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The duodenal «diverticulization» is a surgical technique described by Berne and colleagues in 1968 for the treatment of combined duodenal pancreatic injuries. It consisted of closure of the duodenal injury by suture and tube duodenostomy, gastric antrectomy with end-to-side isoperistaltic Billroth II gastrojejunostomy, and abdominal drainage. As evidenced from the literature in few reports, this technique has also been adopted for lateral duodenal lacerations in non traumatic conditions. Most biliary disease may be responsible for duodenal injury.Herein, we describe the application of this emergency technique for the treatment of a wide lateral duodenal laceration discovered intra-operatively during laparoscopic cholecystectomy for acute cholecystitis. A comprehensive critical review of the different surgical methods proposed for duodenal protection in case of severe duodenal lesions has been performed and discussed.Duodenal injuries represent a challenging condition, especially for surgeons with limited experience in this field. The key-message of this report is to consider emergency surgical techniques in difficult unexpected intra-operative situations which may occur during routine surgical practice.Duodenal diverticulization, Duodenal fistula, Laparoscopic cholecystectomy, Surgical repair.La “diverticolizzazione” del duodeno è una tecnica chirurgica descritta da Berne e Coll. nel 1968 per il trattamento di lesioni pancreatiche e duodenali associate. Consiste nella sutura della lesione duodenale ed una duodenostomia su tubo di drenaggio, antrectomia gastrica con gastrodigiunostomia termino-laterale isoperisttaltica secondo Billroth II, drenaggio del cavo peritoneale. Come è messo in evidenza in pochi riferimenti della letteratura, questa tecnica è stata adottata anche per lacerazioni laterali del duodeno per condizioni non traumatiche. Molte patologie delle vie biliari possono essere responsabili di danni al duodeno. A titolo di esempio viene presentato un caso di utilizzazione di questa tecnica per il trattamento di un’ampia lacerazione laterale del duodeno scoperta durante un intervento di colecistectomia laparoscopica per colecistite acuta. Si è proceduto ad una revisione critica complessiva dei differenti metodi chirurgici proposti per proteggere il duodeno nel caso di gravi lesioni duodenali, e alla loro discussione. In conclusione le lesioni duodenali rappresentano una condizione di sfida specie per chirurghi di limitata esperienza in questo campo. Il messaggio che si vuole inviare con questo contributo è quello di ricordare tecniche chirurgiche emergenziali nel caso di situazioni intraoperatorie difficili e inaspettate che possono manifestarsi nella pratica chirurgica routinaria.

Annular pancreas is a rare congenital intestinal obstruction to be found in infants. It is characterized by nonbilious vomiting, abdominal distention, and feeding intolerance that share similar symptoms with other intestinal obstructions. We reported a case of 11-month-old female infant with a history of nonbilious vomiting after coughing as much as 6 times per day 1 day before admission. The patient had an incorrect provisional diagnosis of hypertrophic pyloric stenosis based on ultrasound. Later on, an upper gastrointestinal series showed dilatation of the second part of the duodenum which was successfully treated by a duodenostomy during laparotomy procedure. It is suggested that treating an intestinal obstruction needs a further investigation when the symptoms were continuously repeated.

A 47-year-old female presented with Easy fatigability, abdominal pain for 4 days. Past history of open cholecystectomy with Common bile duct exploration and Choledocho Duodenostomy done 13 years before. She later had multiple episodes of abdomen pain with fever on and off. ERCP revealed stone in common bile duct but not retrieved and patient lost follow-up. During this hospitalisation patient had fever, Jaundice and Sepsis with Acute Kidney Injury. Ultrasound Abdomen showed Hypoechoic lesion in seg IV left lobe liver. Mild pneumobilia. CECT Abdomen showed Pneumobilia, ill-defined hypodense lesions in segment IVA, II, III causing left lobe Intrahepatic biliary radicle dilation. MRCP showed Multiple tiny T2 hyperintense lesions with surrounding edema in SEGMENT IVB? Cholangitic abscess. Patient was taken up for surgery. Intraoperatively Left lateral segment II, III fibrotic, left hepatic duct & branches grossly dilated, stones retrieved from LHD; Left lateral sectionectomy, hepaticojejunostomy, jejunojejunostomy with access loop done. This was a rare case of recurrent pyogenic cholangiohepatitis managed surgically.

Smoking is clinically associated with high postoperative pain scores and increased perioperative analgesic requirements. However, the association between the duration of smoking cessation and postoperative opioid requirements remains unclear. Therefore, this study aimed to evaluate the association between the duration of smoking cessation and postoperative opioid requirements. We retrospectively analyzed the data of 144 male patients who received intravenous patient-controlled analgesia (IV PCA) after laparoscopic distal gastrectomy with gastroduodenostomy. All patients were divided into three groups: G0, nonsmoker; G1, smoker who quit smoking within 1 month preoperatively; G2, smoker who quit smoking over 1 month preoperatively. Analgesic use, pain intensity, and IV PCA side effects were assessed up to postoperative day 2. As the duration of smoking cessation increased, the amount of postoperative opioid consumption decreased (β = −0.08; 95% confidence interval (CI), −0.11 to −0.04; P < 0.001 ). The total postoperative opioid requirements in G1 were significantly higher than those in G0 and G2 (G0, 75.5 ± 15.9 mg; G1, 94.6 ± 20.5 mg; and G2, 79.9 ± 19.4 mg P < 0.001 ). A multivariate regression analysis revealed that G1 was independently associated with increased postoperative opioid requirements (β = 12.80; 95% CI, 5.81–19.80; P < 0.001 ). Consequently, male patients who had ceased smoking within 1 month of undergoing a laparoscopic distal gastrectomy with gastroduodenostomy had higher postoperative opioid use than patients who had ceased smoking for more than 1 month and nonsmokers.

Preduodenal portal vein (PDPV) is a rare congenital vascular anomaly in which the portal vein passesanterior to the duodenum rather than posteriorly. Generally asymptomatic, PDPV may rarely cause aduodenal obstruction in the newborn. It is usually associated with gastrointestinal tract, cardiac,pancreatic, as well as biliary tract anomalies or may, occur as a single isolated malformation. Tillnow, only a few cases have been reported with duodenal obstruction and associated anomalies. Thepresent study report one such case of PDPV with multiple congenital anomalies. A full-term, one-day-old baby who had an antenatal history of polyhydramnios, presented to us with abdominaldistension and non-bilious vomitings soon after birth. Surgical exploration revealed a hugely dilatedstomach, multiple Ladd bands, malrotation of the small intestine, preduodenal portal vein, and anannular pancreas causing external duodenal compression. Intraoperative recognition of PDPV isimportant because iatrogenic injury during surgery can cause profuse hemorrhage from the vein andmay cause damage to the biliary tract or duodenal wall. Prompt evaluation of associated cardiacanomalies is important before surgery. Duodenostomy anterior to the portal vein is the definitivetreatment. Studies in animal models (AKR/J mice) have shown an autosomal recessive mode ofinheritance.

Introduction: Robotic distal gastrectomy (RDG) is now thought to be less invasive than conventional laparoscopic distal gastrectomy (LDG) for gastric cancer. Although the delta-shaped anastomosis i...

Treatment of medically refractory postprandial hypoglycemia after Roux-en-Y Gastric bypass (RYGB) is often unsuccessful. Various operations have been described with poor results. We describe a novel procedure and retrospective review of 8 patients who underwent Roux jejuno-duodenostomy for postprandial hypoglycemic symptoms refractory to dietary modification and medications. Mean follow-up was 35 months. Complete resolution occurred in two of the patients, marked improvement in four, and no improvement in two. The mean frequency of hypoglycemic symptoms decreased from 30 to 7 episodes per week (p = 0.015). One complication was noted with no mortality. Mean weight decreased postoperatively by 0.8 kg (p = 0.93). Conversion to a Roux jejuno-duodenostomy appears to be a safe and effective treatment with maintenance of post-RYGB weight loss in most such cases.

Background and aims Segregated right intrahepatic duct dilatation (IHD) results from complete obstruction of the biliary tract proximal to the hilar level. We aimed to evaluate long-term efficacy and safety of endoscopic ultrasound (EUS) hepaticoduodenostomy (HDS) in segregated right IHD. Methods Consecutive patients who had undergone EUS-guided HDS with a fully covered self-expandable metal stent (FCSEMS) in an academic tertiary center were recruited. All patients had segregated right hepatic duct and failed drainage by endoscopic retrograde cholangiopancreatography (ERCP). Demographic data, endoscopic findings, procedure details, and outcome data were extracted from a prospectively maintained database. Results From 2013 to 2017, there were 35 patients who had undergone EUS-guided HDS with a median follow-up duration of 169 (3-2091) days. Malignancy accounted for 71.4% of the ductal segregation, followed by surgical complication (17.1%). Technical and clinical success rate was 97.1% and 80%, respectively. Early adverse event (AE) happened in seven patients (20%), two of them required endoscopic reintervention, and no percutaneous transhepatic biliary drainage (PTBD) or surgery was performed because of AE. The median stent patency duration was 331 (3-1202) days. The median duration of fistula tract keeping was 1280 (3-1280) days. There was no significant difference in terms of patency rate with respect to whether the underlying pathology was benign or malignant (P = 0.776). EUS-guided HDS for right posterior sectional duct segregation was associated with higher 3-month stent patency rate when compared with right anterior sectional duct (79.1% vs 38.1%, P = 0.012). Conclusion Endoscopic ultrasound-guided HDS with an FCSEMS appears to be a safe and effective treatment as a viable alternative option to PTBD after failed ERCP. It creates a durable and reliable fistula tract for permanent access to an isolated ductal system, and this application deserves more attention.

Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.

Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU) perforation remains a common surgical emergency. Most DU perforations are small and can be managed with omental patch repair. However, occasionally the surgeon may encounter a giant perforation not amenable to this. Giant DU perforations are defined as > 2cm. They are associated with high leak rates and mortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities. Furthermore, there are no specific recommendations for their management despite a variety of repair techniques being described. Here, we aim to describe a novel technique used to treat such patients, especially those of advanced age, in our institution and to review the current literature. Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repair with our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinically and radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 years with an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderately severe). All presented with peritonitis and two had concomitant bleeding. There were two anterior and two posterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initial perforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery was uneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks, intra-abdominal collections, gastric outlet obstructions or mortalities. Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderly patients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniques but no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlled tube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy. Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensures definitive repair of giant ulcer perforation in a single setting in the high-risk patient.

Highlights • Although most complications following LAGB are confined to the stomach and port site, some may envolve the entire bowel causing extensive damage. • One must be wary of the presentation of long term complications, as it may initially present as an unrelated pathology, such as acute pancreatitis. • Long term complications may be asymptomatic for years despite extensice damage, including multiple contained perforations. • The surgical procedure performed to treat long term complications should be planned and performed by physicians experienced in foregut surgery., Introduction Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported. Presentation of case A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum. Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21. Discussion Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature. Conclusion Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Introduction: A newly appeared challenge for the healthcare system is the variety of clinical symptoms of COVID-19. In this research, we report 2 cases admitted to Modarres Hospital with unusual postoperative anastomotic failure. Case Presentation: In a 72-year-old man with a perforated peptic ulcer in D2 and signs of leakage after the first operation and during the second operation due to massive unexpected hemorrhage, we found fully disrupted anastomosis on the second part of the duodenum. Accordingly, the suture ligature of the bleeding ulcer with the closure of the duodenal stump and loop gastrojejunostomy and tube duodenostomy were performed. During the postoperative period, he developed dyspnea, and the diagnostic test of SARS-CoV-2 confirmed him as a case of COVID-19. Unfortunately, 1 week after the second surgery, evidence of anastomotic leakage appeared again by bile discharge from drains; although it was managed conservatively, he died because of respiratory failure. In another case, a 65-year-old woman was admitted to the emergency ward with closed-loop small bowel obstruction. After emergency laparotomy, resection of ischemic bowel with primary anastomosis was performed. The same as the previous case, she developed dyspnea, and the diagnostic test resulted positive for COVID-19. After 2 weeks, she was admitted to the hospital with signs of anastomotic leakage that was subsequently confirmed by abdominal computed tomography (CT); although it was managed conservatively, she died because of respiratory failure due to COVID-19. Conclusions: These cases were unique in that intestinal microangiopathies can cause very severe problems, weaken the body, and eventually death, as we have seen in these 2 cases.

Situs inversus totalis is the mirror image transposition of the abdominal-thoracic viscera. Approximately one in every 5,000 to 20,000 live births has situs inversus totalis. Most commonly, it is found incidentally and is asymptomatic. A number of malformations, including cardiac, splenic, and gastrointestinal, have been associated with this condition. Coexistence with duodenal atresia is extremely rare, reported in fewer than 30 cases worldwide and one case in Saudi Arabia. We report a preterm neonate who presented with bilious vomiting. Diagnosis of situs inversus totalis with duodenal atresia type III was established and other anomalies were ruled out. The patient was managed surgically by duodenal-duodenostomy and Ladd’s procedure. The report emphasizes the importance of identifying this condition and recognizing the "mirror anatomy" before carrying out an operation. Once the diagnosis is confirmed, surgical intervention must be performed as soon as possible to prevent complications.

Background: Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous fistula which increases morbidity and mortality. Treatment of duodeno-jejunal flexure transection has been traditionally done by pyloric exclusion with gastrojejunostomy, but more recent evidence suggests that end-to-end anastomosis or primary closure may be equally effective in which duodeno-jejunal anastomosis is protected via an external tube duodenostomy. Objective: The objective of the study is to provide a modification to the technique of management of duodeno-jejunal flexure injury, avoiding external tube duodenostomy. Material and Methods: Patients admitted from July 1, 2015 to June 1, 2018 were identified and examined for duodeno-jejunal flexure transection. Non-accidental injury cases were excluded. Results: In the study period, a total of 10 patients were admitted with duodeno-jejunal flexure transection. All cases were admitted 24 hours after the injury and presented with shock. After fluid resuscitation and investigations, they were taken for urgent laparotomy. The whole of duodenum was mobilised, the transected ends were debrided and end-to-end duodenojejunal anastomosis was performed in two-layer fashion. An 18-French Nasojejunal (NJ) tube was placed beyond the anastomosis, and an 18-French nasogastric (NG) tube was placed in the stomach for gastric decompression. A feeding jejunostomy was performed in all cases. Both NG and NJ tubes were removed after bowel movements started and FJ was removed on first follow up. There was no incidence of duodenum related complications, and all were doing well on follow up. Discussion and conclusion: Placing the nasojejunal and nasogastric tube eliminates the need for duodenostomy and gastrostomy, respectively. This method protects the duodeno-jejunal anastomosis and decreases the incidence of duodenum-related complications.

Pancreas transplantation is considered the curative treatment for severe type 1 diabetes mellitus in selected cases. Since the first procedure in 1966, surgical techniques have been improved. The current trend among most medical centers, as well as at our Institution, is enteric drainage and systemic venous or portal anastomosis. The aim of this pictorial essay is to describe the main imaging features of pancreatic transplantation with duodenoduodenostomy drainage.

The authors outline their stapling technique and retrospectively compare outcomes of laparoscopic staplers versus robotic staplers in patients undergoing robotic distal gastrectomy (RDG) with Billroth I gastroduodenostomy for gastric cancers.Of our 28 consecutive patients who underwent RDG, 18 underwent Billroth I gastroduodenostomy using laparoscopic staplers (fusion group); robotic staplers were used in the remaining 10 patients (robot group). All RDG procedures were performed using the da Vinci Surgical System.The duration of reconstruction was significantly longer for the robot group than for the fusion group. There were no conversions to conventional laparoscopy or open surgery in the fusion group, but 1 patient in the robot group required conversion to laparoscopic reconstruction for duodenal injury during anastomosis. No postoperative complications developed in the fusion group.Regarding short-term surgical outcomes, robotic-assisted laparoscopic stapling techniques for reconstruction after RDG are both feasible and safe for gastric cancers.

Patient: Male, 33 Final Diagnosis: Superior mesenteric vein syndrome Symptoms: Epigastric pain Medication: — Clinical Procedure: Laparoscopic duodenojejunostomy Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Duodenal compression between the superior mesenteric vessels and aorta or its branches is a rare disease in which the angle between the superior mesenteric vessels and aorta becomes acute, resulting in duodenal obstruction. Reduction in retroperitoneal fat due to several debilitating conditions is considered to be the cause of the decreased angle between the 2 vessels. Nutcracker phenomenon is the asymptomatic compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. Case Report: We report the case of a 33-year-old man who presented with postprandial abdominal pain, mainly at the epigastric region, colicky in nature, without radiation, accompanied by nausea, postprandial vomiting, and loss of weight. Computed tomography (CT) of the abdomen showed duodenal compression between the SMV and the right common iliac artery, which has never been reported before. Laparoscopic duodenojejunostomy was performed. Conclusions: Vascular compression of the duodenum presents with manifestations of proximal small bowel obstruction, which may have chronic, intermittent, or acute symptoms. Diagnosis is difficult due to the lack of knowledge of this rare disorder. Most of these symptoms can be present in other diseases, and symptoms sometimes do not correspond with imaging findings. Therefore, for a better outcome, the clinician should have a high index of suspicion and should be able to exclude other causes with similar manifestations.

Choledochal cysts are congenital dilations of the biliary tree. Complete cyst excision and biliary-enteric reconstruction have been the standard operations. In our center, more than 95% of choledochal cyst excision is now performed laparoscopically. Majority of current studies describe laparoscopic-assisted reconstruction using Roux-en-Y hepaticojejunostomy (HJ). However, only a few have studied laparoscopic hepaticoduodenostomy (HD) as an alternative method of biliary-enteric reconstruction. In this study, we focused on comparing longer-term outcomes between laparoscopic HJ and HD reconstruction following choledochal cyst excision. We performed retrospective analysis of 54 children who had undergone laparoscopic choledochal cyst excision and biliary-enteric reconstruction between October 2004 and April 2018. Short-term outcomes including operative time, complications such as anastomotic leakage and bleeding, and hospital stays were included. Long-term outcomes including contrast reflux into biliary tree, cholangitis, anastomotic strictures, and need of reoperation were analyzed. Of the 54 patients, 21 of them underwent laparoscopic HD and 33 underwent laparoscopic Roux-en-Y HJ anastomosis reconstruction. There were no significant differences in gestation, gender, age at operation, antenatal diagnosis, and Todani type of choledochal cyst between HD and HJ group. Operative time was significantly shortened in HD group (p = 0.001). Median time to enteral feeding was 3 days in both groups. Median intensive care unit (p = 0.001) and hospital stay (p = 0.019) were significantly shorter in HD group. There was no perioperative mortality. There was no significant difference in anastomotic leakage requiring reoperation (p = 0.743). There were no significant differences in long-term outcomes including anastomotic stricture (p = 0.097), cholangitis (p = 0.061), symptoms of recurrent abdominal pain or gastritis (p = 0.071), or need of reoperation (p = 0.326). All patients had normal postoperative serum bilirubin level. Laparoscopic excision of choledochal cyst with HD reconstruction is safe and feasible with better short-term outcomes and comparable long-term outcomes compared to Roux-en-Y HJ reconstruction.

Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004–2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52–54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.

Background Cholecystoduodenostomy is a surgical procedure that bypasses the extrahepatic biliary tree and connects the gallbladder directly to the duodenum. This case describes the successful use of this procedure in a novel situation. Case presentation A premature (34 weeks gestation) female infant with cystic fibrosis required a laparotomy on day 1 of life due to an intrauterine small bowel perforation. Resection of small bowel and ileostomy formation resulted in short gut syndrome, with 82 cm residual small bowel and intact ileocaecal valve. Post-ileostomy reversal at 2 months old, she developed conjugated hyperbilirubinaemia. Despite conservative management including increased enteral feeding, ursodeoxycholic acid, cholecystostomy drain insertion and flushes, her cholestatic jaundice persisted. A liver biopsy revealed an “obstructive/cholestatic” picture with fibrosis. To avoid further shortening her gut with an hepatoportoenterostomy, cholecystoduodenostomy was performed at 3 months of age with subsequent post-operative improvement and eventual normalisation of her clinical jaundice and liver biochemistry. Conclusions This is the first reported case of a cholecystoduodenostomy being used successfully to treat an infant with persistent conjugated hyperbilirubinemia, cystic fibrosis and short gut syndrome. Cholecystoduodenostomy is a treatment option that with further study, may be considered for obstruction of the common bile duct in patients with short gut and/or where a shorter operating time with minimal intervention is preferred.

A rare case of complex heart malformatrion with right isomerism in a full-term baby boy which was the first case published in Indonesia is reported. The patient was initially managed as a healthy baby, but on the 20th hours after delivery he repeatedly vomitted, and from the rontgenographic finding diagnosis at that time was duodenal atresia. During the duodenostomy operation the surgeon noticed that the spleen was absent. Cyanosis appeared after operation. Techocardiography and electrocardiography was done immediately, which showed complex cyanotic congenital heart disease. Diagnosis complex cyanotic congenital heart disease with right isomerism then was suspected. Unfortunately the baby died on the 12th day of admission. 1be cause of death was sepsis and anoxia because of complex cyanotic congenital heart disease. Autopsy findings confirmed the diagnosis of right isomerism (bilateral trilobes lung, bilateral right atrial appendages).

BACKGROUND The presence of hepatic parenchyma at ectopic locations is infrequently reported in neonatal age. Case details: A male neonate presented with clinical signs and symptoms of duodenal obstruction. At exploration, an annular pancreas was found as the causative factor and he underwent a Kimura's duodeno-duodenostomy. A pedicled cyst was attached to the stomach's greater curvature, was excised, and histologically was a mesothelial-lined cyst with ectopic liver, complete with bile ducts, in the cyst wall. Conclusion: Ectopic liver tissue may be clinically silent and found within the wall of a mesothelial cyst. Long-term complications of this ectopic tissue are not known.

Laparoscopic cholecystectomy is the routine method to treat gallbladder polyps. Nowadays, endoscopic ultrasound (EUS)-guided cholecystostomy as a bridge for per-oral transmural endoscopic resection of gallbladder polyps is introduced because preservation of gallbladder is increasingly getting attention. The aim of our study was to evaluate the approach in the treatment of patients with gallbladder polyps and symptomatic gallstones. EUS-guided cholecystostomy with the placement of a lumen-apposing metal stent (LAMS) was performed for those patients with accompanying gallbladder polyps and symptomatic gallstones. Several days after the cholecystostomy with LAMS, a gastroscope was introduced into the gallbladder to remove gallbladder polyps. All patients were successfully performed with the procedures of EUS-guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 1) and endoscopic resection of gallbladder polyps. One patient experienced severe peritonitis. During the follow-up at 3 months, 1 patient was performed with laparoscopic cholecystectomy because ultrasonography examination showed the reappeared gallstones. No stone recurrence was found in other patients. During the follow-up of 3 to 15 months, no polyp recurrence was found in all the patients. The approach is novel for performing EUS-guided gallbladder fistulization, which can subsequently allow procedures of per-oral transmural endoscopic resection of gallbladder polyps to avoid cholecystectomy in the patients with gallbladder polyps and gallstones. However, further studies are needed before clinical recommendation because of the complications and stone recurrence.

Cases of isolated duodenal stenosis in the neonatal period are minimally reported in pediatric literature. Causes of small bowel obstruction such as duodenal atresia or malrotation with midgut volvulus have been well documented and are often diagnosed due to their acute clinical presentation. Duodenal stenosis, however, causes an incomplete intestinal obstruction with a more indolent and varying clinical presentation thus making it a diagnostic challenge. We present a neonate with a unique case of congenital duodenal stenosis. The neonate presented with poor weight gain and frequent "spit-ups" as per the mother at the initial newborn visit. The clinical presentation was masked as the patient was being fed infrequently and with concentrated formula. We postulate that this may be due to the fact that the mother was an adolescent and relatively inexperienced with newborn care. During the hospital course, the patient had recurrent episodes of emesis with notable electrolyte abnormalities including hypochloremia and metabolic alkalosis. Further investigation with an abdominal X-ray showed dilated loops of bowel. Pyloric stenosis was ruled out via abdominal ultrasound. An upper gastrointestinal (GI) series ultimately confirmed a diagnosis of duodenal stenosis and the infant underwent surgical repair with full recovery. Congenital duodenal stenosis may have atypical presentations in neonates requiring pediatricians to have a high index of suspicion for diagnosis and to ensure timely therapy.

Superior mesenteric artery (SMA) syndrome is a rare reason of small bowel obstruction (SBO). İt is a complicated sickness. We aim to analyze the diagnosis, clinical presentation, SMAS management and postoperative outcomes after laparoscopic duodenojejunostomy.A total of 19 patients who were diagnosed with SMAS and did not respond to the traditional treatment between January 2010 and November 2017 in Afyon Health Sciences University Hospital were included in the study.Their average age was 22.3 years (17-31 years). Number of males and females were 6 and 13, respectively. Clinical presentations of patients are as follow: 14 patients were referred to as postprandial distress syndrome, 3 were unexplained weight loss, and 2 were gastroesophageal reflux disease. Considering CT angiography findings, 14 patients had duodenal dilatation. The mean aortamesenteric angle was 10.6 mm. The mean of aorta-SMA distance was 5.1 mm. The mean hospital stay and follow-up times were 3.7 days and 40.2 months, respectively. No morbidity or mortality was found within patients. Preoperative, postoperative 6th month and postoperative 12th month CONUT scores were 9.1, 3.7, and 0.8, respectively.Laparoscopic duodenojejunostomy can be performed safely to the patients who do not benefit from conservative treatment.Aortamesenteric angle, Duodenojejunostomy, Weight loss.La sindrome dell’arteria mesenterica superiore (Superior mesenteric artery, SMA) rappresenta una rara causa di ostruzione dell’intestino tenue (small bowel obstruction, SBO). È una malattia complicata. Il nostro obiettivo è quello di analizzare la diagnosi, la presentazione clinica, la gestione della sindrome dell’arteria mesenterica superiore e degli esiti postoperatori dopo duodenodigiunostomia laparoscopica. Sono stati studiati 19 pazienti a cui è stata diagnosticata la sindrome dell’arteria mesenterica superiore tra gennaio 2010 e novembre 2017 presso l’ospedale universitario Afyon Health Sciences e che non hanno risposto al trattamento tradizionale. La loro età media era di 22,3 anni (17-31 anni): 6 uomini e 13 donne. Alla presentazione clinica 14 pazienti lamentavano una sindrome da sofferenza postprandiale, 3 una inspiegabile perdita di peso e 2 una GERD. 14 pazienti presentavano una dilatazione duodenale all’angio- Tac. L’angolo aorto-mesenterico era in media di 10,6 mm. La media della distanza tra l’aorta e la SMA era di 5,1 mm. I tempi medi di degenza e di follow-up sono stati rispettivamente di 3,7 giorni e 40,2 mesi. Non è stata riscontrata morbilità o mortalità nei pazienti. I punteggi CONUT riguardanti il 6° mese preoperatorio e il 6° e 12° mese postoperatorio erano rispettivamente di: 9,1; 3,7 e 0,8. Dall’esperienza si conclude che la duodenodigiunostomia laparoscopica può essere eseguita in modo sicuro per i pazienti che non beneficiano del trattamento conservativo.

We report a case of a patient who presented with biliary colic while in Tijuana, Mexico. Laparoscopic cholecystectomy was attempted but abandoned and only a biopsy of the gallbladder was performed with pathologist reporting gallbladder adenocarcinoma. Upon return to the United States, extensive evaluation was undertaken including imaging, biopsy, and ultimately two separate exploratory surgeries revealing no neoplasm. Only at the second surgical exploration did we discover a benign cholecystoduodenal fistula successfully treated with completion fenestration cholecystectomy, pyloric exclusion, loop gastrojejunostomy, and duodenostomy tube through the gallbladder remnant into the fistula itself. This is a unique surgical treatment of a rare problem made even more confusing by an erroneous pathology report from another country.