Gavin A. Falk

A 57-year-old woman presented with a 5-day history of worsening right upper quadrant pain, bilious emesis and approximately 20 pounds of weight loss. The patient was afebrile, without jaundice and had mild tenderness in her right upper quadrant. She noted an incidental finding of asymptomatic cholelithiasis on imaging 4 years earlier. An abdominal radiograph revealed pneumobilia and a large ectopic calculus. An abdominal CT scan confirmed pneumobilia, a large concretion completely obstructing the third portion of the duodenum and a soft tissue communication between the gallbladder and proximal duodenum. She was brought to the operating room for definitive treatment and had the obstructing gallstone removed via a transverse duodenotomy. Bouveret syndrome is a rare cause of small bowel obstruction that requires a high index of suspicion for diagnosis. It should be considered in older patients with clinical evidence of gastric or duodenal obstruction, particularly with a history of cholelithiasis.

Temporary or long-term nutritional support through gastrojejunal (GJ) feeding tubes is a safe and common means of enteral feeding in adults and children. It is indicated in patients with severe gastroesophageal reflux disease, gastric outlet obstruction, ...

Acute massive gastric dilatation (AMGD) is a rare distinctive condition but associates with high morbidity and mortality. Though usually seen in patients with eating disorders, many aetiologies of AMGD have been described. The distension has been reported to cause gastric necrosis with or without perforation, usually within 1–2 days of an inciting event of AMGD.We report the case of a 58-year-old male who presented with gastric perforation associated with AMGD 11 days after surgical relief of a proximal small bowel obstruction. The AMGD arose from a closed loop obstruction between a tumour at the gastro-oesophageal junction and a small bowel obstruction as a result of volvulus around a jejunal feeding tube.To our knowledge, this is the first case of a closed loop obstruction of this aetiology reported in the literature, and the presentation of this patient’s AMGD was notable for the delayed onset of gastric necrosis. The patient underwent an exploratory laparotomy and a partial gastrectomy to excise a portion of his perforated stomach. Surgeons should be aware of the possibility of delayed ischaemic gastric perforation in cases of AMGD.

Clear cell sarcoma (CCS) is an uncommon tumor that usually presents as an extremity mass but can rarely manifest as a gastrointestinal tumor with a diverse spectrum of symptoms, most commonly related to a mass effect or ulceration. Herein we report a case in which two separate tumors, one in the duodenum and the other in the jejunum, present concurrently. The subject presented with symptomatic anemia and underwent imaging and endoscopic studies that culminated in the discovery of the two lesions. He subsequently underwent operative treatment with resection of both tumors and made an unremarkable recovery. The resection specimen consisted of two separate clear cell sarcomas with negative margins. Under microscopic evaluation, they demonstrated nested growths of epithelioid cells with scattered spindled cells infiltrating the enteric wall. The neoplastic cells were positive for S100 with scattered expression of Melan A. Florescence in situ hybridization revealed a translocation at the EWRS1 locus. He was disease-free for 30 months following the procedure; then he developed a rapidly progressing metastatic disease with subsequent death 4 months later.

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery.Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal.Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate.Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.

A 47-year-old woman presented with a history of vague abdominal pain for several years, which worsened over the past 2 months, with pain more prominent in the right upper quadrant. She also had a history of peptic ulcer disease. The ultrasound scan of right upper quadrant revealed normal gallbladder and oesophagogastroduodenoscopy was unremarkable. A^99mtechnetium labelled hepato iminodiacetic acid (HIDA) scan with cholecystokinin provocation demonstrated a decreased gallbladder ejection fraction (EF) of 32%. On this basis, the patient was diagnosed with biliary dyskinesia and underwent an elective laparoscopic cholecystectomy. Histopathological analysis revealed chronic cholecystitis withCystoisospora belliidentified in the gallbladder wall.Cystoisosporahas been identified to cause an opportunistic acalculous cholecystitis among immunocompromised hosts, especially those with AIDS. This is the first case report of chronic cholecystitis due toC. belliin an immunocompetent patient.