ASASJournal11 JOURNALFall05 1/11/11 9:38 AM Page … Sarma, MD Julie Ann Sosa, MD Eyiyemisi Damisah,...

Winter 2010/Spring 2011

ABDOMINALSURGERY

OFFICIAL JOURNAL OF THE AMERICAN SOCIETY OF ABDOMINAL SURGEONS, INC.

2011 is theAmerican Society’s52nd Year of Service

ASASJournal11_JOURNALFall05 1/11/11 9:38 AM Page 1

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WINTER 2010/SPRING 2011 1

ABDOMINALSURGERY

Official Journal of theAmerican Society of Abdominal Surgeons, Inc.

Index 1

Jejunal Gastrointestinal Stromal Tumours Presenting as Common Abdominal Symptoms and a Review of the Literature 2Rosemary Smith, MBChBNeeraj Bhasin, BSc (Hons) MB, BS, MD, MRCSPhilip Da Costa, MB, BS, MRCS, LRCP, FRCPathTarig Ahmed, MBBCh (Hon) FRCS I (Gen)C Raj Kapadia, MS FRCS, MBA

Recurrrent Abdominal Wall Hernia After Adjustable Gastric Band Placement – A Case Report 5Fernando Miranda, MDAudencio Alanis, MD

Venous Air Embolism During Laparoscopic Surgery Due to a Patent Foramen Ovale 8Aiesha Ahmed, MDMax R. Lowden, MDGary Thomas, MD

Successful Simultaneous Laparoscopic Hand-AssistedBilateral Nephrectomy And Living Donor KidneyTransplantation For Polycystic Kidney Disease 11Lena Sibulesky, MDDarrin L. Willingham, MDC. Burcin Taner, MDDana K. Perry, MDJustin H. Nguyen, MD

Adjustable Gastric Band Erosion: Endoscopic, Laparoscopic, or Open Approach? A Case Report and Literature Review 13Fernando Miranda, MD, FACSAudencio Alanis, MD

Closure of the Perforated Gastric Ulcer Using theRound Ligament of Liver, Pathologically ChangedDue to Ulcer Penetration: Report of a Case 16Yuri N. Shiryajev, MDMaria A. Bernstein, MDVladimir D. Evstratov, MDElena V. Bulanova, MDMikhail A. Protchenkov, MD

Retroperitoneal Bronchogenic Cyst Masquerading as an Adrenal Mass, Successfully Treated with Hand-Assisted Laparoscopic Surgery 19Nelly Tan, MDDeba Sarma, MDJulie Ann Sosa, MDEyiyemisi Damisah, BASanziana Roman, MD

Macrodactylia and Intestinal Lipomatosis 22Ghaith Khair, MDCharan Singh, MDSheila Major, MDMatthew J. Hyser, MD, FACS

The Surgeon Newsletters 25

Future Meetings 27

ASAS Application 28

ABAS Procedure for Certification 31

Guidelines for Authors 32

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Jejunal Gastrointestinal Stromal Tumours Presenting as Common Abdominal Symptoms and a Review of the LiteratureRosemary Smith, MBChB*

Neeraj Bhasin, BSc(Hons) MB, BS, MD, MRCS(Eng)*

Philip Da Costa, MB, BS, MRCS, LRCP, FRCPath†

Tarig Ahmed, MBBCh (Hon) FRCS I (Gen)*

C Raj Kapadia, MS FRCS, MBA*

*Departments of General Surgery and †Histopathology Airedale General HospitalSkipton Road, Steeton, Keighley, West Yorkshire,BD20 6TD. ENGLAND

Corresponding author:Dr Rosemary Smith FHO1 to Mr KapadiaCare of Mr Kapadia Secretary Airedale General HopsitalSkipton RoadSteeton, Keighley, West Yorkshire, BD20 6TDTel: 07786 102291Fax: 01535 292927E-mail: [email protected]

ABSTRACT AND SUMMARYGastrointestinal stromal tumours (GISTs) are rare repre-senting 0.1-3% of all gastrointestinal malignancies. Theyare mesenchymal tumours whose behaviour is driven bymutations in the tryrosin kinase receptor c-KIT.

We report two jejunal GISTs presenting as commonabdominal problems along with a review of the literature.

INTRODUCTIONGastrointestinal stromal tumours (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tractcharacterised by the over expression of the tyrosin kinasereceptor c-KIT,[1] representing only 0.1-3% of all gastrointestinal cancers with an estimated incidence of 15per million people.[2] We report two GISTs treated in ourhospital which presented as common surgical abdominalproblems along with a review of the literature.

CASE 1A 36-year-old male presented acutely with fresh red per-rectal bleeding. He was clinically shocked on admissionwith a haemoglobin of 9.6g/dL. He was investigated for anaemia 10 years previously when he had normal gastroscopy and colonoscopy. Following a collapse on theward an emergency CT angiogram showed a bleedingpoint at the proximal jejunum but the bleeding pointcould not be embolised (Figure A). The patient had anemergency laparotomy which showed a tumour at the

proximal jejunum which was removed with primary anas-tomosis. Histology showed a GIST. The jejunal tumourwas strongly positive for CD 117 and CD 34, weakly pos-itive for smooth muscle actin, and negative for S100 anddesmin, confirming the diagnosis on immunochemistry.This was stratified as low risk as the tumour was between2 and 5 cm in diameter and showed less than 5 mitosesper 50 high power fields. His postoperative recovery wasuncomplicated.

JEJUNAL GASTROINTESTINAL STROMAL TUMOURS PRESENTING AS COMMON ABDOMINAL SYMPTOMS2

Figure A: CT scan showing the jejunal GIST (arrow)


JEJUNAL GASTROINTESTINAL STROMAL TUMOURS PRESENTING AS COMMON ABDOMINAL SYMPTOMS 3

CASE 2A 75-year-old female presented with a 3 month history ofgradually worsening epigastric pain, associated with nauseaand approximately 1/2 stone in weight loss. On examinationthere was a palpable smooth tender mobile mass in the rightumbilical region. A CT scan showed a 6.8 cm lobular solidmass within the right side of the lower abdomen in closeproximity to both large and small bowel but not definitelyarising from either, one loop of small bowel was insepara-ble from the mass at one point (Figure B). The patient wenton to have a laparotomy and the mass involving the jejunumand greater omentum was completely excised (Figure C).Histology showed a GIST, confirmed on immunochemistry.This was stratified as low to intermediate risk as the tumourwas between 5 and 10 cm in diameter and showed less than5 mitoses per 50 high power fields. Her postoperative recov-ery was uncomplicated.

DISCUSSIONGISTs are gastrointestinal mesenchymal tumours occur-ring in 15 per million people. In one particular study of906 GISTs [3] there was a 55:45 male-to-female ratio with amedian age of 59 years (range 13-94 years). Only 0.6%occurred before 21 years and 13.6% before 40 years. KITwas immunochemically detected in 98%, CD34 in 40%,smooth muscle actin in 34%, desmin in 0.2%, and S-100protein in 14% of the tumours tested.

Presentation depends on the size and the location of theGIST. [4] The diameter of GISTs can range from a few mil-limetres to greater than 30 cm. Large GISTs can causenon-specific abdominal discomfort, pain, bloating, earlysatiety or increasing abdominal girth. Erosion in to thegastrointestinal tract can induce significant haemorrhagepresenting as haematemesis, malena, or the clinical signs

of anaemia. They have also been known to cause dyspha-gia, biliary obstruction, and intestinal obstruction in thesmall bowel.

Gastrointestinal bleeding (50%) is the most common presentation, followed by abdominal pain (20-50%),obstruction (20%), and approximately one third are detect-ed incidentally.[5] A review of surgical emergencies showedsimilar findings with every GIST in the study presentingwith GI bleeding.[6] Our cases highlight GISTs presentingwith gastrointestinal bleeding and abdominal pain.

They are found primarily in the stomach (60-70%) withthe small intestine being the second most common loca-tion (30%) as reported in our cases.[7] Less frequent sitesinclude the colon, rectum and the oesophagus.

Surgery remains the first line treatment for resectable non-metastatic GISTs. They are not responsive to conventionalradiotherapy and chemotherapy and therefore unresectableGISTs were considered to be untreatable. However, in May2002 the c-KIT tyrosine kinase inhibitor Imatinib wasgranted a license for the treatment of advanced unre-sectable or metastatic GISTs. Data presented at the 2007American Society of Clinical Oncology meeting showedthat adjuvant treatment with Imatinib following surgicalresection of GIST tumours can significantly reduce the riskof disease recurrence (6% recurrence on imatinib versus17% without therapy at 12 months).[8]

GISTs are one of the most common mesenchymal tumoursof varying differentiation. Grossly they are well-demarcatedspherical masses that appear to arise from the muscularispropria layer of the gastrointestinal wall.

Figure C: Macroscopic appearance of the resected GISTFigure B: CT scan showing the jejunal GIST (arrow)


JEJUNAL GASTROINTESTINAL STROMAL TUMOURS PRESENTING AS COMMON ABDOMINAL SYMPTOMS4

The number of mitotic figures present can be used to histologically grade GISTs, but currently no standardexists for the classification of GISTs. In general, those withless than one mitotic figure per fifty high-powered fields(HPFs) are correlated with benign behaviour, one to fivemitoses per ten HPFs suggests potential malignancy,greater than five per ten HPFs indicates malignancy anda finding of greater than ten per ten HPFs denotes high-grade malignancy.[9]

Although radiological or histological findings may suggesta GIST, the diagnosis must be made immunochemically.Most GISTs express the CD34 antigen (70-78%) and the CD117 (72-94%) antigen. The CD34 protein is ahaematopoietic progenitor cell antigen that occurs in avariety of mesenchymal tumours. CD117 is also known as

the c-KIT protein; it is a membrane receptor with a tyro-sine kinase component. Mutations in the CD117 gene havebeen linked to malignant behaviour in GISTs.[9, 10]

Other markers that have been used in the evaluation ofGISTs include desmin, actin and S100. Approximately 20-30% of GISTs express smooth muscle actin, 5-10%desmin, and 10% S100.[9]

In conclusion, although rare, GISTs must be consideredin the differential diagnosis of patients presenting withabdominal pain or upper gastrointestinal bleeds as shownin our cases of patients with jejunal GISTs. Surgicalremoval is generally indicated at the time of detection forresectable non-metastatic tumours, otherwise the use ofImatinib is indicated.

REFERENCES

1. De Silivia MCV, Reid R. Gastrointestinal Stromal Tumours(GIST): C-kit Mutations, CD117 Expression, DifferentialDiagnosis and Targeted Cancer Therapy with Imatinib.Pathological Oncology Research 2003; 9: 13-19.

2. Kim CJ, Day S, Yeh KA. Gastrointestinal stromal tumours:analysis of clinical and pathological factors. The AmericanSurgeon 2001; 67: 135-137.

3. Miettinen M, Makhlouf H, Sobin LH, et al.Gastrointestinal Stromal Tumours of the Jejunum andIleum: A Clinicopathologic, Immunochemistry, andMolecular Genetic Study of 906 Cases Before ImatinibWith Long-term Follow-up. American Journal of SurgicalPathology 2006; 30(4): 477-489.

4. Fletcher CD, Bermenn JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumours: a consensus approach.Human Pathology 2002; 33: 459-465.

5. Rossi CR, Mocellin S, Mancarelli R, et al. Gastrointestinalstromal tumours: from a surgical to a molecular approach.International Journal of Cancer 2003; 107: 171-176.

6. Catena F, Ansaloni L, Gazzotti F, et al. Small boweltumours in emergency surgery: specificity of clinical presentation. ANZ Journal of Surgery 2005; 75: 997-999.

7. Miettinen M, Virolainen M, Maarit Sarlomo R.Gastrointestinal stromal tumour of the stomach: a clinicopathological, immunohistochemical and moleculargenetic study of 1765 cases with long-term follow-up.American Journal Surgical Pathology 2005; 29: 52-68.

8. DeMatteo R, Owzar K, Maki R, et al. and the AmericanCollege of Surgeons Oncology Group (ACOSOG) IntergroupAdjuvant GIST Study Team. Adjuvant imatinib mesylateincreases recurrence free survival (RFS) in patients withcompletely resected localized primary gastrointestinal stromal tumour (GIST): North American Intergroup PhaseIII trial. Proceeding from the American Society of ClinicalOncology. Chicago, IL. 2007.

9. Miettinen M, Lasota J. Gastrointestinal stromal tumours-definition, clinical, histological, immunohisto-chemical, and molecular genetic features and differentialdiagnosis. Virchows Arch. Jan 2001; 438(1): 1-12.

10. Tazawa K, Tsukada K, Makuuchi H, et al. An immunohistochemical and clinicopathological study ofgastrointestinal stromal tumors. Pathology International.Sep 1999; 49(9): 786-98.


Recurrrent Abdominal Wall Hernia After Adjustable Gastric Band Placement – A Case Report

Fernando Miranda, MD

Audencio Alanis, MD

Department of SurgerySurgery Specialty Hospitals of AmericaPasadena, Texas

Corresponding author:Fernando E. Miranda, M.D.4141 SW FreewaySuite 400Houston, Texas 77027Tel: (713) 960-0590Fax: (713) 960-0722E-mail: [email protected]

INTRODUCTIONAbdominal wall hernias present at the time of bariatricsurgery raise the issue of concomitant repair versus subsequent repair after weight loss. A case report of apatient who underwent a gastric band placement withan incidental finding of an umbilical hernia repairedprimarily is presented recurring with small bowel incar-ceration and obstruction.

CASE REPORTA 50 year-old male underwent a gastric band place-ment in July of 2009. An adjustable gastric band wasplaced with no complications. An umbilical hernia wasidentified. It was repaired primarily with absorbablesuture. He appeared with a non-reducible abdominalwall hernia with obstruction. A resection with anasto-mosis was performed. The hernia defect was repairedwith biodegradable mesh. No post operative complica-tions developed.

CONCLUSIONAbdominal wall hernias, discovered at the time of bandplacement should be repaired. Controversy still remainsregarding the type of repair for hernias at risk of incar-ceration.

PURPOSEIncidental abdominal wall hernia repair during bariatricsurgery still remains controversial in view of theincreased recurrence rate due to obesity. A case reportis presented of a patient with an adjustable gastric bandrepair and a concurrent umbilical hernia repair thatlater recurred.

INTRODUCTIONThe number laparoscopic adjustable gastric band placementprocedures has steadily increased.[1,2] Patients undergoingbariatric surgery, commonly have comorbidities due to theirobesity [3]. Abdominal wall hernias present at the time ofbariatric surgery raise the issue of concomitant repairversus subsequent repair after weight loss. Obesity is a riskfactor for abdominal wall hernia occurrence and recurrence.[4]

A case repot is presented of a patient who underwent anadjustable gastric band placement with an incidental find-ing of a 3 cm umbilical hernia, repaired primarily, andrecurred 8 months after repair with small bowel incarcer-ation and obstruction.

CASE REPORTA 50 year old Hispanic male underwent an adjustable gastric band placement in July of 2009. His comorbiditiesincluded diabetes mellitus type two, hypercholesterolemia,hypertension, and obstructive sleep apnea. His BMI at thetime of band placement was 52 Kg/m2. An AP largeadjustable gastric band (Allergan, Irvine, CA) was placedwith no complications. A 3cm umbilical hernia was identi-fied. The repair was performed laparoscopically through asmall incision over the hernia using a Carter-Thompsondevice with figure of eight absorbable sutures. The patientwas compliant with his follow up and diet. By the time ofpresentation, he had lost 38.4 Lb (8 months). He contactedthe primary surgeon soon after being discharged fromanother hospital with a diagnosis of abdominal wall hernia with obstruction. He was discharged after bowel restand symptoms of obstruction resolved. However, his symp-toms recurred and was admitted with initial decompressionand fluid resuscitation. At the time of presentation, he wasnormotensive, nontachycardic, and afebrile. He appeared

5RECURRRENT ABDOMINAL WALL HERNIA AFTER ADJUSTABLE GASTRIC BAND PLACEMENT – A CASE REPORT


non-toxic with a mildly distended abdomen, and tendernessover the umbilical area where there was a non-reducibleabdominal wall hernia. He had no peritonitis. A cat scan ofthe abdomen showed a loop of small bowel incarcerated inthe hernia. His white count was 6.73.

In the operating room, the laparoscope was used. Anabdominal wall hernia was found with incarcerated smallbowel (Figure 1). Questionable viable bowel was reduced,and eventually a small bowel resection with anastomosiswas performed. The Hernia defect was repaired by placinga large biodegradable mesh (Covidien, Mansfield,Massachusetts) secured with transfascial sutures (Figure 2).No post operative complications developed.

DISCUSSIONSmall bowel obstruction is a rare complication afteradjustable gastric band placement. Causes of obstructionsuch as bowel twisting around the tubing and erosion ofband with intraluminal migration have been described inthe literature.[5,6,7,8,9,10] Small bowel obstruction due to anabdominal wall hernia after adjustable gastric band place-ment has been rarely described. Concomitant repair ofabdominal wall hernias along with bariatric procedures isa controversial issue seldom evaluated in the literature.There is no clear consensus among bariatric surgeons onthe optimal time and method of abdominal wall herniarepair.[11] Obesity is a well known risk factor for the occur-rence of incisional hernias. [12] Schuster [12] describes safe andlow recurrence in the concurrent repair of abdominal wallhernias at the time of gastric bypass. Biodebradable meshrepair is now favored.[13] Anthony [14] compared recurrencerates between obese and non-obese patients. While therewas no statistical difference between both groups, the spe-cific group with mesh repair showed a significant increasedrecurrence rate (p=0.03).

Although there are few reports describing the abdominalwall hernia repair dilemma at the time of gastric bypass,there are minimal data regarding concurrent or delayedrepair of these hernias along with adjustable gastric band-ing placement. Although the gastric band placement posesa simpler dilemma due to the clean nature of the proce-dure, controversy still remains regarding the type of repairand timing of the procedure. Although concurrent meshrepair if favored, due to the high recurrence of primaryrepair, mesh repair carries its own risks, including entero-cutaneous fistula, sinus tract fistula, chonic pain, smallbowel obstruction, mesh infection, and seroma formation,in addition to the high cost added to the procedure.Burger[15] reported a higher incidence of complications withmesh repair including 3% enterocutanoeous fistulae and5% sinus trach fistulae. There seems to be a consensus thatafter weight loss, the risk of recurrence decreases. However,small abdominal wall hernias posing a risk of incarcera-tion, such as a small reducible hernia, may need to berepaired at the time of discovery. This was the impressionat the patient’s primary surgery, and, therefore, the herniawas repaired at the time. By the time the hernia wasrepaired for the second time, questionable viable bowel wasfound, and a small bowel resection was performed prior torepairing the hernia with biodegradable mesh.

CONCLUSIONAbdominal wall, reducible hernias, discovered at the timeof laparoscopic adjustable band placement should berepaired. Controversy still remains regarding the type ofrepair for hernias at risk of incarceration.

6 RECURRRENT ABDOMINAL WALL HERNIA AFTER ADJUSTABLE GASTRIC BAND PLACEMENT – A CASE REPORT

Figure 1: Incarcerated abdominal wall hernia. Figure 2: Hernia repair with mesh.


RECURRRENT ABDOMINAL WALL HERNIA AFTER ADJUSTABLE GASTRIC BAND PLACEMENT – A CASE REPORT 7

REFERENCES

1. Zappa M, Lattuada E, Mozzi E, Francese M, Antonini I,Radaelli S, Roviaro G. An Unusual Complication ofGastric Banding: Recurring Small Bowel ObstructionCaused by the Connecting Tube. Obesity Surg. 2006; 16: 939-941.

2. Campbell N, Brown W, Smith A, Skinner S, Nottle P.Small Bowel Obstruction Creates a Closed Loop inPatients with a Laparoscopic Adjustable Gastric Band.Obes Surg. 2008; 18: 1346-1349.

3. Varela J, Hinojosa M, Nguyen N. Correlations betweenIntra-Abdominal Pressure and Obesity-Related Co-morbidities. Surg Obes Relat Dis. 2009; 5: 524-528.

4. Binatti H, Hoeller E, Kirchmayr W, Muhlmann, Zitt M,Aigner F, Klaus A. Ventral Hernia Repair in BariatricSurgery. Obes Surg. 2004; 14: 655-658.

5. Egbeare D, Myers A, Lawrence R. Small BowelObstruction Secondary to Intragastric Erosion andMigration of a Gastric Band. J Gastrointest Surg.2008; 12: 983-984.

6. Arbell D, Koplewitz B, Zamir G, Bala M. Midgut VolvulusFollowing Laparoscopic Banding-A Rare and DangerousSituation. Laparoendosc Adv Surg Tech A. 2007; 17: 321-323.

7. Strobos E, Antanavicius G, Josloff R. UnusualComplication: Small Bowel Obstruction Caused by Tubingof Gastric Band. Surg Obes Relat Dis. 2009; 5: 637-640.

8. Shipkov C, Uchikov A, Uchikova E. Small BowelObstruction by the Silicone Tube of the Gastric Band.Obes Surg. 2004; 14: 1280-1282.

9. Mills J, Zakon J, Nguyen M. Strangulation of the Small Bowel Mesentery and internal Hernia Due to theConnecting Tube of a Gastric Band. ANZ J Surg. 2008;78: 1128-1129.

10. Reavis K, Hinojosa M, Smith B, Nguyen N. Treatment ofChronic Obstruction as Late Complication of AdjustableGastric Band. Surg Obes Relat Dis. 2008; 4: 770-772.

11. Sukeik M, Alkari B, Ammori B. Abdominal Wall Herniaduring Laparoscopic Gastric Bypass: A SeriousConsideration. Obes Surg. 2007; 17: 839-842.

12. Schuster R, Curet M, Alami R, Morton J, Wren S, Safadi B. Concurrent Gastric Bypass and Repair ofAnterior Abdominal Wall Hernias. Obes Surg. 2006; 16: 1205-1208.

13. Elid G, Mattar S, Hamad G, Cottam D, Lord J, Watson A, Dallal R, Schauer P. Repair of Ventral Herniasin Morbidly Obese Patients Undergoing LaparoscopicGastric Bypass Should Not Be Deferred. Surg Endosc.2004; 18: 207-210.

14. Anthony T, Bergen B, Kim L, Henderson M, Fahey T, Rege R, Turnage R. Factors Affecting Recurrence following Incisional Herniorrhaphy. World J Surg. 2000;24: 95-101.

15. Burger J, Luijendijk R, Hop W, Halm J, Verdaasdonk E,Jeekel J. Long-term Follow-up of a RandomizedControlled trial of Suture Versus Mesh Repair of IncisionalHernia. Annals of Surgery. 2004; 240: 578-585.


8 VENOUS AIR EMBOLISM DURING LAPAROSCOPIC SURGERY DUE TO A PATENT FORAMEN OVALE

Venous Air Embolism During Laparoscopic Surgery Due to a Patent Foramen Ovale

ABSTRACTVenous air embolism (VAE) is the entry of air into thecentral or peripheral vasculature. In patients undergo-ing laparoscopic procedures, venous air embolism canoccur due to instrumentation particularly during inser-tion of catheters or trocars. The resultant entrapmentof intravascular gas can lead to severe neurologic injury,cardiovascular collapse, and even death.

INTRODUCTIONThis article presents the case of a 44-year-old woman whowas undergoing laparoscopic surgery to remove the gastricbanding with intention for further conversion to gastricbypass. She suffered an inferior vena cava laceration due topresumable trocar injury. As she had an unknown PFO, sheinfarcted bilateral cerebral hemispheres due to paradoxicalembolism. The factors that determine the subsequent morbidity and mortality in VAE include the rate of airentrainment, the volume of air introduced, the position ofthe patient at the time of the embolism and presence of apatent foramen ovale (PFO). This case highlights the discussion regarding the assessment of factors, pre andintraoperatively that can lead to air embolism.

CASE PRESENTATIONA 44-year-old woman with history of obesity had alaparoscopic gastric banding procedure done 1 year agowith resultant dysphagia, reflux symptoms and inade-quate weight loss. For these complaints the patient wasscheduled for an elective laparoscopic removal of the gastric band with further conversion to a gastric bypass.Pre-operative evaluation including physical examinationwas unrevealing.

Surgery was complicated by intraperitoneal scar tissueencountered that made optical trocar entry difficult andthis approach was aborted with removal of the trocar. Asubcutaneous dissection was started in order to performan open port placement. At that time the patient’s bloodpressure was noted to drop dramatically requiring fluidresuscitation. In view of a potential vascular injury, theperitoneal cavity was rapidly opened and free blood wasseen with laceration of the inferior vena cava (IVC). Theperitoneal cavity was packed with laparotomy pads and the IVC was compressed. An emergent transesophagealechocardiogram (TEE) demonstrated air in the cardiacchambers and a large PFO.

The patient’s condition continued to deteriorate requiringvasoactive medications and ultimately complete cardiacbypass after performing a sternotomy. The IVC wasexplored carefully and a through-through injury to the vessel was noted. Initial attempts to repair both aspects ofthe vessel failed requiring ligation by the vascular surgeryteam to allow a more careful repair. Return of homeostasiswas achieved after this and discontinuation of cardiacbypass was possible.

PHYSICAL EXAMINATIONOn examination after the surgery, the patient was comatose on ventilator support. Neurologic examinationrevealed 4mm pupils bilaterally which were sluggishly reactive, no facial asymmetry, no purposeful movementsnoted to verbal or pain stimulation.

Aiesha Ahmed, MD

Max R. Lowden, MD

Gary Thomas, MD

Department of Neurology, Penn State College of Medicine

Corresponding author:Aiesha Ahmed MDDepartment of Neurology, Penn State College of MedicineEC037, 30 Hope Drive, Hershey, PA 17033Tel: (717) 531-1802Fax: (717) 531-0384E-mail: [email protected]


IMAGING STUDIESBased on the neurological exam and in the setting of a com-plicated surgery, a severe neurological insult was suspectedand a computerized tomography (CT) scan of the brainwas obtained. This demonstrated diffuse cerebral edemawith large areas of hypoattenuation in the bilateral cerebralhemispheres that are most consistent with evolving infarcts.(Figure 1).

Magnetic resonance imaging (MRI) obtained 3 days aftersurgery (Figure 2) showed extensive areas of restricted diffusion involving the gray matter of the cerebral hemi-spheres bilaterally right more than left consistent withcortical ischemia.

CLINICAL COURSETen days after surgery, our patient continued to be ventila-tor dependent requiring a tracheostomy. Neurologicalevaluation revealed continued unresponsiveness to verbalstimuli. Cranial nerves showed no facial asymmetry and 3 mm pupils bilaterally which were reactive. Motor testing

showed a left hemiplegia and a right hemiparesis. Palliativemedicine was involved for continued support and plans forlong term care.

DISCUSSIONEarly complications associated with laparoscopic gastricprocedures are pulmonary embolism and death which areboth <1% respectively. Late complications include gastricprolapse, band slippage, and access port problems.[1]

Saunders et al mention that technical complications due tosurgery (such as perforation, bleeding, stricture, bowelobstruction etc) are the leading reasons for readmissionafter bariatric surgery.[2] VAE is the entrainment of air intothe venous system producing a broad array of outcomessuch as circulatory obstruction. A circulatory arrest occursultimately due to the trapping of air in the right ventriclaroutflow tract. Large emboli may cause arterial emboliza-tion by acutely increasing the right atrial pressure andfacilitating a right to left shunt through a PFO.[3] Gasembolism can occur through a tear in a vessel on theabdominal wall or on the peritoneum. This can occur dueto inadvertent placement of Veress needle into a vein or anorgan. In patients undergoing gastrointestinal and urologiclaparoscopic procedures, the incidence of major vascularinjuries is approximately 0.03 to 0.06 %. Vascular compli-cations occur due to instrumentation particularly duringinsertion of the Veress needle or tocar.[4] The insertion ofVeress needle or trocar into major vessels such as aorta,common iliac, or inferior vena cave have been reported.Injuries to the vessels in the abdominal wall (such as epi-gastric vessels) are becoming increasingly common due tothe use of multiple trocars. Stretching of vascular adhesionsbecause of the expansion caused by pneumoperitoniumcan tear vessel walls and lead to bleeding.[4] Markedembolism is noted in the distal inferior vena cava occlu-sion or when there has been significant blood loss.[5] Inaddition manipulation of the venotomy hole and higherintraperitoneal pressures leads to higher degree ofembolization.[5] Material coming from the IVC is directedagainst the fossa ovalis, causing paradoxical embolizationif the foramen ovale is open.[6] Approximately 27% of theadult population is known to have a PFO, which tend toincrease with age.[6] This risk can be assessed with TEE.

The presenting signs of gas embolism during laparoscopyinclude sudden hypotension, hypoxemia, tachycardia andpulmonary edema. Neurologic impairment can occurbecause anoxic damage or paradoxic embolism through aPFO.[4] Clinically significant gas embolism is rare duringgynecologic laparoscopic procedures. In contrast, emboliare seen at a higher rate in laparoscopic cholecystectomyand nephrectomy.[7] The degree of embolization is thoughtto be proportional to the decrease in central venous pres-sure from blood loss or distal venous compression, the timethe venotomy was open, the intraperitoneal pressure, theamount of manupilation during repair.[5] Factors that may

9VENOUS AIR EMBOLISM DURING LAPAROSCOPIC SURGERY DUE TO A PATENT FORAMEN OVALE

Figure 1: CT scan ofthe brain non-contrastshowing diffuse cerebral edema withlarge evolving infarctnoted on the righthemisphere. There is 9 mm of right to lefttranstentorial hernia-tion and significanteffacement of thesuprasellar cistern.

Figure 2: Axial MRI Diffusion weighted image (A) and apparent diffusion coefficient (B) obtained 3 days after surgeryshowing extensive areas of restricted diffusion involving thegray matter of the cerebral hemispheres bilaterally right morethan left consistent with embolic infarcts.


decrease the incidence of gas embolism include increasein central venous pressure due to adequate hydration,head-down position as it may reduce gas embolism to thehead as bubbles are buoyant.[7] Tuppurainen et al used TEEto assess hydration. The movement of the mobile part ofthe interatrial septum can provide information on the volume status of the patient. Hypovolemia can bend the septum to the left. By expanding the intravascularvolume the shunt can be reduced.[6] Management involves expeditious control of bleeding, distal and proximalcompression or vascular clamping.[5] This brings up thediscussion of routine use of TEE during the procedureto assess the volume status of the patient as well as tomonitor other entities such as air embolism and valvularregurgitation which could cause hemodynamic compro-mise.[6,7] The other alternative would be to perform apre-operative transthoracic echocardiogram with salineinfusion to evaluate for a PFO which may pose a risk fordevelopment of complications during surgery.

REFERENCES

1. Sarker S, Herold K, Creech S, Shayani V. Early and latecomplications following laparoscopic adjustable gastricbanding. Am Surg. Feb 2004;70(2):146-149; discussion149-150.

2. Saunders JK, Ballantyne GH, Belsley S, et al. 30-day readmission rates at a high volume bariatric surgery center:laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Ygastric bypass. Obes Surg. Sep 2007;17(9):1171-1177.

3. Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth.May 1997;9(3):251-257.

4. Joshi GP. Complications of laparoscopy. Anesthesiol ClinNorth America. Mar 2001;19(1):89-105.

5. O’Sullivan DC, Micali S, Averch TD, et al. Factors involvedin gas embolism after laparoscopic injury to inferior venacava. J Endourol. Apr 1998;12(2):149-154.

6. Tuppurainen T, Makinen J, Salonen M. Reducing the riskof systemic embolization during gynecologic laparoscopy—effect of volume preload. Acta Anaesthesiol Scand.Jan 2002;46(1):37-42.

7. Fahy BG, Hasnain JU, Flowers JL, Plotkin JS, Odonkor P,Ferguson MK. Transesophageal echocardiographic detection of gas embolism and cardiac valvular dysfunction during laparoscopic nephrectomy. Anesth Analg. Mar 1999;88(3):500-504.

10 VENOUS AIR EMBOLISM DURING LAPAROSCOPIC SURGERY DUE TO A PATENT FORAMEN OVALE


11LAPAROSCOPIC NEPHRECTOMY IN KIDNEY TRANSPLANTATION

Lena Sibulesky, MD

Darrin L. Willingham, MD

C. Burcin Taner, MD

Dana K. Perry, MD

Justin H. Nguyen, MD

Division of Transplant Surgery, Department ofTransplantation, Mayo Clinic, Jacksonville, Florida

Corresponding author:Justin H. NguyenDivision of Transplant SurgeryDepartment of TransplantationMayo Clinic4500 San Pablo RoadJacksonville, Florida 32224Tel: (904) 956-3261Fax: (904) 956-3359Email: [email protected]

SHORT SUMMARYLaparoscopic nephrectomy is the procedure of choicefor patients with polycystic kidney disease and can bedone pre-, concomitantly, or post kidney transplanta-tion. In our case report we describe a technique ofsimultaneous bilateral laparoscopic hand-assistednephrectomy for polycystic kidney disease at the timeof living donor kidney transplantation.

ABSTRACTAdult polycystic kidney disease leads to end-stagekidney disease in more than 40% of people. There areseveral indications for nephrectomy, including uncon-trolled pain, urinary tract infections, bleeding, and largesize of the kidneys preventing placement of the renalallograft. Laparoscopic nephrectomy is the preferredapproach. We describe a technique of simultaneouslaparoscopic hand-assisted bilateral nephrectomy andliving donor kidney transplantation.

Polycystic kidney disease (ADPKD) is an autosomal domi-nant disorder, found in approximately 1 in every 400 to1000 live births.[1] More than 40% of these patients devel-op end-stage renal disease. The affected patients maypresent with flank pain, renal insufficiency, and hyperten-sion. Bilateral nephrectomy is indicated in patients whohave severe medically uncontrolled pain, urinary tractinfections, bleeding, and large size of the native kidneyspreventing placement of renal allograft.[2] Laparoscopicnephrectomy is the procedure of choice for patients with

ADPKD and can be done pre-, concomitantly, or post kidney transplantation. In our case report we describe atechnique of simultaneous bilateral laparoscopic hand-assisted nephrectomy for ADPKD at the time of livingdonor kidney transplantation.

CASE REPORTPatient is a 36-year-old Caucasian female who was diag-nosed with polycystic kidney disease 10 years prior andwas initiated on hemodialysis 2 months prior to presen-tation to our hospital. Her other past medical history wassignificant for hypertension and Cesarean section. Shehad no history of hemorrhage or infections of the cysts,however she did complain of pain and discomfort fromenlarged kidneys. A living donor became available and thedecision was made to perform simultaneous bilaterallaparoscopic hand-assisted native bilateral nephrectomyat the time of kidney transplantation.

The patient was placed and secured supine on the operat-ing room table. A midline incision of approximately 7 cmwas made above the umbilicus for a GelPort placement(Applied Medical Resources, Rancho Santa Margarita, CA,Ref # C8XX2NONCE), Figure 1. Twelve-mm trocars wereplaced in the midclavicular and anterior axillary lines justlateral to the umbilicus on the left side of the abdomen.Another 12-mm trocar was placed in the midline below the xiphoid midclavicular line on the right side of theabdomen. The operating table was rotated approximately30 degrees up and to the right. Harmonic scalpel was usedfor the entire dissection. The left colon was mobilized,

Successful Simultaneous Laparoscopic Hand-Assisted Bilateral Nephrectomy And Living Donor Kidney Transplantation For Polycystic Kidney Disease


LAPAROSCOPIC NEPHRECTOMY IN KIDNEY TRANSPLANTATION

exposing the left kidney. The ureter was identified anddivided. The kidney was fully mobilized. The hilum wasisolated and both renal artery and vein were dividedtogether with an endovascular stapler (ENDO GIA, USSurgical Corp., Norwalk, CT). The left adrenal gland wasidentified and preserved. Some of the cysts requireddrainage prior to extraction of the kidney through the handport. The patient was rotated approximately 30 degrees upand to the left. The right nephrectomy was performed in asimilar fashion after mobilizing the right colon. Both vascular stumps were examined and appeared intact. Afterobtaining complete hemostasis, a separate curvilinear inci-sion was made in the right lower quadrant for placementof the living donor kidney in the retroperitoneal position.After reperfusion of the kidney, urine was observed on the table. Both procedures together lasted 5 1/2 hours. The estimated blood loss was 150 cc, requiring no blood trans-fusions. Anatomy of the left native kidney was 23 cm x 12cm x 8 cm and weighed 1,136 grams. The right kidney was19.5 cm x 10.5 cm x 6 cm and weighed 1,244 grams. Bothkidneys had innumerable cysts measuring up to 4 cm ingreatest dimension. The patient’s creatinine on admissionwas 6.6 mg/dL, decreasing to 0.9 mg/dL the day of discharge. The patient did excellent without complication and was discharged home on postoperative day 5. Thymo-globulin was used on induction, and her immuno-suppressants are Prograf and Cellcept. Currently 7 monthspostoperatively, she is doing well and her creatinine remains0.9 mg/dL.

DISCUSSIONLaparoscopic nephrectomy is the procedure of choice forsymptomatic patients with autosomal dominant polycystickidney disease. It has been shown that compared with openprocedure, laparoscopic nephrectomy is associated with significantly less blood transfusion requirement, analgesiarequirement, and shorter hospital stay.[3] Concomitantnephrectomy and kidney allograft transplantation has several advantages over staged procedures. It requires admin-istration of single anesthesia, single hospital stay, and avoidsdialysis if nephrectomy is done prior to transplantation.Tabibi et al. reported that open concomitant approach wasreasonable and safe in this population group.[4] Glassman etal. found open simultaneous approach to have similar riskof morbidity and mortality as well. Interestingly, in additionthe satisfaction rate was higher in these patients.[5]

We report a case of a concomitant laparoscopic hand-assisted bilateral nephrectomy performed at the time ofliving donor kidney transplantation. In our case the bloodtransfusion requirement, pain control, hospital stay, andallograft function was similar to our average living donorkidney transplant population. Laparoscopic nephrectomyof polycystic kidneys does require advanced laparoscopicskills; however, as in our case, simultaneous procedurescan be successful and should be considered in patientswith symptomatic polycystic disease.

REFERENCES

1. Gabow PA: Autosomal dominant polycystic kidney disease.N Engl J Med. Jul 29 1993;329(5):332-342.

2. Desai MR, Nandkishore SK, Ganpule A, Thimmegowda M:Pretransplant laparoscopic nephrectomy in adult polycystickidney disease: a single centre experience. BJU Int.Jan 2008;101(1):94-97.

3. Dunn MD, Portis AJ, Elbahnasy AM, et al.: Laparoscopicnephrectomy in patients with end-stage renal disease andautosomal dominant polycystic kidney disease. Am JKidney Dis. Apr 2000;35(4):720-725.

4. Tabibi A, Simforoosh N, Abadpour P, Gholamrezaie HR,Nafar M: Concomitant nephrectomy of massively enlargedkidneys and renal transplantation in autosomal dominantpolycystic kidney disease. Transplant Proc.Sep 2005;37(7):2939-2940.

5. Glassman DT, Nipkow L, Bartlett ST, Jacobs SC: Bilateralnephrectomy with concomitant renal graft transplantationfor autosomal dominant polycystic kidney disease. J Urol.Sep 2000;164(3 Pt 1):661-664.

12

Figure 1: The hand port placed centrally with operating andcamera ports set for each side of the nephrectomy. Surgeonstands opposite to side of nephrectomized organ.


ADJUSTABLE GASTRIC BAND EROSION 13

Fernando Miranda, MD, FACS

Audencio Alanis, MD

Department of SurgerySurgery Specialty Hospitals of AmericaPasadena, Texas

Corresponding author:Fernando E. Miranda, MD, FACS4141 SW FreewaySuite 400Houston, Texas 77027Tel: (713) 960-0590Fax: (713) 960-0722E-mail: [email protected]

ABSTRACTThe adjustable gastric banding is a purely restrictive procedure that continues to grow in popularity. Gastricband erosion is a well described complication with still a controversial approach of treatment includingendoscopy, laparoscopy, and laparotomy. A case reportof an adjustable band erosion is presented along witha comprenhensive literature search with emphasis onthe described approaches for removal. When suspicionof an erosion arises, endoscopy is the most effectivemethod of diagnosis. An attempt to remove the bandthrough endoscopy if most of it is eroded into thestomach lumen. Laparoscopy is the next option followedby laparotomy. The patient was first diagnosed throughendoscopy and later explored with the laparoscope. Dueto the erosion being at the anterolateral aspect of thestomach, the decision was made to repair the gastrotomyusing the open approach. This systematic approach followed in this case report and described literature is asafe approach for band removal.

PURPOSEMore than one method is described for the removal ofthe eroded gastric adjustable band. A case report isdescribed with emphasis on the intraoperative decision-making of the appropriate approach for band removal.

INTRODUCTIONBariatric surgery cases continue to increase as the obesityepidemic reach record numbers.[1,4,6,7,8,10,12,13, 14] The adjustablegastric banding is a purely restrictive procedure that continues to grow in popularity due to its low mortality,reversibility, simplicity, and prompt recovery.[2,12,14]

Complications of the adjustable gastric band include gastric slippage, port inversion, tubing detachment, portinfection, esophageal dilatation, pouch dilatation, band

erosion, pulmonary embolism, among others.[3,4,6,8] Gastricband erosion is a well described complication with still acontroversial approach of treatment.[5] A described conser-vative approach is endoscopic removal of the bands whenmost of it has eroded, followed by close observation andearly discharge. Another approach is by laparoscopy over-sawing the gastric defect after band removal. The combinedendoscopic/laparoscopic approach has been described withgood results. Finally, the approach by laparotomy has beendescribed as the last resort when the circumstances aredeemed too difficult for the above two procedures. Fewarticles in the literature describe the technique of removaland the circumstances that lead to their approach. The current article presents a patient with a gastric band erosion retrieved by laparotomy.

CASE REPORTThe patient is a 22 year old Caucasian female with a BMIof 39.5 Kg/m2. Her comorbidities included type 2 diabetesmellitus, hypertension, osteoarthritis, and gastroesophagealreflux disease. She received an adjustable gastric band (Lap-Band, Allergan) with no intraoperative complica-tions. Three months later, she was seen for chest pain,nausea, and vomiting. These symptoms were attributed to

Adjustable Gastric Band Erosion: Endoscopic, Laparoscopic, or Open Approach?A Case Report and Literature Review

Figure 1: Eroded band in the gastric lumen.


ADJUSTABLE GASTRIC BAND EROSION14

her 2 mL of saline in her port. Her symptoms resolved afterall fluid was removed. She was lost to follow-up, when shereported one year after her initial surgery with epigastricabdominal pain, vomiting, and minimal nausea. She deniedadditional symptoms of hematemesis, hematochezia, melena, or recurrence of her chest pain. Restriction was stillpresent, but decreased from the time her reservoiur’s salinewas removed. An esophagogastroscopy was performedshowing a 30-40% eroded adjustable gastric band in thestomach lumen. The decision was made to remove the bandlaparoscopically. Upon entering the peritoneal cavity, significant inflammation was encountered in the upperabdomen. Adhesions were incised, and after the band wasreleased at the buckle, it was removed from the stomach.The band was noted to have eroded on the left lateral aspectof the stomach, were the fundus was folded over the band,with the defect seen under the fold with the proximal endunable to be seen. The decision was made to perform therepair performing laparotomy. The defect was closed in twolayers, drains and nasogastric tube placed. The patient didwell postoperatively. The nasogastric tube was removed onpost op day one, and she was started on clear liquids thenext morning. Her diet was slowly advanced, and was discharged from the hospital on post operative day five. Shewas seen a week after discharge, having developed a woundinfection treated with dressing changes.

DISCUSSIONThe described incidence of adjustable band erosion is 0.3to 11%.[6,7,8,9,11,12] Band erosion is a common diagnosisamong patients undergoing a major reoperation after bandplacement.[23] Our patient’s presentation was epigastricabdominal pain and nausea one year after band placement.Silecchia [26] described an erosion rate of 7.5% with mini-mal or no presenting symptoms done by periodic EGDsurveillance. However, presentation is varied from lack ofsymptoms to peritonitis, arterial bleeding, small bowelobstruction, or esophageal erosion.[10, 13, 14, 15, 18, 19, 21]

Debate still continues regarding the etiology of theadjustable gastric band erosion.[7,8] Time of presentationseems to suggest the mechanism of insult. Gastric injury atthe time of surgery account for the earliest presentation oferosion, with infection, gastric wall ischemia, peptic ulcer,among others are proposed as causes.[7] Several causes have

been proposed: infection, band overinflation, gastric wallinjury, gastric wall ischemia, use of NSAIDS, smoking, andalcohol consumption.[2,8, 12] Our patient presented threemonths after her initial surgery with proximal gastricobstructive symptoms, and removal of fluid resolved hersymptoms. The possibility of overinflation remains as acause. One year after her surgery, she presented with symp-toms raising the suspicion of band erosion. The patientdenied consuming NSAIDS or alcohol, but admitted beinga one pack-per-day smoker.

The diagnosis is done with endoscopy, upper gastrointesti-nal imaging, or CT scan.[7, 20] During work up endoscopy isrecommended to evaluate the extent of erosion.

The treatment of gastric erosion of an adjustable gastricband is removal with gastrotomy repair.[11] Differentapproaches have been described including endoscopic,laparoscopic, and open.[7,9,22,24] Endoscopic removal is considered for bands mostly eroded into the stomach.Laparoscopic removal is recommended for bands partiallyeroded.[7,8,22] The most commonly described method isremoval with gastric oversaw. Karmali describes a transgas-tric removal through a distal gastrotomy due to extensiveinflammation around the band.[17] The patient presented inthe current paper was approached laparoscopically initially. After the band was removed, the erosion was identified at the left anterolateral aspect of the stomachextending under the gastric fold created at the initial place-ment. Furthermore, the extent of this erosion was difficultto evaluate laparoscopically. Part of the gastric fold wastaken down laparoscopically. Release of the most proximalsuture close to the esophagus was deemed difficult due tothe extensive inflammation in the area. The decision wasmade to perform the rest of the operation though laparo-tomy. The erosion was exposed and closed in two layers.This systematic approach in the presented case anddescribed literature is safe for the successful removal of theeroded gastric band.

CONCLUSIONOpen gastrotomy repair is a safe method of gastrotomyrepair once endoscopic and laparoscopic approaches aredeemed difficult or unsafe for completion of the eroded lapband removal procedure.


15ADJUSTABLE GASTRIC BAND EROSION

REFERENCES

1. Biagini J, Karam L. Ten Years Experience withLaparoscopic Adjustable Gastric Banding. Obes Surg.2008; 18: 573-577.

2. Abu-Abeid S, Keidar A, Gavert N, Blanc A, Szold A. theClinical Spectrum of Band ErosionFollowing LaparoscopicAdjustable Silicone Gastric Banding for Morbid Obesity.Surg Endosc. 2003; 17: 861-863.

3. Fried M, Miller K, kormanova K. Literature Review ofComparative Studies of Complications with Swedish Bandand Lap Band. Obesity Surg. 2004; 14: 256-260.

4. Gagner M, Milone L, Yung E, Broseus A, Gumbs A.Causes of Early Mortality after Laparoscopic AdustableGastric Banding. J Am Coll Surg. 2008; 206: 664-669.

5. Chaptini L, Bhambri S, Greenbaum D, Elfant A.Successful Endoscopic Management of Band ErosionComplicating Bypass Surgery. J Clin Gastroenterol. 2004;38: 914-915.

6. Suter M, Giusti V, Heraief E, Calmes J. Band Erosion afterLaparoscopic Gastric Banding: Occurrence and Resultsafter Conversion to Roux-en-Y Gastric Bypass. Obes Surg.2004; 14: 381-386.

7. Chousleb E, Szomstein S, Lomenzo E, Higa G, PodkameniD, Soto F, Zundel N, Rosenthal R. Laparoscopic Removalof Gastric Band after Gastric Erosion. Surg LaparoscEndosc Percutan Tech. 2005; 15: 24-27.

8. Lattuada E, Zappa M, Mozzi E, Fichera G, Granelli P, DeRuberto F, Antonini I, Radaelli S, Roviaro G. Band ErosionFollowing Gastric Banding: How to Treat It. Obes Surg.2007; 17: 329-333.

9. Angrisani L, et al. Italian Collaborative Study Group:Features of Intragastric Band Migration (Erosion) for Past 7 Years. Surg Obes Relat Dis. 2005; 1: 231.

10. Mathtemework Y, Powers C, Geiss A, Barsoumian R,Howard M, Hamilton D, Warman J, Kern N. JejunalErosion in Adjustable Gastric Band. Surg Obes Relat Dis.2009; 5: 269-270.

11. Niville E, Dams A, Van Der Speeten K, Verhelst H. Resultsof Rebanding Procedures after Lap-band Removal forband Erosion-A Mid-Term Evaluation. Obes Surg. 2005;15: 630-633.

12. Angus L, Rizvon L, Zhou D, Seitelman E, Cardoza S.Intra-Gastric Band Erosion from an Un-inflated Lap Band:A Case Report. Obes Surg. 2008; 18: 1636-1639.

13. Antanavivius G, Leslie D, Torres-Villalobos G, Andrade R,Kellogg T, Slusarek B, Ikramuddin S. Distal EsophagealErosion after Laparoscopic Adjustable Gastric BandPlacement with Nissen Fundoplication Takedown. Obes Surg. 2008; 18: 1350-1353.

14. Rao A, Ramalingam G. Exanguinating Hemorrhage following Gastric Erosion after Laparoscopic GastricBanding. Obes Surg. 2006; 16: 1675-1678.

15. Pinsk I, Dukhno O, Levy I, Ovnat A. Gastric OutletObstruction Caused by Total Band Erosion. Obes Surg.2004; 14: 1277-1279.

16. Basa N, Dutson E, Lewis C, Derezin M, Han S, Mehran A.Laparoscopic Transgastric Removal of Eroded AdjustableBand: A Novel Approach. Surg Obes Relat Dis. 2008; 4:194-197.

17. Karmali S, Sweeney J, Yee K, Brunicardi C, Sherman V.Transgastric Endoscopic Rendezvous Technique for Removal of Eroded Molina Gastric Band. Surg Obes Relat Dis. 2008; 4: 559-562.

18. Iqbal M, Manjunath S, Seenath M, Kahn A. MassiveUpper Gastrointestinal Hemorrhage: An UnusualPresentation after Laparoscopic Adjustable GastricBanding due to Erosion into the Celiac Axis. Obes Surg.2008; 18: 759-760.

19. Campos J, Ramos A, Neto M, Siqueira L, Evangelista L,Ferraz A, Ferraz E. Hypovolemic Shock due to IntragastricMigration of an Adjustable Gastric Band. Obes Surg.2007; 17: 562-564.

20. Hainaux B, Agneessens E, Rubesova E, Muls B,Gaudissart Q, Moschopoulos C, Cadiere G. IntragastricBand Erosion after Laparoscopic Adjustable GastricBanding for Mobid Obesity: Imaging Characteristics of anUnderreported Complication. AJR. 2005; 184: 109-112.

21. Png K, Rao J, Lim K, Chia K. Lap-Band, Causing LeftGastric Artery Erosion Presenting with TrorrentialHemorrhage. Obes Surg. 2008; 18: 1050-1052.

22. Ayloo S, Bueno R. Band Erosion: Laparoscopic Removalof Lap Band. Surg Endosc. 2009; 23: 657-658.

23. Silecchia G, Bacci V, Bacci S, Casella G, Rizzello M,Fioriti M, Basso N. Reoperation after LaparoscopicAdjustable Gastric Banding: Analysis of a Cohort of 500Patients with Long-Term Follow-up. Surg Obes Relat Dis.2008; 4: 430-436.

24. Egbeare D, Myers A, Lawrance R. Small BowelObstruction Secondary to Intragastric Erosion andMigration of a Gastric Band. J Gastrointest Surg. 2008;12: 983-984.

25. Lattuada E, Zappa M, Mozzi E, Gazzano G, Francese M,Antonini I, Radaelli S, Roviaro G. Histologic Study ofTissue Reaction to the Gastric Band: Does it Contribute to the Problem of Band Erosion? Obes Surg. 2008; 16:1155-1159.

26. Sileccia G, et al. Laparoscopic Adjustable Silicone GastricBanding: Prospective Evaluation of Intragastric Migrationof the Lap-Band. Surg Laparosc Endosc Percutan Tech.2001; 4: 229-34.


CLOSURE OF THE PERFORATED GASTRIC ULCER16

Yuri N. Shiryajev, MD1,2

Maria A. Bernstein, MD1,2

Vladimir D. Evstratov, MD2

Elena V. Bulanova, MD3

Mikhail A. Protchenkov, MD1,2

1] Department of Faculty Surgery named after Professor A.A. Rusanov, Saint-Petersburg State Pediatric Medical Academy,Saint-Petersburg, Russian Federation

2] Sixth Department of Surgery, Mariinsky Hospital,Saint-Petersburg, Russian Federation

3] Department of Anesthesiology, Mariinsky Hospital,Saint-Petersburg, Russian Federation

Corresponding author:Yuri N. Shiryajev, MDAssistant LecturerDepartment of Faculty Surgery named after Professor A.A. RusanovSaint-Petersburg State Pediatric Medical AcademyLitovskaya str., 2194000 Saint-Petersburg, Russian FederationTel: +7 (812) 2757362Fax: +7 (812) 2757326E-mail: [email protected]

SHORT SUMMARYWe report a rare case of gastric ulcer with penetrationinto the round ligament of liver. After disconnection ofthe ligament from the gastric wall the patient wasadmitted urgently with symptoms of perforated ulcer.Its closure was carried out using pathologically changedround ligament—for the first time in the literature.

ABSTRACTPenetration of the gastric ulcer into the round ligament ofliver (RLL) is rare. We present a case of perforation of gastric ulcer, previously penetrated into the RLL, and theRLL was used for perforated ulcer closure. The female 47year-old patient was admitted urgently with the symptomsof peptic ulcer perforation. Large perforated ulcer of distalstomach, partially covered with the RLL, was found at theoperation. On the dorsal surface of the RLL marks of previous ulcer penetration were clearly seen. We refusethe distal gastrectomy in favor of perforation closure dueto severe patient’s condition and persisted hypotension.Perforation was closed in one row of single sutures andthen reinforced with the RLL patch. The RLL was turnedto the stomach with the ventral surface, and area of ulcerpenetration remains outside. No serious complicationswere observed. Sixteen months later the patient was operated on repeatedly (distal gastrectomy by Finsterer)for marked pyloroduodenal stenosis with good result.

We believe that the presented case is the first report ofplastic use of the RLL, pathologically changed due to ulcerpenetration.

KEY WORDS: perforated peptic ulcer, penetration, roundligament of liver

ABBREVIATIONS: RLL, round ligament of liver; PUD, pepticulcer disease

INTRODUCTIONThe role of the round ligament of liver (RLL) in clinical,pathological and surgical aspects of peptic ulcer disease(PUD) is not significant. In our opinion, there are only two«crossing fields» of the RLL and PUD. First, the RLL maybe object of PUD extension. However, penetration of gastric ulcer into the RLL is a very rare type of such a complication. As far as we are concerned there is only onecase described in literature.[1] Secondly, it is possible to useRLL in PUD surgery, mainly, as a plastic material.Utilization of the RLL was described for duodenal stumpclosure in distal gastrectomy,[2, 3] duodenoplasty after ulcerexcision.[4] Bibliography regarding perforated ulcer closurewith the RLL patch is more extensive, but the number ofpublished cases is relatively small.[5-10]

Closure of the Perforated Gastric Ulcer Using theRound Ligament of Liver, Pathologically ChangedDue to Ulcer Penetration: Report of a Case


CLOSURE OF THE PERFORATED GASTRIC ULCER 17

The aim of this article is to present an interesting case, whichdemonstrates both the options of clinically significant rela-tionship of the RLL and PUD. The RLL, pathologicallychanged due to previous gastric ulcer penetration, was usedfor perforated ulcer closure. We believe, this is the first suchcase described in literature.

CASE REPORTThe female patient S., 47-year-old, was admitted urgentlyto our hospital on March 01, 2007 with the symptoms ofpeptic ulcer perforation. Prior to admission she has devel-oped severe abdominal pain which lasted for 4,5 hours.Abdominal radiography showed free air under thediaphragm. Initial assessment of the patient revealedmarked hypotension (65/40 mm Hg). Past medical history(information was given by the patient’s daughter) includedmigraine for the length of time which deteriorated recently.She was taking peroral analgesics for the past severalmonths almost every day and at some point started to com-plain of constant epigastric pain for past three months.

Urgent operation was carried out. Upper median laparo-tomy. Considerable amount of muddy exudate with fibrinclots and threads was present in the abdominal cavity. Largeperforated ulcer was located at the anterior wall of distalstomach and was partially covered with the RLL. After com-plete division of round ligament from the stomach wenoted: the size of perforation was 30 x 18 mm, edges weredense and friable. On the dorsal surface of the RLL signs ofprevious penetration were clearly seen (Fig. 1).

Thus, the ulcer has penetrated into the RLL over the periodof time, and after disconnection of the latter from the gastric wall turned to perforated. Indications for distal gas-trectomy were dictated by severity of ulcerous process andits complicated character. But we were forced to refuse this

operation in favor of simple closure due to severe patient’scondition and persisted hypotension. Standard ulcer closure with two rows of sutures might have led to gastricoutlet obstruction. After ulcer edge excision (for biopsy)perforation was closed in one row of single sutures. TheRLL was mobilized, placed upon the suture line and fixedto the stomach wall. For better realization of plastic possi-bilities of the RLL it was turned to the stomach with theventral surface. Penetration area remains outside (Fig. 2).Abdominal cavity was washed thoroughly and drained.

Postoperative course was quite uneventful. During the firstpostoperative week mild nausea and hiccup were observed,but have been resolved after conservative treatment. On13th day the patient was transferred into the health resortfor subsequent treatment. We have planned to admit thepatient again for the control check up to decide on anoth-er surgical procedure if necessary, unfortunately the patientdefaulted from our follow up. Sixteen months later she wasadmitted for marked pyloroduodenal stenosis. Distal gastrectomy by Finsterer was performed successfully. Afterthe six months since the operation patient has improvedand never complained of abdominal pain.

DISCUSSIONPenetration of gastric ulcer into the RLL is the very rarevariant of this complication. We have found only one paperon this subject.[1] Belgian authors presented one clinicalcase. The patient was a young woman, who have used for along time analgesics for migraine (similar to the patient inour case) and corticosteroids for hypothyroidism. Radiologicexamination following the complaints of abdominal painrevealed a large gastric ulcer. It was located on anterior gas-tric wall and penetrated into the RLL. Distal 2/3 gastrectomyen block with the RLL and vagotomy were performed.

Figure 2: The round ligament of liver is fixed over suturedulcer. Area of penetration remains outside (arrow).

Figure 1: View of the operation field after laparotomy. Large perforated ulcer of the stomach [1] and the round ligament of liver with marks of previous ulcer penetration.[2, 3]


Use of the RLL as a plastic material in surgery of PUD (andin gastric surgery in general) is described more extensively.Round and falciform ligaments of liver are used for closureof difficult duodenal stump, [2, 3] reinforcement of suture linein duodenoplasty,[4] distal[11] and total[2] gastrectomy. Thoughit is more beneficial to use this plastic material for perforat-ed ulcer closure.

Varies authors have been using different techniques of perforated ulcer closure with the RLL. R.J. Doerr et al.,[7]

D.E. Fry et al.,[8] F.T. Jordan et al.[10] fixed the mobilized RLLupon perforation similar to Graham’s omentoplasty.[12]

D. Davila and B. Narbona fixed the RLL patch with four all-thickness U-shaped sutures, placed in a crown-fashion– below through the duodenal wall, above – through theround ligament.[6] We have used the different technique –after perforation closure in one row of single sutures peri-tonization of this suture line with the RLL was carried out.In our opinion, this technique is more reliable in aspect ofprevention of possible leakage. We have published two ourcases in local proceeding book.[13] Each ulcer was chronic, thearea of perforation – fairly large, but risk of gastrectomy was unacceptably high – due to the worsening of generalconditions and/or severity of peritonitis. The choice of theRLL for perforated ulcer closure was based on the currentcircumstances which made impossible the usage of theomental patch. In the first case omentum was massive,inflamed and friable; sutures cutted through its tissue easily.In the second patient, who was liberated from the jail, majoromentum was very thin, fatty tissue – almost absent, andomentoplasty of perforation would not be reliable, in fact itwas impossible. Unfortunately, both patients died of massive bleeding from sutured ulcer, on 13th and 5th day,

respectively. Secure, rigid attachment of the RLL with thegastric wall was confirmed at the autopsies. That fact definedthe further use of the RLL in perforated ulcers, and inreported case this technique was used as a method of choice.

The most of surgeons use the major omentum, but not theRLL for plastic closure of perforated ulcers. However, someauthors showed their preferences of the RLL over the omen-tum in this aspect. In severe peritonitis omentum can beoedematous, friable and unsuitable for using it as a patchfor perforated ulcer closure.[6, 13] Sometimes the major omen-tum is too thin, cicatrically changed or firmly attached thepelvis as a result of previous surgical procedures.[7, 8, 10, 13]

The size and mechanical durability of the RLL are moreconstant. Therefore, some colleagues have used the RLLinstead of omental patch in perforated ulcers.

Some cases, similar to our, were published earlier. In allthose reports surgical circumstances – large ulcer, severecondition and/or old patient’s age (gastrectomy was toorisky), forced perforation closure – were the same.[8, 10, 13]

As D. Fry et al.,[8] we were constrained to operate on thepatient secondarily for gastric outlet obstruction. Yet, wewould like to believe that the presented case is the firstreport of plastic use of the RLL, pathologically changeddue to ulcer penetration.

In summary, we hope to draw our colleague’s attention togood plastic properties of the RLL for perforated ulcers closure. This method is not indicated for the routine impli-cation, because it is not necessary.[13] But this technique,which is rarely used and until now little-known in common practice, can help in difficult surgical situations.

CLOSURE OF THE PERFORATED GASTRIC ULCER18

REFERENCES

1. Lambert-Lecler G, Lambert-Grisard LM, Lombard R, Dreze C. Perforated gastric ulcer blocked by the round ligament of the liver. Rev Med Liege. 1974;29:265-7.

2. Strode JE. Utilization of the round and falciform ligaments as a peritonealizing structure in surgery of the upper abdomen. Ann Surg. 1950;131:581-3.

3. Angelov N & Temelkov T. Plastic possibilities of the lig. falciforme hepatis. Khirurgia (Sofia). 1979;32:258-60.

4. Babiı̌ VP. Application of round hepatic ligament for the securing of reliable hemostasis and restoration ofpylorus in the presence of big penetrating duodenal ulcercomplicated by hemorrhage. Klin Khir. 2004;(1):21-3.

5. Costalat G & Alquier Y. Combined laparoscopic and endoscopic treatment of perforated gastroduodenal ulcerusing the ligamentum teres hepatis (LTH). Surg Endosc.1995;9:677-80.

6. Dávila D & Narbona B. A new technique for closing perforated duodenal ulcers using the round (teres) ligament. Res Surg. 1990;2:33-5.

7. Doerr RJ, Luchette FA, Gundlach TE, et al.Further clinical application of the falciform ligament. Surg Gynecol Obstet. 1990;170:167-8.

8. Fry D, Richardson JD, Flint LM Jr. Closure of an acuteperforated peptic ulcer with the falciform ligament. Arch Surg. 1978;113:1209-10.

9. Guidicelli H, Dupré A, Marthouret M. “Peritonizations” inthe supra-mesocolic area using the falciform ligament ofthe liver. Nouv Presse Med. 1976;5:1483.

10. Jordan FT, Winkler JM, Hoshal VL Jr. Falciform ligamentclosure of an acute perforated gastric ulcer. J AbdomSurg. 1981;23:109-10.

11. Morgoshiia TS. Billroth-I subtotal resection and its efficacy in the treatment of distal gastric cancer.Khirurgiia (Mosk). 2006;(7):10-3.

12. Graham RR. The treatment of perforated duodenal ulcers.Surg Gynecol Obstet. 1937;64:235-8.

13. Shiryajev YN & Filimonov MV. Utilization of the round ligament of liver for perforated gastric ulcer closure. In: Proceedings of Mariinsky Hospital, Vol 5; Saint-Petersburg, Russia: Saint-Petersburg State PediatricMedical Academy; 2006:205-7.


19RETROPERITONEAL BRONCHOGENIC CYST MASQUERADING AS AN ADRENAL MASS

Nelly Tan, MD

Deba Sarma, MD

Julie Ann Sosa, MD

Eyiyemisi Damisah, BA

Sanziana Roman, MD

Department of SurgeryYale University School of MedicineNew Haven, CT 06520

Corresponding author:Sanziana Roman, MD, FACSAssistant Professor of SurgeryChief, Endocrine SurgeryYale University School of Medicine333 Cedar Street TMP 208New Haven CT 06520Tel: (203) 785-2563Fax: (203) 737-4067E-mail: [email protected]

SHORT SUMMARYRetroperitoneal bronchogenic cysts are rare in adults. Thisis the first case-report of a retroperitoneal bronchogeniccyst successfully resected using trans-abdominal hand-assisted laparoscopic technique. A review of the literatureis presented.

ABSTRACTRetroperitoneal bronchogenic cysts are rare in adults. Wepresent a patient with a known longstanding adrenalmass and increased back pain with hip flexion. Hand-assisted laparoscopic resection documented a separatebronchogenic cyst. We present the case and review theliterature.

CASE REPORTA 69 year old woman presented to her physician with com-plaints of vague abdominal and back pain, especially withhip flexion. The patient was taking no medications and wasotherwise in good health. She was known to have a leftadrenal mass, which had been discovered a decade earlier,and was documented to be stable at 3.5 cm several years

before her current presentation. Prior hormonal biochem-ical evaluation was not available at the time of presentation.

On examination, she was well-appearing, with stable vitalsigns. Her physical examination was unremarkable, exceptfor vague discomfort in the left abdomen with hip flexion.Adrenal hormonal evaluation only showed very mild elevation of urinary metanephrines. The patient underwentrepeat adrenal computed tomography (CT) scanning, documenting a growing left adrenal mass, measuring 5 cm(Figure 1). Non-enhanced CT density was measured at 35-40 Hounsfield Units (HU). A meta-iodo-benzyl-guanidine(MIBG) scan was negative.

The patient underwent a hand-assisted laparoscopicresection of the mass. Intra-operatively, the mass was easily separated from the adrenal gland. It appeared tooriginate from the psoas or the paraspinal muscles. It wasadherent to the paraspinal muscles and vertebral body,but was resected in toto. Ex-vivo evaluation showed a cysticmass containing viscous, light greenish fluid (Figure 2).Pathologic examination revealed a benign retroperitonealcyst lined by respiratory epithelium with cartilage and

Retroperitoneal Bronchogenic CystMasquerading as an Adrenal Mass, SuccessfullyTreated with Hand-Assisted Laparoscopic Surgery

Figure 2: Gross specimen of the resected mass.

Figure 1:Computedtomography of the leftretroperitoneal/adrenal mass.


bronchial glands consistent with a bronchogenic cyst(Figure 3). The patient did well post-operatively, and wasdischarged home after two days.

COMMENTRetroperitoneal bronchogenic cysts are uncommon, andtheir incidence is represented by a few cases described in theliterature. They are congenital and derive from abnormalseparation of buds from the tracheobronchial tree duringfetal development.[1] More commonly, they occur in the posterior mediastium.[1, 2] In the retroperitoneum, the subdiaphragmatic area is the most common site of development. Bronchogenic cysts usually are discoveredincidentally; they have no consistent clinical presentation.Most have been thought to represent adrenal masses pre-operatively. When this was the case, patients underwentstandard biochemical evaluation for pheochromocytoma,Conn’s syndrome, and hypercortisolism; these proved tobe unremarkable. Biopsy has not been reported, as therewas never concern for malignancy or metastatic disease.Bronchogenic cysts in the retroperitonium can be compli-cated by infection, perforation, and pain stemming fromthe cyst compressing adjacent organs.[2-5] The treatment ofchoice is laparoscopic surgical resection.

This is the first reported case of a retroperitoneal bron-chogenic cyst followed for over a decade. Initially, it wasthought to represent a benign adrenal mass. This casedemonstrates that these entities can be slow-growing.Eventually, they can reach a size that leads to compressivesymptoms, including back or flank pain. Retroperitonealbronchogenic cysts should be included in the differentialdiagnosis of a retroperitoneal mass. Given their viscous contents, these cysts may have higher HU on CT exami-nation, and they may have mild enhancement withintravenous contrast administration, raising the suspicionfor intermediate-risk lesions. They also may be mistakenfor pancreatic mucinous tumors.[3] The differential diag-nosis of a retroperitoneal mass should include an adrenalmass (pheochromocytoma, adenoma, and adrenocorticalcarcinoma), paraganglioneuroma, pancreatic cyst, sarcoma,lymphoma, lipoma, metastatic tumor, neural-based tumor,cyst of the foregut or urogenital origin, teratoma, dermoidcyst, bronchopulmonary sequestration, fibromatosis, andlymphangioma.[2, 4-7]

Definitive pre-operative diagnosis of retroperitoneal bron-chogenic cysts can be challenging. On CT, they present aswell-rounded, sharply demarcated, hypo-attenuated masseswith HU from 20-130 due to their high protein concentra-tion.[1, 2, 8] This feature also can lead to reduction in T1relaxation time on magnetic resonance imaging (MRI) andhigh signal intensity on T2 weighted imaging.[9, 10] Benignneuroendocrine tumors and malignant adrenal lesions alsoshow high-signal T2 qualitative images on MRI.[9, 11, 12]

However, the integration with in- and out-of-phase chemical-shift sequences helps to differentiate adrenaladenomas from other lesions. Post-gadolinium T1 imagesallow adenomas, cysts, and myelolipomas to be distin-guished from pheochromocytomas and malignancies.[9]

Bronchogenic cysts may be difficult to differentiate pre-operatively from benign cysts, lymphangiomas, andganglioneuromas.

RETROPERITONEAL BRONCHOGENIC CYST MASQUERADING AS AN ADRENAL MASS20

Figure 3 (C): Pathologic findings of the mass, showingbronchial glands (40X), consistent with a bronchogenic cyst

Figure 3 (B): Pathologic findings of the mass, showingcartilage (40X)

Figure 3(A): Pathologic findings of the mass, showing (A)pseudostratified columnar ciliated epithelium (100X)


RETROPERITONEAL BRONCHOGENIC CYST MASQUERADING AS AN ADRENAL MASS 21

REFERENCES

1. Buckley, J.A., et al., Bronchogenic cyst appearing as a retroperitoneal mass. AJR Am J Roentgenol,1998. 171(2): p. 527-8.

2. Murakami, R., et al., Retroperitoneal bronchogenic cyst:CT and MR imaging. Abdom Imaging, 2000. 25(4): p. 444-7.

3. Andersson, R., et al., Retroperitoneal bronchogenic cystas a differential diagnosis of pancreatic mucinous cystictumor. Dig Surg, 2003. 20(1): p. 55-7.

4. Chung, J.M., et al., Retroperitoneal Bronchogenic CystPresenting as Adrenal Tumor in Adult SuccessfullyTreated with Retroperitoneal Laparoscopic Surgery.Urology, 2008.

5. Foerster, H.M., et al., Retroperitoneal bronchogenic cystpresenting as an adrenal mass. Arch Pathol Lab Med,1991. 115(10): p. 1057-9.

6. Itoh, H., et al., Retroperitoneal bronchogenic cyst: report of a case and literature review. Pathol Int, 1999.49(2): p. 152-5.

7. Stocker, J.T., Sequestrations of the lung. Semin Diagn Pathol, 1986. 3(2): p. 106-21.

8. Gaeta, M., et al., CT and MRI findings of mucin-containing tumors and pseudotumors of the thorax: pictorial review. Eur Radiol, 2002. 12(1): p. 181-9.

9. Maurea, S., et al., [Magnetic resonance in the study of suprarenal neoplasms. Qualitative and quantitativeanalysis of signal intensity]. Radiol Med, 1998. 95(3): p. 199-207.

10. Levine, D., et al., Progressive fetal bronchial obstructioncaused by a bronchogenic cyst diagnosed using prenatalMR imaging. AJR Am J Roentgenol, 2001. 176(1): p. 49-52.

11. Marin, M.L., et al., Bronchogenic cyst: a case reportemphasizing the role of magnetic resonance imaging. J Thorac Imaging, 1991. 6(2): p. 43-6.

12. Nakata, H., et al., MRI of bronchogenic cysts. J Comput Assist Tomogr, 1993. 17(2): p. 267-70.

13. Cetinkursun, S., et al., Isolate abdominal bronchogeniccyst: a case report. Eur J Pediatr Surg, 1997. 7(2): p. 103-5.

14. Tokuda, N., et al., A retroperitoneal bronchogenic cysttreated with laparoscopic surgery. J Urol, 1997. 157(2):p. 619.x

15. Yamamoto, E., et al., Laparoscopically resected foregut cyst adjacent to the right adrenal gland. Diagn Ther Endosc, 1998. 5(1): p. 53-6.

16. Ishikawa, T., et al., Retroperitoneal bronchogenic cystmanaged with retroperitoneoscopic surgery. J Urol, 2003.169(3): p. 1078-9.

17. Ishizuka, O., et al., A retroperitoneal bronchogenic cyst: laparoscopic treatment. Urol Int, 2004. 72(3): p. 269-70.

18. Chu, P.Y., et al., A retroperitoneal bronchogenic cyst successfully treated by laparoscopic surgery. Ann Saudi Med, 2007. 27(3): p. 199-200.

19. Minei, S., T. Igarashi, and D. Hirano, A case of retroperitoneal bronchogenic cyst treated by laparoscopicsurgery. Hinyokika Kiyo, 2007. 53(3): p. 171-4.

20. Terry, N.E., et al., Retroperitoneal foregut duplication cyst presenting as an adrenal mass. Am Surg, 2007.73(1): p. 89-92.

21. Akos, M.B., et al., [Laparoscopic extirpation of retroperitoneal bronchogenic cyst]. Magy Seb, 2006.59(1): p. 37-41.

22. Orellana, F., et al., [Retroperitoneal bronchogenic cyst:Report of one case]. Rev Med Chil, 2007. 135(7): p.924-31.

This is the first description of a retroperitoneal bron-chogenic cyst removed with a hand-assisted laparoscopictrans-abdominal approach, and it is just the eleventh caseto be reported following laparoscopic resection.[4, 13-21] Thehand-assisted technique permitted early intra-operativeappreciation that the lesion was separate from the left adre-nal gland; unnecessary adrenalectomy was avoided, and theoperation was significantly expedited. All retroperitonealbronchogenic cysts reported in the literature followinglaparoscopic resection were located adjacent to the adrenalgland on the left side. All were hormonally inactive. Two patients had an en bloc adrenalectomy, and one patient required a distal pancreatectomy.[15, 20, 22] Most cysts

were adherent to local tissues. Both trans-abdominal andretroperitoneal surgical approaches have been described inthe literature.[4,16]

In summary, retroperitoneal bronchogenic cysts areuncommon. They usually are incidentally identified on surveillance cross-sectional imaging. Slow growth,normal hormonal studies, and characteristic findings onCT and MRI suggest a benign process. Surgery is the preferred treatment to avoid infectious complications orsymptoms of compression. Laparoscopy or hand-assistedlaparoscopic techniques can facilitate resection and avoidunnecessary en-bloc adrenalectomy.


MACRODACTYLIA AND INTESTINAL LIPOMATOSIS

Macrodactylia and Intestinal LipomatosisGhaith Khair, MDMetropolitan Group HospitalsResidency in General Surgery

Charan Singh, MDRadiology Resident

Sheila Major, MDRadiology Attending

Matthew J. Hyser, MD, FACSGeneral Surgery

St. Francis Hospital, Evanston, IL

Corresponding author:Matthew J. Hyser MD, FACSMetropolitan Group Hospitals Residency in General Surgery Chicago(St. Francis Hospital, Evanston, IL)Surgical Associates, S.C.800 Austin, E. Tower Suite 563Evanston, IL. 60202 Tel: (847) 869-0522Fax: (847) 869-0652E-mail: [email protected]

ABSTRACT Intestinal lipomatosis is a rare disorder affecting thesmall intestine. Symptoms when present are vague andcommon complications include intussusception, pain,malabsorption, bleeding, or volvulus. Macrodactyliafibrolipomatosis is also an unusual condition affectingthe hands and feet producing massive digital hypertro-phy and deformity. Two prior case reports documentthese two conditions occurring simultaneously. Wereport a third instance of a 69 year old male present-ing with small bowel obstruction, intestinal lipomatosis,and macrodactylia fibrolipomatosis together with jejunal diverticulosis. Exploratory laparotomy and smallbowel resection led to resolution of the obstruction.

INTRODUCTIONLipomas are a common benign tumor of the small intestine. Most are solitary and asymptomatic, however;multiple lipomas can involve a long segment of the smallintestine. Multiple intestinal lipomatosis was firstdescribed by Hellstrom in 1906.[1] Since then, thirty onecases of diffuse small intestine lipomatosis have beenreported worldwide,[2-9] with the ileum being most com-monly affected.[10] While occasionally found subserosally,most lipomas are located within the submucosal layer ofthe bowel wall. Endoluminally, they may appear as poly-poid or pedunculated lesions.

Macrodactylia fibrolipomatosis is an uncommon anomalyof the extremities affecting the fingers and toes. Hands aremore commonly involved than feet. The digits are abnor-mally large due to fibrofatty infiltration of soft tissue alongwith bony hypertrophy. The most frequently involved digitof the hand is the index finger.[11, 12]

The presence of the two conditions arising simultaneouslyis extremely rare, with only two prior case reports describ-ing the combination of macrodactylia and small intestinallipomatosis.[13, 14]

CASE REPORTA 69 year old Chinese farmer immigrated to the UnitedStates 10 years ago. On a prior admission in 2007 for vagueabdominal complaints, a CT scan of the abdomen demon-strated diffuse small intestinal lipomatosis and lipomatouschanges involving the colon wall. A colonoscopy at that timedid not demonstrate mucosal involvement with lipomatouschange and a barium contrast study revealed multiple radi-olucent masses projecting into the jejunal lumen (Figure 1).He now presents with a four day history of abdominal full-ness, obstipation, along with nausea and vomiting.

His past medical history includes coronary artery disease,hypertension and hyperlipidemia while past surgical history included a urological procedure performed inChina. Medications were valsartan, simvastatin, metopro-lol, and isosorbide.

22

Figure 1: Barium study of small bowel shows multiple smooth-walled radiolucent masses (*) projecting into the jejunal lumen.


On examination his vital signs were within normal limits.He had an obvious deformity of his left hand consisting ofmassive hypertrophy of the fourth and fifth fingers (Figure2). His abdomen was distended but non-tender. Laboratoryfindings were within normal limits. In the emergencydepartment an abdominal x-ray was performed whichdemonstrated dilated small bowel loops and stool in adecompressed colon. CT scan of the abdomen and pelvisdemonstrated diffuse fatty infiltration of the small bowelwith multiple polypoid lesions within the lumen of theproximal and mid small bowel, and acute small bowelobstruction. Lipomas were also present in the decom-pressed colon wall (Figure 3).

A nasogastric tube and Foley catheter were placed, and afterresuscitation, the patient was taken to the operating roomfor an exploratory laparotomy. Operative findings demon-strated a short segment of normal proximal jejunum fromthe ligament of Treitz extending for several centimeters at which point the bowel became thickened and dilatedwith a marked change in caliber. The proximal jejunumcontained multiple wide mouth diverticulae along theantimesenteric border. Finally there were innumerablelipomatous changes found throughout the jejunum andileum up to the point of obstruction while the terminalmost ileum was decompressed and relatively spared of thisprocess (Figures 4&5). The obstructing segment of thesmall bowel was resected and primary anastomosis wasperformed. The patient had an uneventful post operativecourse and was discharged from the hospital with normalbowel function. The final pathology report showed multi-ple, confluent submucosal and intramuscular lipomas inthe resected segment (Figure 6).

DISCUSSION Small intestinal lipomatosis is rare with only 31 reportedcases. Symptoms when present are often vague and com-plications include intussusception, chronic abdominal pain,malabsorption, bleeding, volvulus, or obstruction.[2, 5, 7, 8]

MACRODACTYLIA AND INTESTINAL LIPOMATOSIS 23

Figure 2: Left hand picture and radiograph shows hypertrophy and deformity of digits with ankylosis of interphalangeal joints along with sclerosis, cortical thickening and medullary cystic change.

Figure 3: Axial CT images show diffuse fat infiltration of bowelwall (white arrows) in addition to several sharply marginatedradiolucent ovoid filling defects within lumen of small boweloutlined by contrast material. The proximal small bowel loopsare dilated with non distended large bowel suggesting distal smallbowel obstruction.

Figure 4: Dilated small bowel loops with transitional point –note extraluminal fatty changes.

Figure 5: Several large mouth proximal jejunal diverticulae seen on the antimesenteric border associated with lipomatouschanges externally.


MACRODACTYLIA AND INTESTINAL LIPOMATOSIS

REFERENCES

1. Bodas, A, Rivilla, F, Maluenda, C. Intestinal lipomatosis in a 10-year-old girl. Eur J Pediatr.2008;167(5):601-602.

2. Ling, CS, Leagus, C, Stahlgren, LH. Intestinal lipomatosis. Surgery. 1959;46:1054-1059.

3. Baumgartner, CJ. Recurrent multiple intussusceptionswith lipomatosis: multiple diverticula. Am Surg.1969;35(1):70-71.

4. Ranchod, M, French, TJ, Novis, BH, et al. Diffuse nodular lipomatosis and diverticulosis of the small intestine. Gastroenterology. 1972;63(4):667-671.

5. Ueda, K, Kitagawa, A, Oka, Y, et al. Multiple lipomas of the ileum with volvulus. Arch Surg.1977;112(9):1144-1145.

6. Climie, AR, Wylin, RF. Small-intestinal lipomatosis. Arch Pathol Lab Med. 1981;105(1):40-42.

7. Reeder, PH, Hopens, T. Intestinal lipomatosis—an unusual case. Am J Gastroenterol. 1983;78(3):185-188.

8. Neilson, D, Wilkinson, N, Magell, J. Case of simultaneousdiverticulosis, lipomatosis and volvulus of the small intestine. Br J Surg. 1990;77(1):105.

9. Duun, S. Lipomatosis of the small intestine. Eur J Surg.1994;160(5):311-312.

10. Yakabe, S, Muranaka, T, Sumii, T, et al. Jejunal lipomatosis with diverticulosis: report of a case. Surg Today. 1998;28(8):846-849.

11. Kalen, V, Burwell, DS, Omer, GE. Macrodactyly of thehands and feet. J Pediatr Orthop. 1988;8(3):311-315.

12. Yaghmai, I, McKowne, F, Alizadeh, A. Macrodactyliafibrolipomatosis. South Med J. 1976;69(12):1565-1568.

13. Mazziotti, S, Salamone, I, Vinci, S, et al.Macrodactylia fibrolipomatosis associated with multiple small-bowel lipomas. AJR Am J Roentgenol.2006;186(4):1195-1196.

14. Gates, LK, Jr., Keate, RF, Smalley, JJ, Jr., et al.Macrodactylia fibrolipomatosis complicated by multiple small bowel lipomas and intussusception. J Clin Gastroenterol. 1996;23(3):241-242.

24

The associated presence of small intestinal lipomatosis andmacrodactylia fibrolipomatosis is an even rarer occurrencewith only two prior case reports.[13, 14] In one case the patientpresented with chronic abdominal pain, and his hand exam-ination showed hypertrophy of the left thumb, index andmiddle fingers with firm fusiform nodules of the soft tissueof the palm. This patient underwent a laparotomy and wasfound to have jejuno-jejunal intussusception and multiplesubmucosal tumors extending from the ligament of Treitzto the mid small bowel. The intussusception was reducedand multiple enterotomies were performed with resectionof the largest tumors.

The second patient presented with a ten year history of malabsorption. An upper gastrointestinal study and a CTscan of the abdomen demonstrated multiple lipomas of thesmall bowel. At operation the largest lipoma was resectedto prevent intussusception. This patient had macrodactyliafibrolipomatosis of his left thumb. In each case the left handis involved suggesting a common somatic genetic mutation.

Our patient had multiple large mouth proximal jejunaldiverticulae located eccentrically on the antimesenteric border in addition to macrodactylia and intestinal lipo-matosis. Lipomatosis associated with jejunal diverticulosishas been described previously but not with macro-dactylia.[3, 4, 8, 10] When present, diverticulosis has not been asource of complications. The left hand macrodactyliainvolved digits four and five while prior case reportsdescribed thumb, index, or middle finger changes.

Barium contrast studies maybe helpful but CT scanningis the best imaging test to diagnose, determine the extent,and assess for complications from this unusual diseaseprocess. The CT differential diagnosis would include multiple polyposis syndromes, lymphoma, neurofibro-mas, multiple hemangiomas, mesenteric masses, andmetastatic lesions. Additional possibilities include latestage ulcerative colitis and post radiation change. CT is preferred for its ability to recognize homogeneous fatattenuation characteristic of lipomatous masses withinthe bowel wall. Heterogeneous attenuation or increasedfat density may suggest liposarcoma.

CONCLUSIONSmall intestinal lipomatosis and macrodactylia fibrolipo-matosis is extremely rare. Our case report is the third to bereported in literature, and is the first case to present withcomplete small bowel obstruction and large antimesentericjejunal diverticulosis.

Figure 6: Multiple intraluminal lipomatosis of the resectedsmall bowel producing bowel obstruction.





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*Revocation of CertificationA certificate issued by the American Board of Abdominal Surgery, Inc. is subject to revocation at any time if there is falsification of any part of theapplication or required documentation. Revocation of an ABAS Certification can also apply, due to the revocation of a physician’s medical license by a state board or governing board of registration in medicine or other circumstances deemed inappropriate by ABAS.

American Board of Abdominal Surgery


WINTER 2010/SPRING 201132

MANUSCRIPTSManuscripts must be typed, upper and lower case letters,double spaced, on 8.5 x 11 inch, white bond paper, with oneinch margins. Each page must be consecutively numberedand should not exceed 12 pages. Acceptable English and read-ability are important factors in the acceptance of articles.

Most manuscripts must include background material,methods and materials used, results derived and conclu-sions reached.

REFERENCESReferences must follow those guidelines referred to abovein the AMA Manual of Style. Examples follow:

Book: Author (last name, initials). Book Title. Edition (ifany). City of Publication: Publisher; Year of Publication:page numbers. [Kowalski, RE. The 8-Week CholesterolCure. New York: Harper & Row; 1992:113-119.]

Chapter in Book: Author (last name, initials). Chapter Title.In: Author. Book Title. Edition (if any). City of Publication:Publisher; Year: page numbers. [Hobsley, M. PyloricReconstruction. In: Cuschieri, A and Hennessy, TPJ, eds.General Surgery. London: Bailliere Tindall; 1985:42-61.]

Journal Articles:Author (last name, initials). Title of Article.Journal Name. Year; Volume: page numbers. [Payne, H &DeWind LF. Surgical Treatment of Obesity. AmericanJournal of Surgery. 1963; 106:273.]

Names of authors must be listed.

FIGURES AND TABLESFigures must be submitted as black and white 5 x 7 inch,glossy photographs, unmounted and in good focus, or ashigh-quality computer-generated likenesses. Number of thefigure, author’s name and title of manuscript must be indi-cated on the back of each figure. Legends must be typed,double-spaced on a separate sheet, as well as on the backof each figure.

Tables must not repeat information in the text of themanuscript. They are to be numbered consecutively inRoman numerals, typed, double-spaced on a separatesheet. Avoid tabs.

CONSENTPermission to print photographs of persons whose identi-ties are not disguised, must be submitted with themanuscript. Informed consent of human subjects involvedin experiments or research programs, must be mentionedin the methods section of the manuscript.

CONFLICTS OF INTERESTPotential conflicts of interest due to financial support orotherwise, must be acknowledged by authors and reviewersalike.

SUBMISSION INFORMATIONAll manuscripts should be submitted to: Diane Pothier, Director of Continuing Medical EducationAmerican Society of Abdominal Surgeons, Inc.824 Main Street, 2nd Floor, Suite 1, Melrose, MA 02176

All articles submitted for publication must conform to the following checklist:1. A short abstract of the article must be submitted on a separate page consisting of 150 words or less.2. The first and last names of all authors, their academic degrees, the institution from which the article came, and the

address, telephone number, e-mail address, and fax number of the author, to whom questions may be directed orreprints requested, must be included in the title page.

3. References, tables and figures should be listed in chronological order as they appear in the text, following the generalguidelines listed in the American Medical Association Manual of Style: a guide for authors and editors, 9th Edition. Theyshould be typed, double-spaced on a separate sheet. Authors must be responsible for the accuracy of their references.

4. Articles must have clarity, organization and style. The articles must be original, unpublished and not posted on the internet, in one of the following categories of abdominal surgery: clinical and/or experimental surgery; new orinnovative surgical technique; book reviews; pharmacology; brief reports and case reports.

5. Two original manuscripts and two complete copies on CD ROM, in a format compatible with “Microsoft Word” for “Windows,”must be submitted to the editor at the address provided.

6. Omit “Keywords”.7. All authors must sign an attestation, that they participated in the work presented, read the article and approve same.8. A “copyright form” will be provided along with a “letter of receipt” upon receipt of an article for review and publication.

This form MUST be returned for the article to be considered for publication.

Manuscripts will not be accepted if all the above Guidelines for Authors are not adhered to.

The Journal of Abdominal Surgery, Inc.Guidelines for Authors


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AMERICAN SOCIETY OF

ABDOMINAL SURGEONS

824 Main Street

2nd Floor, Suite 1

Melrose, MA 02176-2711

Tel: (781) 665-6102

Fax: (781) 665-4127


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