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The management of colorectal liver metastasis (CRLM) is complicated and benefits from a multidisciplinary team approach. Liver-directed therapy has been emerging as a modality for better progression-free control. In its early years, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) was confined as an end-of-line therapy. However, literature has supported other roles including: a first-line treatment for CRLM alone or in combination with systemic chemotherapy; an adjunct to second or third-line chemotherapy; and a salvage treatment for chemo-refractory disease. Although future liver remnant (FLR) hypertrophy may take 3–12 months, the SIRT effect on loco-regional disease control has rendered it to be a useful tool in some pathologies with certain strategic goals. This paper reviews the use of SIRT with Y-90 in a surgical treatment pathway. This includes: (I) an element of multidisciplinary treatment of low-volume CRLMs, (II) convert an R1 to R0 resection by sterilizing the margins of tumor near critical structures, and (III) radiation lobectomy to induce contralateral hypertrophy in order to aid in a safer resection. There are many opportunities to validate the role of SIRT as a first-line therapy along with surgical resection including an umbrella clinical trial design.

Signet-ring cell gastric cancer (SRGC) is a histological variant of gastric adenocarcinoma (GAC) with a worse prognosis compared to non-signet-ring cell gastric cancer (NSRGC). To our knowledge, the overall survival (OS) among patients with SRGC undergoing total/near-total (TG) versus partial gastrectomy (PG) has never been reported from a large-scale Western database.We performed a retrospective analysis of patients with both SRGC and NSRGC using The National Cancer Database.In total, 17,086 patients were included. Patients who underwent TG versus PG were 25.5% (n = 770) versus 74.5% (n = 2246) for SRGC, and 20.9% (n = 2943) versus 79.1% (n = 11,127) for NSRGC, respectively. Patients who had SRGC were more likely to undergo TG (25.5% versus 20.9% P0.0001). Patients with distal gastric tumors were less likely to undergo TG (16.5% versus 25.4% P0.0001). Patients undergoing PG for the SRGC histological variant had better OS (HR = 0.68, CI=0.61-0.76; P0.0001) versus those who underwent TG. Similarly, NSRGC patients undergoing PG also had improved OS, but to a lesser extent (HR = 0.91, CI = 0.85-0.96; P= 0.002). Overall, PG for GAC was associated with improved OS compared to TG, although the OS benefit is more profound in the SRGC histological variant (P0.0001).Our results show that TG is not associated with improved OS in patients who undergo gastrectomy for GAC, even when adjusted for tumor location. The survival differences are more pronounced in the SRGC histology variant. The worst survival is observed in patients with SRGC who undergo TG after adjusting for different covariates.

Background: Ampullary carcinoma is rare with a more favourable prognosis compared to pancreatic ductal adenocarcinoma. The role of histological classification, including pancreatobiliary (PB) and intestinal (INT), on survival and recurrence outcomes in ampullary cancer is still debatable. Methods: 42 patients were identified between 1996-2010. Results: Nineteen classic pancreatoduodenectomies (PD) and 23 pylorus-preserving PDs were performed. Pathological review revealed 23, 18 and 1 patients with the PB, INT and mixed histology, respectively. Adjuvant chemoradiation (ACRT), chemotherapy, and radiation were given to 14 (33.3%), 4 (9.5%) and 2 (4.8%) patients, respectively. Recurrence-free survival (RFS) and overall survival (OS) from time of surgery were higher in the PB histological variant compared to INT (p=0.005 and 0.012, respectively). A landmark (LM) analysis found higher survival in the PB variant patients compared to INT (RFS p=0.023; OS p=0.048). There was no difference in RFS between both histological variants for patients who underwent surgery alone (p=0.42). However, the PB had higher RFS compared to the INT histology for patients who underwent ACRT (p=0.008). Conclusion: Ampullary carcinoma with PB histological variant was associated with significant survival benefit. The PB versus INT survival benefit was seen in the setting of ACRT, but not with surgery alone.

The lymph node yield (LNY) and lymph node ratio (LNR) of nodal metastases following pancreatoduodenectomy (PD) have been reported as prognostic parameters in patients with pancreatic ductal adenocarcinoma (PDAC). However, they have not been compared in the setting of various neoadjuvant therapy modalities.A single institutional retrospective study identified 134 patients diagnosed with resectable, BLR- and LA-PDAC who underwent PD at Fox Chase Cancer Center between 2010 and 2019. Patients were categorized based on first-line treatment as follows: surgery first (SF), total neoadjuvant therapy (TNT), and single modality neoadjuvant therapy (SMNT). The histopathological reports of the surgical specimens were examined to obtain LNY and determine the counts of lymph nodes with metastases. Subsequently, LNR was calculated as the number of positive lymph nodes divided by the number of lymph nodes examined.Overall, 49, 38, 27, 12, and 8 patients underwent SF approach, SMNT, incomplete TNT, induction TNT, and consolidation TNT, respectively. There was no difference in R0 resection and vascular resection between the groups (P = 0.096 and 0.794, respectively). The median counts of LNY were 22, 15, 21, 11.5, and 10, respectively (P 0.001). The average LNR was 0.16, 0.07, 0.03, 0.02, and 0.02, respectively (P 0.001). There were statistically significant differences in overall survival in the TNT groups (log-rank test P = 0.030).PDAC patients who undergo the TNT modality exhibit lower LNY and improved LNR compared with the SF approach and SMNT neoadjuvant therapy groups. This is likely explained by the increased treatment response and lymph node obliteration associated with the TNT approach. Our results question the minimal requirement of 11-18 harvested lymph nodes for PD following TNT.

The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease. A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021. Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable. The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials.

Pancreatic adenocarcinoma remains one of the deadliest malignancies affecting the older population. We are experiencing a paradigm shift in the treatment of pancreatic cancer in the era of coronavirus disease 2019 (COVID-19) pandemic. Utilizing neoadjuvant treatment and further conducting a safe surgery while protecting patients in a controlled environment can improve oncological outcomes. On the other hand, an optimal oncologic procedure performed in a hazardous setting could shorten patient survival if recovery is complicated by COVID-19 infection. We believe that oncological treatment protocols must adapt to this new health threat, and pancreatic cancer is not unique in this regard. Although survival may not be as optimistic as most other malignancies, as caregivers and researchers, we are committed to innovating and reshaping the treatment algorithms to minimize morbidity and maximize survival as caregivers and researchers.

The literature lacks large-scale population studies comparing survival outcomes between signet-ring cell gastric carcinoma (SRGC) and non-SRGC (NSRGC) when treatment is delivered at academic versus community cancer centers. The National Cancer Database (NCDB) from 2004 to 2016 was queried to examine the association between treatment facility category and overall survival of patients who underwent gastrectomy for resectable gastric adenocarcinoma (GAC). The study investigated 22,871 patients. Upstaging of resectable GAC to pathologic stage 4 was more evident at community centers (3.5%) than at academic centers (2.8%) for the NSRGC variant (p = 0.211), whereas it was comparable between the two facility categories for the SRGC variant (5.9% vs 6%, respectively). Patients with pathologic stage 1 or 3 NSRGC who underwent gastrectomy at academic programs had better overall survival (OS) (hazard ratio [HR], 0.68; p

Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract. Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD. All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26–147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4–13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42–138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9–16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention. PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract.

Familial adenomatous polyposis affects primarily the colon but can also involve other locations within the gastrointestinal tract, including the duodenum. The aim of this study was to describe a single center experience with pancreas-sparing duodenectomy for familial adenomatous polyposis and to compare outcomes with pancreatoduodenectomy performed for duodenal polyp disease.A retrospective review of a prospectively maintained database identified patients who had undergone pancreas-sparing duodenectomy during the period 2001 to 2016. This population was matched 1:1 with a cohort of patients undergoing pancreatoduodenectomy for duodenal adenomas, both sporadic and familial, during the same time period. Baseline demographics and perioperative (short- and long-term) outcomes were compared.A total of 88 patients were included; 44 in each group. The pancreas-sparing duodenectomy cohort was younger (52.6 vs 64.3 years; P.001) and more patients had undergone prior colectomy (100% vs 32%; P.001) or additional prior abdominal surgery (27% vs 9% (P.001). Median operative times were greater for pancreatoduodenectomy (391 vs 460 min; P = .002). There was no difference in any of the early postoperative complications. There was 1 30-day mortality in the pancreatoduodenectomy group secondary to aspiration. Late acute pancreatitis was more common after pancreas-sparing duodenectomy (16% vs 0%; P = .012) and exocrine pancreatic insufficiency was more common after pancreatoduodenectomy (30% vs 11%; P = .034).Pancreas-sparing duodenectomy is a reasonable option for duodenal cancer prophylaxis in familial adenomatous polyposis with high-risk features. The perioperative safety profile is comparable to pancreatoduodenectomy done for similar indications, and pancreas-sparing duodenectomy has a favorable long-term with a lesser incidence of exocrine impairment.

Western literature lacks large-scale population studies comparing the influence of academic and high-volume (HV) versus low-volume (LV) cancer centers on gastric cancer oncologic outcomes.The National Cancer Database from 2004 to 2016 was used.22871 patients were studied. Patients with stage III signet-ring cell gastric carcinoma (SRGC) received neoadjuvant treatment (NAT) more frequently at academic and HV comprehensive cancer centers (OR: 4.27 and 2.42; p 0.0001 and 0.009) compared to community centers. Patients with stage III non-SRGC (NSRGC) had a 2.4 times higher odds of receiving NAT at academic centers. The R1 resection rate for NSRGC was lower at academic centers (OR: 0.67; p = 0.0018). Lymph node harvest ≥15 nodes was 1.6 and 1.9 times higher at academic centers for NSRGC and SRGC, respectively. Patients treated at academic centers had a significantly improved overall survival (OS).Treatment at academic centers is associated with significant improvements in oncologic metrics and OS.

The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease.A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021.Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable.The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials.

The literature lacks large-scale population studies comparing survival outcomes between signet-ring cell gastric carcinoma (SRGC) and non-SRGC (NSRGC) when treatment is delivered at academic versus community cancer centers.The National Cancer Database (NCDB) from 2004 to 2016 was queried to examine the association between treatment facility category and overall survival of patients who underwent gastrectomy for resectable gastric adenocarcinoma (GAC).The study investigated 22,871 patients. Upstaging of resectable GAC to pathologic stage 4 was more evident at community centers (3.5%) than at academic centers (2.8%) for the NSRGC variant (p = 0.211), whereas it was comparable between the two facility categories for the SRGC variant (5.9% vs 6%, respectively). Patients with pathologic stage 1 or 3 NSRGC who underwent gastrectomy at academic programs had better overall survival (OS) (hazard ratio [HR], 0.68; p 0.0001) than those who underwent gastrectomy at community centers (HR, 0.79; p 0.0065). Similarly, patients with stage 2 SRGC had better OS when treated at academic versus community centers (HR, 0.54; p = 0.0019). No statistically significant improvement in OS was observed between patients with stage 2 NSRGC (HR, 0.84; p = 0.083) and those with stage 3 SRGC (HR, 0.78; p = 0.054) who were treated at academic centers. No survival benefit was demonstrated for stage 1 SRGC when academic and community centers were compared (p = 0.56).This is the first study based on a large-scale database in the Western population that addressed the overall survival-by-stage of two distinct GAC histologic variants. Treatment at academic centers was associated with significant improvements in OS.

Background Adenosquamous carcinoma (ASC) of the pancreas is a rare form of malignancy with a poor prognosis. We herein report our case series with review of the contemporary literature. Methods With institutional review board approval, we identified 23 patients with pancreatic ASC. Results ASC was more common in women (61%), with a median age of 73 y at presentation. The tumor was in the head of the pancreas in 65% of cases. Six cases (26%) had resectable disease, three (13%) were borderline resectable, and eight (34.7%) were locally advanced or metastatic. First-line treatment included pancreatic resection in eight cases (34.8%), concurrent neoadjuvant chemoradiation in three (13%), and neoadjuvant chemotherapy in two (8.7%). Most resected tumors had pathological T3 stage (80%). Pathological nodal disease was demonstrated in 60%, and margins were positive in three cases. Complete pathological response was not observed, although fibrosis presented in only one case (10%). Eventually, twenty patients developed metastatic disease. Overall survival is 11.5 [95% confidence interval 6, 14.5] months. Conclusions ASC demonstrates a more aggressive malignant phenotype and carries a worse prognosis. Oncological resection is the mainstay of treatment. Neoadjuvant chemoradiation is an emerging approach in the management of ASC that has been extrapolated from the adenocarcinoma neoadjuvant trials.

Background Hereditary diffuse gastric cancer is associated with E-cadherin (CDH1) germline mutations. The implications of CDH1 mutations detected with multigene panels in those without family history of HDGC are uncertain. Methods A registry of patients who underwent genetic counseling for CDH1 mutation was queried for the period 2011–2017. Results Twenty-one patients with CDH1 mutation were identified. The most common indication for CDH1 genetic screening was family history of hereditary diffuse gastric cancer (known risk) in 10 patients (48%); 11 patients (52%), however, were diagnosed by multigene cancer panels (unknown risk). Nine of the 21 patients underwent total gastrectomy, and 5 others had metastatic gastric cancer at presentation. In the gastrectomy group, 5 of the 9 patients (56%) were known to have gastric cancer based on preoperative screening endoscopy, but final pathologic examinations indicated diffuse gastric cancer in 8 of the 9 patients. The 11 patients with unknown risk for CDH1 mutation tended to be older (median 41 vs 24 years) and more likely to have metastatic disease and to die of the disease (43% vs 29%) compared with patients with family history of hereditary diffuse gastric cancer. Conclusion CDH1 mutation–associated hereditary diffuse gastric cancer is a biologically aggressive variant of gastric cancer that appears to behave similarly in patients detected only by multigene panels. The detection of CDH1 mutation at a minimum warrants genetic counseling and preferably total gastrectomy.

Background Duodenal cancer is the second most common cause of cancer death in familial adenomatous polyposis (FAP) patients. In this study, we compare oncologic outcomes between sporadic and FAP-associated duodenal cancer. Methods In this retrospective study, all patients who underwent surgeries between 2000 and 2014 for either sporadic or FAP duodenal cancer were identified. The patients were grouped based on diagnoses and perioperative and survival outcomes were compared. Results A total of 56 patients with duodenal cancer (43 sporadic, 13 FAP) who underwent surgery were identified. Pancreatoduodenectomy (PD) was the most common procedure performed. The overall median survival was 7.5 years (1 year: 92%; 5 years: 58.1%). FAP patients had earlier tumor, node, and metastasis stage, less margin involvement, less perineural, and angiolymphatic invasion but had a comparable survival to sporadic patients. The median survival for FAP duodenal cancer was 7.4 vs 9.6 years for sporadic (P = .97) with similar utilization of adjuvant chemotherapy. Although not statistically significant, PD had an improved median survival compared to segmental duodenal resection (SDR) (9.6 years for PD vs 3.6 years for SDR, P = .17). Non-periampullary location and presence of positive lymph nodes were significant predictors of mortality on multivariate analysis. Conclusions FAP duodenal cancer has no survival advantage compared to sporadic duodenal cancer despite an improved stage of resection with extraampullary lesions having a worse survival.

Diffuse gastric cancer (DGC) is a distinct histopathologic and molecular disease, characterized by mutations in CDH1, RHOA, and others. In addition, DGC is associated with familial syndromes, including hereditary DGC and germline mutation in CDH1. Clinically, this subtype of gastric adenocarcinoma is associated with a poor prognosis and possible resistance to available systemic therapies. An understanding of the genetic and molecular underpinnings of DGC may help inform of its clinical behavior and aid in screening, diagnosis, and response to treatment. In this review, we will review the current histologic, molecular, and genetic landscape of DGC and its relevance to clinical practice.

We report a case of a 56-year-old woman who presented with worsening abdominal pain located in the left upper quadrant together with abdominal distention, nausea and anorexia. One month prior to this admission, she had presented and had been diagnosed with concurrent acute pancreatitis and rapidly expanding abdominal aortic aneurysm. The aneurysm was prioritised over the pancreatitis and she underwent uncomplicated endovascular repair. Cross-sectional imaging was consistent with infected pancreatic necrosis and also revealed a large collection located in the anterior pararenal space with extensive gas formation. An image-guided fluid aspiration revealed Clostridium perfringens as the causative organism. She was treated by placement of large bore drains along with irrigation and targeted intravenous antibiotic for 6 weeks. The collections resolved completely and at 6 months follow-up she was well and symptom free.

Background To review our experience in patients undergoing operative treatment for duodenal polypoisis associated with familial adenomatous polyposis with an emphasis on operative approach and long-term outcomes. Methods Duodenal polypoisis associated with familial adenomatous polyposis patients undergoing operative treatment were studied retrospectively excluding patients with preoperative duodenal cancer. Results Of 767 patients in the database, 63 (8.2%) patients underwent operative treatment: 42 (67%) pancreas-sparing duodenectomy, 15 (24%) pancreatoduodenectomy, and 6 (9.5%) segmental duodenal resection; the majority for Spigelman stages III and IV polyposis. Overall 9.6% had adenocarcinoma postoperatively (28.6% in the pancreatoduodenectomy group; P = .01). The proportion of Spigelman stages III and IV with cancer were 9.5% and 6.5%, respectively. Pathologic upgrade to cancer in patients with low grade dysplasia and high-grade dysplasia on preoperative biopsy was 5.7% and 6.7%, respectively (P = .13). At a median follow-up of 16 years, 7.7% needed a second duodenal polypoisis associated with familial adenomatous polyposis-related operation. Progression to high grade dysplasia or cancer in the stomach occurred in 15.4% of patients. Median overall survival and recurrence-free survival was at least 16 years and 15.6 years. No significant group-based differences were noted on follow-up. Conclusion The majority of patients with duodenal polypoisis associated with familial adenomatous polyposis can achieve long-term, cancer-free survival with organ-preserving approaches (pancreas-sparing-duodenectomy and segmental-duodenal-resection) with survival not dependent on the type of resection.

Introduction. Kaposi’s sarcoma (KS) usually manifests as a cutaneous disease but GI manifestation is often rare. It is associated with human herpes virus-8 (HHV-8) and seen in immunocompromised patients. In the USA, use of highly active antiretroviral therapy (HAART) has drastically reduced incidence of KS in HIV patients. Case Presentation. A 65-year-old male with human immunodeficiency virus (HIV) was admitted to the intensive care unit (ICU) with cardiopulmonary arrest secondary to hyperkalemia of 7.5 meq/L. Following placement of orogastric and endotracheal tube (ETT), a significant amount of blood was noticed in the ETT. Hemoglobin trended down from 9.6 mg/dL to 6.7 mg/dL over five days. Stool guaiac was positive. Esophagogastroduodenoscopy (EGD) was performed and revealed multiple large hypervascularized violaceous submucosal nodular lesions with stigmata of bleeding seen on the soft palate and pharynx and within the cricopharyngeal area close to the vocal cords. Biopsy of the soft palate lesions showed proliferation of neoplastic spindle shaped cells arranged in bundles with slit-like capillary spaces containing erythrocytes consistent with Kaposi’s sarcoma. Biopsy was positive for HHV-8. Colonoscopy was unremarkable. There were no cutaneous manifestations of the disease. Conclusion. GI involvement of Kaposi’s sarcoma must be considered in immunocompromised patients and can be confirmed by endoscopic methods.

Background The risks from super obesity (SO) following cholecystectomy have not been studied. Methods NSQIP analysis of patients undergoing cholecystectomy from 2005 to 2011. Non-obese (NO) patients (BMI 18.5–30) were matched 1:1 by age, sex, race and comorbidities to morbidly obese (MO) (BMI 35–50), and separately to SO (BMI≥50) individuals. Clavien 4 complications and 30-day mortality were compared. Results 13780 MO and 1410 SO patients were matched to NO patients. Obese patients were more likely to present with chronic (CC) rather than acute cholecystitis (AC). Compared to NO patients, Clavien 4 complications were significantly increased among SO patients overall especially with AC where rate of open surgery was significantly higher. Conclusion SO patients have an increased risk of serious morbidity after cholecystectomy especially with AC where rate of open surgery remains high. Aggressive recommendation for cholecystectomy to reduce presentation with AC and increase likelihood for laparoscopic surgery may be beneficial in SO patients.

Drug-induced acute pancreatitis (DIP) is uncommon and may account for 2%-5% of cases, although the incidence may be increasing nowadays. DIP has been documented for more than 160 drugs in the literature. The most common nonsteroidal anti-inflammatory drugs (NSAIDs) that have been reported to cause pancreatitis are sulindac and salicylates. In this report, we present a case of probable ibuprofen-induced pancreatitis. A 60-year-old white woman presented with the sudden onset of mild acute pancreatitis (AP) 5 hours following the ingestion of 6 tablets of ibuprofen (Advil) 200 mg (equivalent to 20.4 mg/kg). She denied any history of alcohol abuse, tobacco smoking, or any other medication use. She has no history of gallstones, choledocholithiasis, abdominal trauma, or hypertriglyceridemia. Laboratory workup revealed elevated amylase and lipase levels more than 3 times the normal limits with complete resolution within 15 hours. Computed tomography scan of abdomen and pelvis and endoscopic ultrasound of the pancreaticobiliary system were within the normal limits. Ibuprofen-induced mild DIP was the most probable diagnosis. She was discharged on her second day of hospitalization with significant improvement in her symptoms. Physicians need to be aware that DIP may occur in patients taking NSAIDs, including ibuprofen. Therefore, all patients with AP of an unknown etiology should be carefully questioned about the usage of NSAIDs, and all patients with idiopathic AP restarted on their medications should be closely monitored, and the drug must be immediately discontinued if symptoms recur.

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

Background Temporary or long-term nutritional support through gastrojejunal (GJ) feeding tubes is a safe and common means of enteral feeding in adults and children. It is indicated in patients with severe gastroesophageal reflux disease, gastric outlet obstruction, or severe gastric dysfunction or gastroparesis. Several techniques for GJ feeding tube placement have been reported. The most technically challenging part of GJ tube placement is the advancement and optimal positioning of the jejunal extension into the proximal jejunum. Methods A novel modified Seldinger technique was used for endoscopic placement of a percutaneous low-profile GJ tube (14 French). After gastric access was established, a dilator was advanced under endoscopic vision into the pylorus. Under fluoroscopy, a guidewire was threaded through the dilator into the duodenum. The dilator was then removed, and the GJ tube advanced over the guidewire. Results A total of 12 patients including 9 pediatric and 3 adult underwent the procedure with no complications. The main indication was gastroparesis with oral intolerance of food. The median operative time was 41.5 minutes. All patients tolerated jejunal tube feeding after surgery. Conclusion The modified Seldinger technique for percutaneous endoscopic GJ tube placement is a safe and efficient procedure in both children and adults. Further studies are necessary to prove its reproducibility in other centers and to compare it to other methods of PEGJ tube placement.

The aim of this study was to assess whether the lack of a radiological mass in patients with periampullary malignancies led to protracted diagnosis, delayed resection, and an inferior outcome. The departmental database was interrogated to identify all patients undergoing pancreatoduodenectomy during the period 2000–2014. The absence of a mass on cross-sectional and endoscopic ultrasound was noted. The interval between imaging and surgery was evaluated and related to the absence of a mass. The relationship between mass/no mass and the pathological profile was also assessed. Among 490 patients who underwent pancreatoduodenectomy for periampullary malignancies, masses were detected in 299 patients. Patients with undetected mass on either endoscopic ultrasonography (EUS) or computed tomography (CT)/magnetic resonance imaging (MRI) had a longer median interval from initial imaging to resection than detected mass with no difference in survival (66 vs. 41 days, p = 0.001). The absence of a mass was more common in cholangiocarcinomas (p

Caroli’s disease is a rare congenital condition characterized by non-obstructive dilatation of intrahepatic ducts. In Caroli’s syndrome, there is additionally an associated congenital hepatic fibrosis. With institutional review board approval, we identified all patients with Caroli’s disease and syndrome. Nine patients were identified, seven males and two females, with a median age of 40 years. Final pathological diagnoses included Caroli’s disease (n = 6) and Caroli’s syndrome (n = 3). Patients presented with deranged liver function, cholangitis, cholangiocarcinoma, abdominal pain, cirrhosis, or were diagnosed incidentally. Four patients underwent resection and two underwent liver transplantation. Of the resection group, two patients subsequently underwent transplantation for recurrent cholangitis due to anastomotic stricture in one patient and for end-stage liver disease in the other. All patients with Caroli’s syndrome underwent liver transplantation. Three patients died during follow-up at 26.2, 7.8, and 3 months post-diagnosis with recurrence of cholangiocarcinoma, liver failure, and metastatic cholangiocarcinoma, respectively. Six patients are alive with a median follow-up of 60 months since presentation (range = 10–134 months). Caroli’s disease and syndrome have a varied presentation. Most individuals with Caroli’s disease may be adequately treated by resection, but transplantation is required for Caroli’s syndrome patients due to the associated hepatic fibrosis.

High-grade dysplasia (HGD) of the cystic duct margin without evidence of concurrent malignancy is a rare occurrence. We present a case of a 36-year-old woman who developed gallstone pancreatitis and subsequently underwent a laparoscopic cholecystectomy. On histopathology, she was found to have HGD at the cystic duct margin. Following evaluation, she underwent excision of the cystic duct remnant with no malignancy being present on final pathology. We present this case to discuss the management of cystic duct dysplasia in the absence of gallbladder malignancy.

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

Background and Objectives: Evidence is increasing that single-port or single-incision laparoscopic cholecystectomy is a safe and feasible alternative for cholecystectomy in children. In this study, we sought to compare the single-port hybrid technique, which we originally reported in 2012, with the conventional 4-port approach, in regards of complications, outcome, operative time and cost. Methods: A retrospective, single-center comparison of hybrid single-port versus conventional 4-port laparoscopic cholecystectomy was performed in 98 consecutive pediatric patients between January 2010 and October 2014. Patient characteristics, intra- and postoperative outcomes, operative costs, and total hospitalization costs were compared between the 2 approaches using univariate and multivariate analyses. Results: The single-port technique was utilized in 56 (57%) pediatric patients who underwent laparoscopic cholecystectomy. The operative time for single-port procedures was shorter than that of the conventional technique (median, 85 minutes vs 114 minutes; P = .003). Patients with single-port procedures were less likely to have a cholangiogram compared to patients who underwent 4-port cholecystectomy. (9% vs 40%; P < .001). No statistically significant differences between the 2 cohorts were observed for intra- or postoperative outcomes. Although the 2 groups shared nearly the same median duration of hospitalization (22 hours vs 21 hours; P = .70), the single-port group demonstrated a lower total cost of hospitalization (median cost, $7438 vs $8783; P = .030) and lower operative cost (median, $3918 vs $4647; P < .001). Conclusion: Hybrid single-port laparoscopic cholecystectomy in children with uncomplicated gallbladder disease is feasible and equally safe, with similar intra- and postoperative outcomes compared with the conventional 4-port approach. It can contribute to global cost reduction because of lower operative and total hospitalization costs.

Rationale: Confocal laser endomicroscopy (CLE) is a novel imaging technique routinely used in endoscopic examinations in the area of gastroenterology and pulmonology for in vivo real time microscopic characterization of the mucosa. The same technique would be helpful during laparoscopic surgery for both real time detection of peritoneal carcinomatosis and real time evaluation of surgical margins. Objective: To evaluate the feasibility and safety of an innovative confocal endomicroscopic device dedicated to the in vivo imaging of tissue for surgical applications during laparoscopic surgery for digestive cancer. Methods: Real time images were obtained as the result of: (a) a robotized confocal mini-probe with a bending distal tip providing access and imaging of peritoneal nodules or a confocal mini-probe including a 19G needle for needle-based CLE (nCLE); (b) a dual wavelength endomicroscopy system that allowed imaging at 2 different wavelengths in the near infrared: 640nm and 785nm (ICG was applied interstitially for lymph nodes staining (1.25 mg/ml) and topically for surface staining (0.25 mg/ml); (c) an audio-visual datalink between the surgeon and the pathologist enabling both real-time transmission of macroscopic andmicroscopic information and interpretation of "optical biopsies". Results: nCLE and pCLE were successfully performed and endomicroscopic images were obtained on the peritoneum (including normal and fibrous nodules), on the liver and in 2 lymph nodes. No adverse event was reported. The robotized miniprobe enabled easy manipulation by the surgeon and stable images improving image quality. The audio-visual connection between the OR and the pathologist room enabled an efficient real-time information sharing. Conclusion: These preliminary results suggest a promising introduction of robotized CLE in laparoscopic surgery leading to a new way of collaboration between the surgeon and the pathologist.