Shawn MacKenzie

Introduction: Duodenal leiomyoma is a rare tumor, originating in the intestinal wall smooth muscle, making up <0.1% of all gastrointestinal tumors. The majority are discovered incidentally on endoscopy due to the small size of tumors at presentation. Larger duodenal leiomyomas may present with anemia from gastrointestinal hemorrhage. Case presentation: A 67-year-old male presented with life-threatening upper gastrointestinal hemorrhage. Magnetic resonance imaging identified an 11.9 × 8.7 cm submucosal mass in the second portion of the duodenum adjacent to the pancreatic head. An urgent upper endoscopy confirmed active hemorrhage, which was controlled with endoscopic clips. The patient underwent a successful resection of the tumor with no postoperative complications. Discussion: The diagnosis of duodenal leiomyomas remains challenging due to the lack of symptom manifestations. The differential diagnosis for a duodenal soft tissue mass includes gastrointestinal stromal tumor, solitary fibrous tumors, schwannoma, lymphoma, duodenal adenocarcinoma, and leiomyosarcoma. Radiographically, leiomyomas have typical imaging characteristics similar to skeletal muscle with marked T2 hypointensity, gradual enhancement on post contrast images, and the absence of extensive lesional necrosis. Surgical resection allows pathological confirmation of tissue diagnosis. Histopathologically, leiomyoma exhibits bland smooth muscle cells, with a low Ki67 proliferative index and absence of mitotic figures. Leiomyoma immunohistochemistry profile is positive for smooth muscle antigen and desmin. Conclusion: Reported is the largest case of an 11.9 cm giant duodenal leiomyoma with life-threatening gastrointestinal hemorrhage, providing the first comprehensive radiological-histopathological correlation for a giant duodenal leiomyoma. Surgical resection remains the primary treatment to confirm the pathological diagnosis of benign leiomyoma and manage symptoms.

Extragonadal locations of teratomas are uncommonly reported in the literature. Teratomas are neoplasms usually found in the gonadal organs: ovaries and testis. The majority of teratomas are found in the pediatric age group. Furthermore, teratomas originating in the liver are exceedingly rare with only 11 case reports in adult populations. We present a case of a 65 year-old female who presented to hospital with sudden onset abdominal pain from a centrally located ruptured hepatic teratoma on CT scan. The patient underwent urgent surgery. The diagnosis of cystic mature teratoma was confirmed on histopathology. Patient was discharged on post-operative day 5. At 12 week follow-up, no post-operative complications were identified. Hepatic teratomas are a rarely encountered neoplasm, especially in the adult population. Our case report is unique, as it represents the only clinical presentation of mass rupture in an adult liver teratoma. CT scan identified a well circumscribed mass containing adipose tissue, fluid, and calcifications characteristic of teratoma. Complete surgical resection is mainstay treatment. A definitive diagnosis of a mature teratoma is confirmed by histopathological findings. Presented is a rare case of ruptured hepatic teratoma in an adult who underwent surgical resection.

Introduction: Transanal minimally invasive surgery (TAMIS) is a valuable surgical option for removal of rectal polyps and early rectal cancers. A potential complication of this technique is abdominal entry if the lesion is located above the peritoneal reflection. We present the first case series describing the use of a laparoscopic stapling device to remove a sessile lesion, and seal the resulting defect simultaneously with full thickness excision of the rectal lesion, avoiding abdominal entry. Presentation of cases: Five patients with rectal lesions between 8 and 14 cm from the anal verge are described in this case series. Each underwent a stapled-TAMIS procedure as the lesion was suspected to be above the peritoneal reflection. The goal specimen was achieved in each procedure. Discussion: This article demonstrates the feasibility of a novel technique to remove sessile polyps in the upper rectum using laparoscopic staplers trans-anally through the TAMIS port. More studies and long-term follow-up are needed to evaluate the oncologic outcomes including the recurrence rate for those lesions removed with a stapler. Conclusion: For rectal lesions suspected to be above the peritoneal reflection, a stapled resection through a TAMIS port could prove be a valuable addition to the standard excisional approach to TAMIS. Highlights:

INTRODUCTION: Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention. PRESENTATION OF CASE: A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively. DISCUSSION: GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality. CONCLUSION: Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention. Highlights:

Aim: To study the long term benefits, toxicity and survival rate in patients with neuroendocrine tumors receiving multiple cycles of high activity In-111 Pentetreotide therapy. Moreover, our secondary aim was to evaluate the value of F-18 FDG PET-CT scan as prognostic indicator in this group of patients.

Advances in robotic surgery have allowed the frontiers of minimally invasive pancreatic surgery to expand. We present a step-by-step approach to the robotic Whipple procedure. The discussion includes port setting and robotic docking, kocherization and superior mesenteric vein identification, portal dissection, releasing the ligament of Treitz, uncinate dissection, and reconstruction. A brief report of our initial 2-year experience with the robotic Whipple procedure is also presented.

Background: Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy.Methods: A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990.Results: Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2·62 (95 per cent confidence interval (c.i.) 1·91 to 3·60)). A higher overall morbidity rate was also demonstrated in this group (RR 1·43 (95 per cent c.i. 1·26 to 1·61)), as was a higher mortality rate (RR 2·51 (95 per cent c.i. 1·61 to 3·91)).Conclusion: Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.