive Upper GI Bleed managed with Segmental Resection of Duodenum. J Postgrad Med Edu Res 2014;48(3):148-150.

A case of wedge resection of duodenum for massive gastrointestinal bleeding due to duodenal metastasis by renal cell carcinoma

BackgroundGastrointestinal bleeding due to duodenal metastasis from renal cell carcinoma is extremely rare. Several previous reports have shown that embolic therapy or pancreatoduodenectomy (radical surgical resection) could be effective in controlling this type of clinical complication. Management is entirely dependent on the general condition and concurrent metastases at other sites. Optimizing the therapeutic strategies thus deserves further discussion and exploration.MethodsIn this report, we describe a patient with severe co-morbidities who underwent successful palliative wedge resection of duodenum and direct duodenal wall defect repair without reconstruction of duodeno-jejunostomy for acute upper digestive tract hemorrhage caused by duodenal metastasis from renal clear cell carcinoma.ResultsThe patient recovered uneventfully and did not experience rebleeding and frequent vomiting after surgery. Since then (1.5 years) he has had no evidence of rebleeding.ConclusionsGastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities, and for palliative treatment.

Mo1516 Effects of Preoperative Enteral Glutamine and Arginine in Patients Submitted to Surgical Treatment of Enterocutaneous Fistulas

anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreatitis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18° +/-1.8 and distance 4.6 +/2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 +/6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improvement in patient weight (pre-operatory mean 50+/-1 kg, post-operatory mean 55+/-9 kg p= 0.003) and BMI (pre-operatory mean 18.1+/-3.4 kg, post-operatory mean 20.0+/-3.4 kg p= 0.004) and there is a significant decreased in need of PPI therapy (p=0.004). We didn't observed significant differences, in the outcome, between the two surgical procedures. Conclusions: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass.

Mo1515 Impact of Abdominal Insufflation for Laparoscopy on Intracranial Pressure

anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreatitis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18° +/-1.8 and distance 4.6 +/2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 +/6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improvement in patient weight (pre-operatory mean 50+/-1 kg, post-operatory mean 55+/-9 kg p= 0.003) and BMI (pre-operatory mean 18.1+/-3.4 kg, post-operatory mean 20.0+/-3.4 kg p= 0.004) and there is a significant decreased in need of PPI therapy (p=0.004). We didn't observed significant differences, in the outcome, between the two surgical procedures. Conclusions: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass.

En bloc Resection for Right Colon Cancer Directly Invading Duodenum or Pancreatic Head

PurposeWe undertook this study to analyze clinical features and surgical outcome of en bloc resections of the right side colon cancer directly invading duodenum and/or pancreatic head.Materials and MethodsThe records of all patients who underwent en bloc resection of duodenum and/or pancreas for right colon cancers were analyzed retrospectively. From September 1994 to September 2006, 1,016 patients underwent curative right hemicolectomy. Nine patients (0.9%) had en bloc resection of a right side colon cancer with duodenum or pancreatic head invasion.ResultsThe median operative time was 320 minutes (range, 200-420) and the median blood loss was 700 mL (range, 100-2,000). The mean size of tumor was 6.6 cm (range, 3.2-10.7). The mean preoperative carcinoembryonic antigen (CEA) was 10.6 ng/mL (range, 0.2-50.8). There was no 30 day perioperative mortality. The median disease-free survival was 23.5 months [95% confidence interval (CI) 5.2-41.8] and the median overall survival was 28.1 months (95% CI 9.7-46.5).ConclusionIn patients with locally advanced right side colon cancer that directly invades the duodenum or pancreas can be safely resected with curative potential with minimum morbidity and mortality. Long term disease free survival can occur in a significant number of patients undergoing curative en bloc resection in this particular subset of patients.

Composite lymphoma with relapse of enteropathy-type T-cell lymphoma

We describe an unusual case of with de novo composite diffuse large B-cell lymphoma and enteropathy-type T-cell lymphoma involving the duodenum in a 65-year-old man with celiac disease. A segmental duodenum resection revealed that two neoplastic components had infiltrated the intestinal wall. The coexistence of two malignancies was confirmed by immunohistochemical and molecular biologic analysis, which revealed clonal T-cell receptor γ and immunoglobulin heavy chain gene rearrangements. Epstein–Barr virus was not detected in the B- and T-cell components. After chemotherapy, the patient experienced two relapses of enteropathy-type T-cell lymphoma only. We review the medical literature on composite B- and T-cell lymphomas and discuss their diagnosis, pathogenesis, prognosis and treatment.

Treatment of vitamin d deficiency due to crohn's disease with tanning bed ultraviolet b radiation

In Crohn's disease, severe skeletal demineralization, secondary hyperparathyroidism, and muscle weakness can occur. This may be caused by impaired vitamin D absorption, resulting from extensive intestinal disease and resection of duodenum and jejunum, where vitamin D is absorbed. We report a 57-year-old woman with a long history of Crohn's disease and short-bowel syndrome who had only 2 feet of small intestine remaining after 3 bowel resections. She was taking a daily multivitamin containing 400 IU of vitamin D(3) and was dependent on total parenteral nutrition that contained 200 IU of vitamin D and calcium (18 mEq in a 1-L bag infused over 8 hours daily) for a period of 36 months. Despite the above replacement, she complained of bone pain and muscle weakness, and she continued to be vitamin D-deficient with a 25(OH)D level <20 ng/mL. She was then exposed to ultraviolet B (UVB) radiation in a tanning bed wearing a 1-piece bathing suit for 10 minutes, 3 times a week for 6 months at the General Clinical Research Center, Boston University Medical Center. She tolerated the irradiation well without evidence of erythema. After 4 weeks, her serum 25(OH)D level increased by 357% from 7 to 32 ng/mL, parathyroid hormone level decreased by 52% from 92 to 44 pg/mL, and the serum calcium level increased from 7.8 to 8.5 mg/dL. After 6 months of UVB treatment, her serum 25(OH)D level was maintained in the normal range and was free of muscle weakness, and bone and muscle pain.