Serosal Tear Research Articles

Laparoscopic versus open radical cystectomy in the treatment of locally advanced T3 and T4 bladder cancer: Perioperative and Mid-term oncological outcomes.

In this study, we aim to compare the perioperative and midterm oncological outcomes in patients with advanced bladder cancer and those who had laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). We retrospectively reviewed medical records of patients who underwent LRC or ORC in a single center between 2008 and 2014 with a pathological diagnosis of pT3 and pT4 bladder cancer. Thirty-five and 39 patients were included in the study as part of the LRC and ORC groups, respectively. There was no statistically significant difference between the two groups in terms of disease-free survival (LRC, 39.8±4.86 months; ORC, 45.47±8.92 months, P=0.896). Average estimated blood loss and length of hospitalization were significantly less in the LRC group. The overall survival rates of patients at 1, 2, and 3 years were 73%, 46%, and 46% in the ORC group and 78%, 65%, and 40% in the LRC group, respectively, and there was no statistically significant difference between the two groups. One patient in the ORC group experienced rectal injury in the form of a serosal tear, which was repaired primarily without any postoperative sequelae. There were no conversions in the laparoscopic group. Similarly, in 1 patient, rectal serosal tear was repaired preoperatively. Our study showed that LRC provides midterm oncological outcomes similar to ORC in the treatment of locally advanced T3 and T4 bladder cancer. However, long-term oncological and functional outcomes are required.

Comparison of laparoscopic and open pyloromyotomy: Concerns for omental herniation at port sites after the laparoscopic approach

Pyloromyotomy is a common surgical procedure in infants with hypertrophic pyloric stenosis and can be performed with a small laparotomy or laparoscopically. No specific complications have been documented about one of the approaches. We aim to study (severity of) complications of pyloromyotomy and to compare complications of both approaches. Children undergoing pyloromyotomy between 2007 and 2017 were analyzed retrospectively. Complication severity was classified using the Clavien-Dindo classification. We included 474 infants (236 open; 238 laparoscopic). 401 were male (85%) and median (IQR) age was 33 (19) days. There were 83 surgical complications in 71 patients (15.0%). In the open group 45 infants (19.1%) experienced a complication vs. 26 infants in the laparoscopic group (10.5%)(p = 0.013). Severity and quantity of postoperative complications were comparable between both groups. Serosal tears of the stomach (N = 19) and fascial dehiscence (N = 8) occurred only after open pyloromyotomy. Herniation of omentum through a port site occurred only after laparoscopy (N = 6) and required re-intervention in all cases. In conclusion, the surgical complication rate of pyloromyotomy was 15.0%. Serosal tear of the stomach and fascial dehiscence are only present after open pyloromyotomy and omental herniation after laparoscopy respectively. The latter complication is underestimated and requires attention.

Epiploic foramen entrapment of the large colon in a 9‐month‐old Thoroughbred filly

SummaryA 9‐month‐old Thoroughbred filly was presented for colic of a few hours’ duration. Examination revealed tachycardia at 64 beats/min, and a colon displaced to the right with wall oedema on ultrasound. After an hour of intravenous fluid therapy, the filly became restless and exploratory laparotomy was performed. Impaction and incarceration of the large colon up to the caeco‐colic fold through the epiploic foramen (EF) were diagnosed. After evacuating the colonic contents through a pelvic flexure enterotomy, the EF entrapment (EFE) was reduced. The large colon appeared congested with a fragile serosa, serosal tear at its antimesenteric aspect, and amotile for the remainder of the surgery. Colon motility resumed as evidenced by ultrasonographic examination on the second day post‐surgery, and despite pasty diarrhoea, the filly made a complete and uneventful recovery and was alive at 6 months’ follow‐up. Epiploic foramen entrapment of the large colon is very rare but should be included as a differential diagnosis of colon displacements, even in young horses, requiring prompt surgical resolution.

2029 Perforated IVC Filter Leading to Duodenocaval Fistula and Massive Gastrointestinal Bleeding

INTRODUCTION: Inferior Vena Cava (IVC) filters are primarily indicated for patients with a history of deep venous thrombosis (DVT) or pulmonary embolism (PE) who have contraindications to anticoagulation. In most patients, the indication for placement of a filter is temporary. Although filter penetration of the IVC wall has been reported to range from 9% to 24% for all IVC filters, symptomatic perforation is rare and is reported to occur in about 0.4%-0.8% of cases. We are presenting a rare case of duodenocaval fistula presenting as massive gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 39-year-old male with a history of motor vehicle accident 10 years ago resulting in paraplegia and multiple lower extremity DVTs which required the placement of an IVC filter at that time was admitted to the hospital with one day of nausea, vomiting and hematochezia. History was very concerning for high volume bright red bleeding per rectum with associated non-bilious vomiting and dizziness. On arrival, he was hypotensive with a blood pressure of 60/40 mmHg, physical examination significant for actively oozing bright red blood per rectum. Labwork was remarkable for a Hemoglobin of 7.0 mg/dL and a BUN of 35 mg/dL. A CT scan of abdomen/pelvis with contrast revealed an IVC filter strut travelling through the IVC wall and perforating to the adjacent small bowel with active extravasation of the IV contrast to the small bowel, suggestive of a fistulous communication between IVC and a perforated loop of bowel. The patient was emergently taken to the operating room for exploratory laparotomy. IVC filter strut was found to be eroding through the IVC and into the duodenum confirming the CT findings. Transverse venotomy was performed and the filter was removed. An area of small bowel serosal tear was incorporated into the enterectomy segment, and end to end small bowel anastomosis was performed. IVC was repaired, and hemostasis was secured. Post-operatively, patient stayed stable clinically and hemodynamically with cessation of hematochezia. DISCUSSION: Duodenocaval fistula is a very rare complication of IVC filter placement, with around 10 reported cases in the literature. Even though it is rare, our case highlights the importance of a thorough and timely sensitive workup for an unstable patient with gastrointestinal bleeding and history of an IVC filter placement to rule out IVC penetration into surrounding viscera, since this can lead to significant morbidity and mortality if not recognized early during the clinical course.

Pneumatic Colorectal Injury Caused by High Pressure Compressed Air.

The pneumatic colorectal injury caused by high pressure compressed air are rare and can be fatal. Herein, we present a case of 45-year-old male who developed sudden onset of severe abdominal pain after cleaning the dust on his pants with high pressure compressed air gun dust cleaner. Emergent exploratory laparotomy was done which findings are a huge rectal perforation with multiple serosal and subserosal tear in sigmoid to splenic flexure of colon. Anterior resection with left hemicolectomy, and temporary transverse colostomy was performed. Postoperative course was uneventful. Recently, prognosis is generally favorable because of prompt diagnosis and emergent surgical management.

Laparoscopic salpingectomy and removal of Essure hysteroscopic sterilisation device: a case series

Objectives: Tubal sterilisation using Essure is a minimally invasive technique for permanent contraception, with high rates of patient satisfaction. However, some women subsequently choose removal of the inserts, due to side effects such as pelvic pain, abnormal bleeding, dyspareunia or allergic dermatitis. This case series presents the management of eight women who underwent laparoscopic removal of Essure inserts in conjunction with salpingectomy. We describe our surgical technique, its underlying principles and immediate surgical outcomes.Methods: Eight patients were identified as having undergone removal of Essure inserts, via an electronic search of the surgical procedures database. A retrospective review of case records was undertaken. The primary outcome was safety and feasibility of the laparoscopic salpingectomy approach. Secondary outcome measures included implant fracture rate, operative time, blood loss and length of patient stay.Results: All eight women were able to undergo laparoscopic salpingectomy and removal of the Essure inserts without the need for laparotomy or hysterectomy. There were no incidences of fracture or incomplete removal of the insert. Immediate postoperative recovery was uncomplicated in all eight women; the mean length of stay was 17 h. One patient had a small bowel serosal tear attributed to laparoscopic entry.Conclusion: This case series suggests that laparoscopic salpingectomy for removal of Essure inserts is safe and feasible. We acknowledge that the numbers were small. However, consistent use of a laparoscopic approach in these eight patients indicates that this procedure is a feasible and suitable alternative to hysterectomy.

Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis

Background: High sigmoid (divided) colostomy has been recommended by various studies for the management of high-type anorectal malformation (ARM). It is postulated to be associated with fewer complications. Aims: To compare the complications related to left transverse loop colostomy and high sigmoid loop colostomy done in male patients with high-type ARM and share our experience. Materials and Methods: A prospective study on all male neonates admitted with high-type ARM at our high-volume tertiary care institute from January 2014 to March 2016 was carried out. The patients were randomized and divided into two groups (group A: left transverse loop colostomy and group B: high sigmoid loop colostomy). The patient's clinical presentation, operative course, and complications were recorded. Results: Of 158 male neonates who were subjected to loop colostomy, 93 (58.9%) were in group A and 65 (41.1%) in group B. Mortality was higher in group B (16.9%) than group A (8.6%), but none directly related to the type of colostomy. Intraoperative complications (technical difficulties) such as difficulty in approaching the sigmoid colon with dilated small bowel loops and identifying the proximal and distal parts of sigmoid colon along with handling of the bowel (including serosal tears) were significantly more in group B (20%) than group A (1.07%) where transverse colon was easily exteriorized. The average time taken for the procedure, pericolostomy excoriation, and bowel obstruction was more in group B when compared with group A. Conclusion: Left transverse loop colostomy works well to relieve the obstruction and is less time-consuming, particularly with late presentation. We recommend left transverse loop colostomy in cases of high-type male ARM because of the ease of procedure and comparatively low complication rates.

Ogilvie’s syndrome treated with an emergency laparotomy, right hemicolectomy and end ileostomy

Acute colonic pseudo-obstruction (ACPO), or Ogilvie’s syndrome, is a rare clinical entity in which there is massive non-toxic colonic dilatation in the absence of a mechanically obstructing lesion. It is...

Traumatic colonic injuries in Westmead Hospital – A paradigm shift in management over 10 years

Over the years, there has been a shift towards more conservative treatment, with primary repair of colonic injuries being preferred over faecal diversion. We present a cohort study of the management of penetrating colon injury over the past 10 years from a major trauma hospital in western Sydney. We aim to evaluate the trend of operative management of penetrating colonic injuries. Methods Patients were identified via the prospectively collected trauma registry at Westmead Hospital from 2003 to 2013. Fifty-seven patients initially identified with a proven diagnosis of penetrating colonic injury had their medical records reviewed. Excluded in the study are patients who had rectal injuries or serosal tears of the colon. Patient characteristics, mechanisms of injury, treatment course and complications were analysed. Extent of colonic injury was graded of using American Association for the Surgery of Trauma scalings. Results A total of 55 patients were then included in the study. Primary repair of colon injuries was the most common method used (63.6%, n = 35) followed by resection and primary anastomosis (21.8% n = 12), diverting colostomy (14.3%, n = 5) and non-operative management (5.5%, n = 3). There was a higher rate of diversion in the earlier time period (2003–2007) when compared to the later time period (2008–2013), p = 0.03. Over the 10-year period, there was no significant difference with regards to complications among groups, particularly intra-abdominal complications. Conclusion From 2003 to 2013, there is a shift of management of penetrating colonic injuries from diversion to resection and primary anastomosis to that of primary repair. Primary repair of colonic injuries is a safe option and is associated with low morbidity. It should be considered as a valid tool in the armamentarium of today’s surgeon.

A Case of Chronic Idiopathic Megacolon

Case: A 42 year old female presents with chronic diarrhea, bloating and increasing abdominal distention for 6 months. A CT scan showed massive colonic dilation with findings concerning for an internal herniation versus sigmoid volvulus. She underwent colonoscopy for decompression which showed diffuse colonic dilation but no evidence of a volvulus. She was managed initially with prokinetic agents and nasogastric and rectal tube decompression. Her celiac panel, vitamin b12, HSV, EBV, CMV, sedimentation rate, hemoglobin a1c, electrolytes, ANA, TSH were unremarkable. Anorectal manometry revealed no evidence of Hirschsprung's disease and an intact rectoanal inhibitory reflex. Unfortunately, the colonic dilation worsened despite conservative measures and she underwent an exploratory laparotomy and subtotal colectomy. Intraoperative findings revealed diffusely dilated colon with a maximum diameter of 15 cm and serosal tears in the transverse colon but without evidence of internal herniation, volvulus or obstruction. Pathology showed edema and congestion without significant inflammation. There was no evidence of fungal elements, spirochete-like organisms, CMV, HSV, amyloidosis or fibrosis. Immunostains revealed the presence of interstitial cells of Cajal, nerves, ganglion cells, and a normal distribution of lymphoid cells. At this point she was thought to have chronic acquired idiopathic megacolon. Discussion: Chronic megacolon is a rare condition and typically manifests as intractable constipation, abdominal pain, and bloating. It is caused by diseases that involve the smooth muscle cells, enteric or extrinsic nervous system, or the connective tissue component of the colonic wall. It is idiopathic in the majority of cases. Secondary causes include myopathic disorders such as Duchenne's muscular dystrophy, and neuropathic disorders such as Hirschsprung's disease and Chagas disease. Some diseases such as Parkinson's disease or diabetes, may cause either extrinsic denervation or intrinsic neuropathy, causing megacolon. Chronic megacolon is also observed in patients with connective tissue disorders such as Ehlers-Danlos syndrome, amyloidosis, and scleroderma. In general, the treatment of chronic megacolon is similar to that of intractable constipation. Short term treatment options include prokinetic agents and acetylcholinesterase inhibitors. Many patients eventually require a colectomy because of failed medical therapy.Figure 1Figure 2Figure 3

Repair of Morgagni Hernia in Adults with Primary Closure and Mesh Placement: First Robotic Experience.

Morgagni hernia (MH) is an uncommon type of diaphragmatic hernia, especially in adults. Laparoscopic or thorascopic approaches have been described in adults. There are few reported cases using the Da Vinci robot in children and no previously described cases in adults. We report our early experience and technique using the robotic approach for MH repair in adults and its potential advantages. Robotic repair of MH was performed in 3 female patients. Four trocars were used to gain access to the abdomen. The hernia contents were reduced, the sac excised, and the defect closed primarily. A 4 × 6 inch bioabsorbable coating mesh was used in 2 patients and a biologic mesh in 1 for reinforcement. Robotic repair of MH was technically successful in all 3 patients. The average operative time was 199.3 minutes, and difficult hernia exposure in one case caused prolonged surgical time. There were no intraoperative complications. Additional interventions, including a repair of a transverse colon serosal tear during the reduction of hernia contents, occurred in 1 patient. Two of the 3 female patients were discharged on postoperative day 1, whereas the other patient was discharged on postoperative day 3. There were no postoperative complications. Robotic MH repair is an alternative minimally invasive approach for adults that allows for precise sac excision and primary tension-free repair with mesh reinforcement.

Pyloromyotomy for infantile hypertrophic pyloric stenosis using a modification of the Tan and Bianchi circumumbilical approach

Background/purpose Different approaches have been advocated for pyloromyotomy. Since the introduction of umbilical pyloromyotomy, a number of studies have shown that it is as safe as the traditional right upper quadrant approach with superior cosmetic results. The aim of this study was to assess the feasibility and the safety of pyloromyotomy for infantile hyprtrophic pyloric stenosis using a modification of the Tan–Bianchi approach. Patients and methods Over a period of 2 years, 20 infants with infantile hypertrophic pyloric stenosis have been clinically evaluated. The umbilical approach was modified so that a transverse muscle cutting incision rather than a longitudinal midline linea alba incision was performed. Results The total number of cases included in this study was 20 [16 male (80%) and four female (20%) patients]. Their ages ranged from 23 to 60 days (average 42.6 ±13.54 days), and their weights ranged from 2700 to 4000 g (mean 3605± 437.4 g). Pyloromyotomy was performed safely with negligible blood loss. Four cases of serosal tear occurred, with an incidence of 20%. None of our cases showed significant complications. The mean operating time was 52.5 ± 5.073 min. The postoperative hospital stay ranged from 24 to 72 h. The postoperative course was uneventful in all patients, and, on follow-up, the circumumbilical incision left an almost undetectable scar. Conclusion Pyloromyotomy for infantile hypertrophic pyloric stenosis using the modified Tan and Bianchi technique is feasible and safe, having an accepted operative time, early initiation of postoperative feeding, and short hospital stay. This modification combines the advantage of circumumbilical incision with its better cosmetic results and right transverse upper abdominal approach with its easy and feasible access to the pyloric mass. Keywords : operative intervention, pyloric stenosis, Tan–Bianchi approach

EUS-guided FNA biopsy of the muscularis propria of the antrum in patients with gastroparesis is feasible and safe

EUS-guided FNA biopsies of the muscularis propria of the gastric wall in patients with gastroparesis could replace the routine use of surgical full-thickness biopsies for assessing the loss of the interstitial cells of Cajal (ICCs) and cellular infiltrates in the myenteric plexus. We investigated the efficacy and safety of EUS-guided FNA biopsies of the muscularis propria of the gastric antrum in gastroparesis and compared the tissue with a surgically obtained full-thickness biopsy specimen in the same patient. This was a prospective, nonrandomized, feasibility trial. Patients with gastroparesis who were undergoing gastric neurostimulator placement were enrolled. Patients had a gastric wall measurement by radial EUS in the body and antrum of the stomach followed by linear EUS examination and FNA of the muscularis propria in the antrum by using a 19-gauge core needle. Within 24 hours, a full-thickness biopsy specimen of the antrum was obtained surgically during neurostimulator placement. Endoscopic and surgical specimens were compared for tissue morphology, number of ICCs (c-kit stain) and enteric neurons (S-100 stain), and fibrosis (trichome) for each patient. The correlation coefficient of the ICC count per high-power field was used to compare both specimens. Continuous data were compared by using a t test. Eleven patients (10 female, 1 male), with a mean age of 40.6 years, were enrolled in the trial. EUS-guided core biopsies were successful in obtaining sufficient tissue for the histologic assessment of ICCs in 9 patients (81%) and for the myenteric plexus in 6 patients (54%). There was a good correlation coefficient (0.65) when both surgical and endoscopic groups were compared for the loss of ICCs. Mild serosal bruising and/or localized hematoma formations were noted at the sites of EUS biopsies, but there were no serosal tears, perforations, or adverse effects on the hospitalization and outcomes. EUS-guided FNA of the gastric muscularis propria in patients with gastroparesis is safe and provides adequate tissue for full histologic assessment. (Clinical trial registration number: NCT01916460.).

Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis

BackgroundRoot cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical...

Upper Tract Urological Laparoendoscopic Single-Site Surgery (LESS).

Background and Objectives:Our objective is to report intermediate-term outcomes for patients who have undergone upper tract urologic laparoendoscopic single-site surgery (LESS) at a single institution.Methods:From January 1, 2008, through November 30, 2012, 107 cases treated with LESS were identified, including pyeloplasty (n = 30), ureterolithotomy (n = 32), nephrectomy (n = 35; simple = 31, partial = 4), and cyst decortication (n = 10). Perioperative data were reviewed, and conversion and complication rates were noted.Results:The median follow-up was 21.5 months for pyeloplasty, 20.5 for ureterolithotomy, 28.0 for simple nephrectomy, 14.0 for partial nephrectomy, and 19.0 for cyst decortication. Major complications were encountered in 8 patients, including 3 intraoperative complications (2 bowel injury with serosal tearing and 1 intraoperative bleeding), which were recognized and repaired with LESS or conversion to conventional laparoscopy (CL). During the intermediate postoperative period (30–90 days) major complications occurred in 5 patients: 4 ureteral strictures (Clavien-Dindo grade [CG] IIIb) and 1 urinoma formation (CG IIIa). During the early postoperative period (<30 days), the most common minor complications were flank pain (CG I) in 16 patients and urinary tract infection (CG II) in 11, followed by urinary leakage (CG I) in 8.Conclusions:Intermediate-term functional outcomes of this single-center study confirm that upper tract LESS is a challenging procedure that can be safe and effective when performed by an experienced team. Prospective studies with longer follow-up periods are needed to investigate the safety of LESS in the treatment of various upper urinary tract conditions.

Laparoscopic ventral hernia repair: defining the learning curve.

Between 2004 and June 2011, 181 patients underwent laparoscopic ventral hernia repair. Three main surgeons, all experienced in laparoscopic procedures, performed all the cases. After analyzing the operative time (OT) for 3 main surgeons, within the first 20 cases the overall performance plateaued. Data from 60 patients (50F, 10M), with a mean age of 42.3 years (range, 26 to 88 y) and a mean hernia defect size of 6.5 cm (range, 4 to 18 y), were evaluated. No significant differences were recorded among the 3 surgeons in OT and intraoperative or postoperative complications. But 3 (5%, P<0.03) patients had complications, and the recurrence rate was 6.6% with a mean follow-up of 54 months (range, 42 to 70 mo). One had prolonged postoperative ileus, the second had bowel serosal tear, and the last had port-site incarcerated hernia. Our results showed that the OT of 98.9 minutes (range, 48 to 205 min) stabilized in 12 cases.

English

CASE REPORT: A 23 year old male working in a biscuit factory was brought to emergency department by the coworkers at 4PM with pain abdomen and distension and bleeding per rectum. On further questioning the patient confessed that his co-workers had held him firmly and directed the stream of air from a compressed-air pipeline towards his anal region in the morning. On examination, he was alerting conscious and oriented and tachypneic. The respiratory rate was 30/min, SPO280%, Pulse was 120/min and B.P. 120/80 mm Hg. On palpation, Abdomen was grossly distended (Fig. 1), tense with generalized tenderness and rigidity of abdominal wall. The percussion note was tympanitic and liver dullness obliterated. No free fluid was detected. Bowel sounds were absent. Examination of the perineum did not show any external injury. Rectal examination showed faeces mixed with fresh blood but did not reveal any laceration or perforation in the anal canal or rectum. Straight X-ray abdomen in erect position showed extensive pneumoperitoneum (Fig. 2) Abdominal decompression was made in view of tension pneumoperitoneum, low saturation and tachypnea. A 20G needle was inserted in the right upper quadrant just lateral to rectus abdominis muscle following which the pneumoperitoneum reduced with sudden improvement in the oxygen saturation (98%) and tachypnea got reduced. A clinical diagnosis of pneumatic rupture of hollow viscera, probably colon was made. An emergency exploratory laparotomy under general anesthesia through a mid-midline incision was carried out. Intraoperative, a single perforation of 3x2cms in the ant mesenteric border of transverse colon 15cms away from the hepatic flexure (Fig. 3) with fecal spillage into the peritoneal cavity was noted. There was also sero muscular tear along the entire length of the transverse colon (Fig. 4) and extensive contusions around the entire colon. Thorough visceral inspection of abdomen did not reveal any other visceral injury. The perforation was closed in two layers using 2-0 vicryl and 2-0 silk and the areas of serosal tears were sutured using 2-0 silk. After a thorough peritoneal lavage, a de functioning transverse loop colostomy was placed in the right upper quadrant and the wound was closed in layers with an abdominal drain. Postoperative recovery was quite uneventful and colostomy reversal is planned later.

Successful Endoscopic Ultrasound Guided Biopsies of Gastric Muscularis Propria in Gastroparesis Patients

Purpose: Loss of interstitial cell of Cajal (ICC) in the muscularis propria (MP) and inflammatory changes in the myenteric plexus are reported from full thickness biopsies (FTB) of the stomach wall in patients with gastroparesis (GP). These findings can aid in the diagnosis and treatment selection. However FTB use is limited by the need for surgery. We hypothesized that endoscopic ultrasound guided core biopsies (EUS-CB) can obtain sufficient MP tissue for histological examination in GP patients. We investigated the efficacy and safety of EUS-CB of the stomach antral wall in GP and compared the tissue to a surgically obtained FTB in the same patient. Methods: This is a prospective non-randomized feasibility trial. Patients with GP who were undergoing gastric neurostimulator placement were enrolled. Patients had a biopsy done by EUS FNA with a 19 G core needle, followed by FTB obtained surgically during neurostimualtor placement within 24 hours. Endoscopic and surgical specimens were compared for tissue morphology, count of ICC (c-kit stain), enteric neurons (S100 stain), and fibrosis (trichome) for each patient. Correlation coeffi cient of the ICC count per HPF was used to compare both specimens. Safety of the endoscopic procedure was assessed by examining the site of EUS biopsy during surgery as well as observing clinical outcomes. Results: Five female patients (mean age 41.6 years) were enrolled in the trial (four diabetic and one idiopathic GP). EUS-CBs were successful in obtaining sufficient tissue for histological assessment of ICC in all patients and for the myenteric plexus in 60% of patients (Table 1). There was a high correlation coefficient (0.8) when comparing both surgical and endoscopic groups for the loss of ICC. Figure 1 shows c-kit staining for ICC in the endoscopically obtained specimen. Mild serosal bruising and/or localized hematoma formations were noted at the sites of EUS biopsies in all five patients but no serosal tear or perforation was noted. No post-procedure complications were reported.Table: Table. Comparison of endoscopic and surgical biopsies obtained from the stomach's muscularis propriaFigure: C kit staining for ICC on EUS biopsy.Conclusion: EUS-CB of the gastric MP in GP patients is safe and provides enough tissue for complete histological assessment. This relatively non-invasive approach can replace surgical FTB and will revolutionize the diagnosis and management of patients with GP.

THE CURIOUS CASE OF THE RIGHT SIDED INGUINO-SCROTAL HERNIA [POSTER

IntroductionInguinal hernia often presents as an emergency with obstruction and subsequent strangulation. We report an interesting case where an inguino-scrotal sliding type hernia contained the hepatic flexure as its lead...

A concealed small bowel perforation in an adult secondary to bicycle handlebar trauma

Traumatic abdominal wall hernia (TAWH) secondary to bicycle handlebar is a rare injury. The majority of the literature describes abdominal wall herniation in children. We present a rare case of TAWH in an adult with a concealed small bowel perforation. Although clinical examination in conjunction with computed tomography can exclude the majority of solid organ injuries, small bowel injuries can often be missed. Our case initially revealed a serosal tear in the small bowel but, on close inspection, a separate 3mm perforation was identified, hidden in the small bowel mesentery. We strongly support a low threshold for operative intervention if there is any suspicion. Moreover, we stress the importance of meticulous examination during laparotomy as this injury could have been easily missed, resulting in potential morbidity or mortality in a patient sustaining such an injury.