Segmental Jejunal Resection Research Articles

Should we perform regular surveillance capsule endoscopies in patients following small-bowel adenocarcinoma resection? A case report and discussion.

Because small-bowel tumors are rare, prospective data on the utility of video capsule endoscopy (VCE) for their detection are limited. Current guidelines do not advocate for surveillance VCEs in patients following small-bowel tumor resection, which is mostly due to a lack of data. Here, we report an 81-year-old male patient who had undergone curative segmental ileal adenocarcinoma resection 15 years ago and another segmental jejunal adenocarcinoma resection (TNM-Classification: pT2 pN0 (0/2) G2M0) 7 years ago. He now presents with melena, progressive dyspnea, and decreased hemoglobin levels. VCE revealed local intestinal recurrence of the previously resected jejunal adenocarcinoma, leading to a second segmental jejunal resection (TNM-Classification: pT3 L1 pN0 (0/5) G2 M0). We believe that regular surveillance VCEs after the first jejunal adenocarcinoma resection might have facilitated earlier detection of tumor recurrence in this patient's case. Therefore, we suggest considering regular surveillance VCEs, at least in patients with recurrent small-bowel malignancies. However, future prospective studies are warranted to validate our findings.

Jejunal diverticular disease complicated with spontaneous perforation: A rare case of acute abdomen and literature review

Introduction: The jejunal diverticular disease is an uncommon clinical pathology. In general, these diverticula are an incidentaloma found on imaging exams that can be seen in elective surgeries for other purposes. In a minority of cases it causes symptoms which result from serious complications such as perforation. Case report: A 56-year-old male patient, previously healthy and without comorbidities, was admitted to the emergency department due to abdominal pain which had started 24 hours ago, without improvement. On examination, the patient was in pain and in Mohammedan prayer's position in bed and had a distended abdomen with signs of peritoneal irritation. An abdominal tomography showed massive distension of intestinal loops and free fluid in the peritoneal cavity. He underwent exploratory laparotomy which showed multiple diverticula in the jejunum and one of them was perforated. Segmental enterectomy with primary anastomosis was performed. Conclusion: Complicated jejunal diverticular disease should be ranked among the differential diagnoses in acute perforating abdomen. Segmental jejunal resection is the treatment of choice. Keywords: small bowel diverticulum; jejuno-ileal diverticula; diverticulitis; perforation; acute abdomen; surgery.

Intestinal thromboangiitis obliterans: a case report

BackgroundThromboangiitis obliterans or Buerger’s disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2% of the cases, when they may present as acute abdomen due to mesenteric ischemia. The uncommonness of the condition makes it a less suspected differential diagnosis, leading to a delay in appropriate management, thereby increasing chances of morbidity or mortality. Cessation of smoking is known to stall the disease progression including visceral involvement, but may not always be the case as happened in the case being presented.Case presentationOur Indian Hindu male patient, a known smoker, presented with diffuse abdominal pain along with bouts of vomiting and loose motions. He had a prior history of amputation of the right foot, 4 years before. At presentation he had abdominal distension with diffuse tenderness and guarding. An omental band attached to the tip of the appendix was discovered at the initial exploration along with dilated proximal bowel loops, for which a release of the omental band along with appendectomy was done. He developed an enterocutaneous fistula on the 6th postoperative day for which he had to be reexplored, and multiple jejunal perforations were found. Segmental jejunal resection and a Roux-en-Y gastrojejunostomy with distal ileostomy were done along with a feeding jejunostomy. The patient however again had feculent discharge from the wound for which a third exploration was done. The gastrojejunostomy and feeding jejunostomy sites were leaky, both of which were repaired primarily. The patient developed septicemia which progressed to refractory septic shock, and he ultimately succumbed to his illness on the 23rd postoperative day of the index surgery.ConclusionAcute abdomen in a young man who is a chronic smoker and having an antecedent history of amputation of some part of an extremity for a nontraumatic cause should raise the suspicion of Buerger’s disease of the intestine. Although it is a progressive disease and the situation has already progressed by the time intestinal symptoms manifest, early detection may give some scope of salvage and decrease the morbidity and mortality.

1966 Jejunal Submucosal Hemangioma as a Cause of Massive Gastrointestinal Bleeding: A Case Report

INTRODUCTION: Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery. CASE DESCRIPTION/METHODS: An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy. DISCUSSION: Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.

Sclerosing mesenteritis mimicking metachronous peritoneal metastases from descending colon adenocarcinoma

BackgroundSclerosing mesenteritis is a non-neoplastic inflammatory disease that occurs in the bowel mesentery. Distinguishing sclerosing mesenteritis from neoplasms may be difficult because of the clinical and radiographic similarities between the two disease entities.Case presentationWe report a case of sclerosing mesenteritis mimicking peritoneal metastases of colorectal carcinoma. A 73-year-old man with stage II descending colon adenocarcinoma with poor prognostic features was found to have developed left lower abdominal quadrant masses on computed tomography (CT) 9 months after undergoing radical surgery. These masses were diagnosed as peritoneal metastases because they grew in size and displayed fluorodeoxyglucose (FDG) uptake 3 months later; thus, a laparotomy was performed. The masses, which were localized in the jejunal mesentery, were excised completely via segmental jejunal resection. Histopathological analysis confirmed that the masses were sclerosing mesenteritis. The patient showed no signs of sclerosing mesenteritis or colorectal carcinoma recurrence during follow-up.ConclusionsIn patients suspected of having localized peritoneal metastasis from malignancies, any masses must be sampled by surgical excisional biopsy and subsequently examined to rule out alternative diagnoses, such as sclerosing mesenteritis.

Emergency Management of Complicated Jejunal Diverticulosis

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

Malignant small bowel gastrointestinal stromal tumor with multiple rare metastases – a case report

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms with uncertain prognosis. Distant metastases are most commonly found in the liver, followed by the lungs and bones. We report one case of a 50-year-old female who presented with diffuse abdominal pain. Ultrasonography showed small bowel obstruction by a lesion of 10 cm in diameter. Segmental jejunal resection was performed with removal of a well-circumscribed submucosal mass, with solid and cystic areas and foci of hemorrhage. Surgery also revealed a nodule in the recto-uterine pouch, a firm tumor in the left ovary, and multiple diffuse nodules in the omentum. Histopatho-logical examination showed mixed pattern of spindle and epithelioid cells, with dense cellularity, high nuclear pleomorphism, 2 mitoses per 50 high-power fields, necrosis and rich vascularization. Immunohistochemical analysis showed diffuse positive staining for CD 117 and VIM. Tumor cells were consistently negative for actin, CD34 and S-100. Based on the above findings, the diagnosis was mixed type malignant GIST of the small intestine with multiple metastases in the pouch of Douglas, ovary and omentum. Histologic subtype, tumor size and site are the most important features in malignant behavior. Mitotic count proved to be less significant. Making the right diagnosis is crucial for patients.

Tumors of the angle of Treitz: A single-center experience

To explore the feasibility and oncologic outcomes of segmental jejunal resection on the left side of the mesenteric vessels in patients with tumors of the angle of Treitz using data from a single center. Thirteen patients with tumors of the angle of Treitz who underwent surgery at our institution were prospectively followed. A segmental jejunal resection on the left side of the mesenteric vessels was performed in all patients. Formalin-fixed and paraffin-embedded tumor samples were examined. The primary end point of this analysis was disease-free survival. In this study, there were 8 males and 5 females (mean age, 50.1 years; range, 36-74 years). The mean tumor size was 8.1 cm (range, 3.2-15 cm). Histologic examination showed 11 gastrointestinal stromal tumors (GISTs) and 2 adenocarcinomas. Five of the GIST patients presented with potential low risk, and 6 presented with intermediate and high risk, according to the National Institutes of Health criteria. One potentially high-risk patient showed tumor progression at 46 mo and died 52 mo after surgery. One patient with locally advanced adenocarcinoma received neoadjuvant chemotherapy and adjuvant radiotherapy, but the disease progressed, and the patient died 9 mo after surgery. One GIST patient without progression died 16 mo after surgery because of a postoperative intestinal obstruction. The median overall survival rate was 84.6 mo, and the median disease-free survival rate was 94.5 mo. The overall survival of patients with tumors of the angle of Treitz was encouraging even when the tumor size was relatively large. A segmental resection on the left side of the mesenteric vessels is considered to be a reliable and curative option for tumors of the angle of Treitz.

Surgical second-look in high risk gastrointestinal stromal tumor of small intestine: A case report

INTRODUCTIONThe peritoneum is one of the most common sites of distant gastrointestinal stromal tumor (GIST) metastases. In particular, GIST arising from the small intestine with resected minimal synchronous macroscopic peritoneal carcinomatosis or with primary tumor rupture has a higher risk of developing peritoneal recurrence. Current clinical practice does not envisage second-look surgery in GIST patients at high risk of developing peritoneal recurrence, and no literature data are available. PRESENTATION OF CASEWe describe a 45-year-old woman who underwent emergency surgical resection of jejunal GIST presenting with spontaneous tumor rupture, synchronous ovarian and minimal macroscopic peritoneal involvement, and subsequent second-look surgery after 13 months of imatinib treatment. DISCUSSIONSecond-look surgery confirmed a 2.6cm lesion close to the mesenteric border of the fourth jejunal loop, and 11 peritoneal lesions with a macroscopic necrotic aspect related to treatment response. After conversion to an open procedure, a segmental jejunal resection was performed with removal of all peritoneal lesions and macroscopic radical cytoreduction. CONCLUSIONSecond-look surgery in selected GIST patients may be performed after at least 12 months of medical treatment with tyrosine-kinase inhibitors to identify those patients with limited peritoneal disease not disclosed by instrumental imaging who could undergo radical cytoreduction of peritoneal lesions.

Adult jejunojejunal intussusception caused by metastasized pleomorphic carcinoma of the lung: Report of a case

Adult small-intestinal intussusception is rare and very different from childhood intussusception. Both benign and malignant pathologies can underlie small intestinal intussusception in adults, but malignancy is much less frequent. We report a case of jejunojejunal intussusception caused by an intestinal metastasis of the sarcomatoid component of pleomorphic carcinoma of the right lung. The patient, a 61-year-old man, underwent successful segmental jejunal resection. Adult small bowel intussusception, though an unusual cause of acute abdomen, requires early diagnosis and timely management. To our knowledge, this is the first report of adult jejunojejunal double intussusception caused by metastatic sarcomatoid carcinoma of the lung.

Morbus Osler als Ursache einer akuten gastrointestinalen Blutung

Ein 73-jähriger Patient wurde aus einem auswärtigen Krankenhaus mit dem Verdacht auf eine Dünndarmblutung zur Videokapselendoskopie übernommen. Aufgrund eines Ventrikelthrombus und eines Myokardinfarktes im Jahre 2005, der mit Koronarstents therapiert worden war, nahm der Patient ASS, Clopidogrel und Marcumar ein. Die umfangreiche endoskopische Diagnostik ergab den Verdacht auf multiple arteriovenöse Malformationen (AVM) im Duodenum und Jejunum. Die gastrointestinalen Blutungen aus wechselnden Lokalisationen hielten trotz Beendigung der antikoagulatorischen Medikation über mehr als 3 Wochen an und erforderten die Transfusion von 30 Erythrozytenkonzentraten. Wegen der Ausdehnung war der Befund für eine Lokaltherapie nicht geeignet, sodass eine intraoperative Intestinoskopie sowie eine Jejunumsegmentresektion erfolgte. Die histologische Untersuchung bestätigte die Verdachtsdiagnose und sicherte einen viszeralen Morbus Osler mit multiplen Herden submuköser Gefäßektasien, überwiegend Venen, teils auch Arterien und Lymphgefäße betreffend, mit fokal stärkeren submukösen, teilweise bis in die Muskelschicht reichenden Einblutungen. In der bisher 3 Monate umfassenden Nachbeobachtungszeit traten keine erneuten Blutungsereignisse auf.

New techniques in the diagnosis and operative management of siamese twins

New techniques of 2-D sonography and radionucleotide Disofenin scanning allowed noninvasive evaluation of thoracoomphalopagus Siamese twins and successful separation at four days of age. Twin girls joined at the lower sternum and upper abdomen and weighing 15 lbs, were transferred at five hours of age after caesarian-section delivery. Scout films revealed high intestinal obstruction in twin A. 2-D sonography showed separate and normal hearts with different rates and attached pericardial sacs. Labeled Disofenin given intravenously to twin A was excreted exclusively in her gallbladder and bile ducts; vice versa for twin B. Because operation was necessary to correct jejunal atresia in twin A, further growth and development was not an option and the parents agreed to total correction. Sternal and pericardial separation and division of common midline-liver was followed by primary diaphragmatic defect repair and Dacron-cloth fascial reconstruction to upper abdominal wall and complete soft-tissue and skin closure in a ten-hour operation. Segmental jejunal resection and anastomosis with gastrostomy was added in baby A. The new tests greatly simplified definition of the anatomical relationships and implemented rapid correction in these newborn conjoint twins.