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Superior mesenteric artery (SMA) syndrome is a rare condition resulting in small bowel obstruction. The third part of the duodenum becomes compressed because of the narrow angle between the aorta and the SMA. Those at risk of developing SMA syndrome include patients who develop rapid weight loss, malignancy, eating disorders, burns, trauma and substance abuse. We present a case of a 73-year-old man that presented 5 days post a total hip replacement with abdominal pain and profuse bilious vomiting for 2 days. A computed tomography scan of his abdomen showed gross distension of his stomach with an abrupt occlusion of the duodenum at the level of the SMA which was consistent with SMA syndrome. The patient was treated conservatively and was later discharged from surgical services once his symptoms resolved and he was able to tolerate diet.

Cyst of the canal of Nuck is a rare abnormality of the female inguinal canal that can present similarly to a hernia. If incompletely obliterated, the patent canal of Nuck may predispose to an inguinal hernia or hydrocele due to direct communication with the abdominal cavity. Such defects are normally detected and repaired in early childhood but can also present later in adult life. We report the case of a 44-year-old woman who presents with a fluctuant, mobile and irreducible left-sided groin mass. Ultrasound of the groin identified a cystic structure in the canal of Nuck. The patient underwent successful open herniorrhaphy with excision of the cyst and mesh repair of the inguinal canal. Subsequent histopathological examination also revealed concurrent endometriosis of the canal of Nuck. A systematic approach to differential diagnoses for a female groin mass, further investigations and management are discussed.

Ganglioneuromas are benign, fully differentiated mature tumours related to neuronal tissues and usually seen in the gastrointestinal tract, retroperitoneum and mediastinum. The few cases of appendiceal ganglioneuromas that were previously described in the literature belong to the paediatric population and were associated with genetic mutations and syndromes. We present a unique case of an Aboriginal Australian adult with acute appendicitis and concurrent ganglioneuroma diagnosed using histopathology and immunohistochemistry using Neu-N, S100 and Sox-10. The patient had no history of any of the syndromes associated with ganglioneuromatosis and had no other relevant family history.

Hiatus hernia is defined as a trans-diaphragmatic protrusion of the intra-abdominal contents through the oesophageal hiatus into the mediastinum. Surgical repair is indicated in symptomatic patients, with some patients presenting emergently with strangulation and ischaemia of hernial contents. In this situation, emergent decompression and surgical repair is indicated. Although it has been suggested previously that kyphoscoliosis may contribute to development and progression of hiatus hernia, there are no published reports of obstruction being caused by severe spinal deformity. A 67-year-old male patient with spina bifida and severe scoliosis who presented with an obstructed hiatus hernia is discussed here. Because of his obstruction, laparoscopic hiatus hernia repair and fundoplication was undertaken. The patient had an uncomplicated recovery following this. This case highlights the importance of providing definitive management to patients with difficult anatomy, which has caused their obstruction, as conservative management is unlikely to lead to an optimal outcome.

Mucinous cholangiocarcinoma is an extremely rare form of intrahepatic cholangiocarcinoma that has been characterized by rapid growth, widespread metastasis and poor prognosis. These tumors have been shown to be a part of the Lynch syndrome tumor spectrum, however, the role of DNA mismatch repair (MMR) deficiency in their development is poorly understood. We present the case of a 74-year-old male with cholangiocarcinoma, who underwent Roux-en-Y hepaticojejunostomy and extended left hepatectomy and was diagnosed with a primary small bowel adenocarcinoma 2 years later. Immunohistochemistry testing for mismatch repair proteins was significant for the loss of nuclear expression of PMS2. Taken together, the cause of both the mucinous cholangiocarcinoma and primary small bowel adenocarcinoma with PMS2 loss in the patient presented here is likely genetic, suggestive of a cancer syndrome.

Gastrointestinal duplication is a rare congenital condition that involves tissues anywhere along the alimentary tract. It may also be referred to as enteric duplication or alimentary tract duplication. It typically presents in children and is hardly found in adults because the presentation varies and the diagnosis is often incidental. Surgical resection is generally indicated to prevent future complications. We present a case of duplicated small bowel discovered during surgery in a young female with the initial diagnosis of small bowel intussusception on CT.

Morgagni hernias are a rare form of congenital diaphragmatic hernia, commonly found on cross-sectional imaging. Repair is generally performed electively for pulmonary or gastrointestinal symptoms. Our case presented acutely with gastric obstruction. Two months prior she had a small bowel obstruction and underwent computed tomography, diagnostic laparoscopy, lysis of adhesions and takedown of the falciform ligament, where a ‘groove’ to the left of the falciform was noted, but not repaired. We collected the presentation, technique, complications and results of 12 prior cases. A trans-abdominal, robotic-assisted tissue repair of the diaphragm with mesh reinforcement utilizing as few as three ports appears to be safe and effective. The robotic platform offers additional degrees of freedom, making retrosternal operating more ergonomic to the surgeon. The rapid progression of our patient suggests that repair at the time of discovery should be considered so that the serious complications can be avoided.

Dwarfism associated with splenomegaly during teenage years is known. The purpose of this report was to present the first case of dwarfism associated with wandering splenomegaly. A 14-year-old boy presented a wandering splenomegaly and torsion of the splenic pedicle associated with a retarded growth and sexual underdevelopment characterized by lack of sexual maturity and absence of secondary sexual physical appearance. The patient was submitted to detorsion of the spleen, and splenopexy. After the surgery, the patient grew up, and his sexual characteristics developed to normal. The size of the spleen reduced from the 22 × 16 × 13 cm to 14 × 12 × 10 cm after the surgical procedure. This is the first report of dwarfism associated with wandering splenomegaly, which was successfully treated without partial or total splenectomy. After releasing the venous blood flow, the spleen reduced its dimension and the patient grew up to the expected family size.

Cystic artery pseudoaneurysm is a rare complication of invasive biliary procedures or of acute or chronic cholecystitis and pancreatitis. Emphysematous cholecystitis is an acute inflammatory process of the gallbladder due to gas forming organisms such as Escherichia coli and Clostridium perfringens. We report the case of a 34-year-old gentleman admitted with a 3-day history of generalized abdominal pain, vomiting and markedly raised inflammatory markers. A computed tomography scan demonstrated acute calculus cholecystitis and an incidental CAP. This was successfully treated with an emergency laparoscopic cholecystectomy. CAPs are reported in the literature as rare and are usually diagnosed after rupture with severe haemorrhage. In this report, we highlight that a non-ruptured CAP identified preoperatively can be safely managed simultaneously with a laparoscopic approach, thus avoiding the need for invasive angiographic procedures or open surgery.

Haemorrhagic cholecystitis (HC) is a rare cause of cholecystitis that can be fatal if management is delayed. HC could present in the setting of trauma, malignancy and bleeding diathesis, such as renal failure, cirrhosis and anticoagulation. Its symptoms are easily confused with acute calculous or acalculous cholecystitis and might include haemobilia or hematemesis as blood drains from the gallbladder into the gastrointestinal tract. Imaging of HC can be misleading unless the possibility of this diagnosis is considered. In this report, we present an interesting case of HC in a patient with none of the above comorbidities and the patient who was not on anticoagulation neither anti platelets. The case includes relevant imaging and a review of the literature on this rare subject.

Rapunzel syndrome is a rare condition typically found in young female patients with mental or psychiatric disorders. It manifests as a large trichobezoar extending beyond the pylorus into the small intestine and leads to various adverse conditions. Early diagnosis and prompt management are crucial to avoiding complications. These bezoars are extracted endoscopically, laparoscopically and via open surgery (most common). In this current report, we discuss a successful laparoscopic extraction of a trichobezoar in a 12-year-old girl with acute abdominal pain due to small-bowel obstruction. We describe our technique compared with others’ techniques and include a literature review on this topic.

Gastric volvulus is a rare condition defined as an abnormal stomach rotation around its axis, which usually presents in children under a year or in adults in their fifth decade. Cases over 70-year-old are rare and only 30% of cases of this disease present with mesenteric-axial rotation of the stomach. In this article, we report a rare case of mesenteroaxial gastric volvulus associated with hiatal hernia, in an 88-year-old woman, who presented to the Emergency Department of our institution with bowel obstruction symptoms. The diagnosis could be difficult due to the rarity of the pathology, the patient's age outside the expected incidence age range and the less common mesenteroaxial presentation. This report highlights the importance of the differential diagnosis of gastric volvulus as a cause of intestinal obstruction.

With recent advances in the treatment of esophageal cancer and long-term survival after esophagectomy, the number of gastric tube cancer (GTC) has been increasing. Total gastric tube resection with lymph node dissection is considered to be a radical treatment, but it causes high post-operative morbidity and mortality. We report an elderly patient with co-morbidities who developed pyloric obstruction due to GTC after esophagectomy with retrosternal reconstruction. The patient was treated using distal partial gastric tube resection (PGTR) and Roux-en-Y reconstruction with preservation of the right gastroepiploic artery and right gastric artery. Intraoperative blood flow visualization using indocyanine green (ICG) fluorescence demonstrated an irregular demarcation line at the distal side of the preserved gastric tube, indicating a safe surgical margin to completely remove the ischemic area. PGTR with intraoperative ICG evaluation of blood supply in the preserved gastric tube is a safe and less-invasive surgical option in patients with poor physiological condition.

Instances of foreign bodies impacted in solid organs are rare, and rarer still are reports of objects in the spleen. A 42-year-old presented septic with abdominal pain, high inflammatory markers and haemodynamic instability. She was found to have a splenic haematoma and a 4-cm hyperdense foreign body within the spleen. Ultrasound-guided drainage of the haematoma isolated Streptococcus anginosus and conservative management with intravenous antibiotics avoided the need for emergency splenectomy. The bacterium isolated was the same cultured 9 months previously from the patient’s empyema fluid. The origin of the foreign body was not identified, though is made of metal and pre-dates any hospital admissions. The case raised the question of how an object might penetrate the spleen without knowledge of the patient and highlighted the risks of foreign body-associated sepsis, the risks and benefits of emergency splenectomy and management of complex cases with paucity of evidence.

Foreign body ingestions are commonly seen and are usually uneventful. Very rarely, ingested foreign bodies will cause perforation of the gastrointestinal tract, which can lead to peritonitis, abscesses or fistulation. This is the case of a patient with vague abdominal pain after voluntary ingestion of bleach and an ink pen. The ink pen was found lodged in the gastric antral wall on esophagogastroduodenoscopy. The foreign body spontaneously migrated into the gastric lumen and was successfully removed with endoscopy.

As medical diagnosis and treatment level improved, patients with ventriculoperitoneal shunt (VPS) live longer and may develop conditions that need laparoscopic surgery. The safety of laparoscopy in patients with VPS continues to be challenged due to pneumoperitoneum. Here, we report a patient with medical history of VPS and hemangioma, diagnosed with ovarian borderline mucinous cystadenoma, received laparoscopic surgery in supine position and 10 mmHg pneumoperitoneum pressure, in which no clamping or externalizing catheter, no perioperative or postoperative complications. We also present a literature review and discuss the precautions needing considering during laparoscopy. For patients with VPS, laparoscopic surgery can be recognized as a potentially safe and feasible procedure.

Gastric schwannomas are rare peripheral nerve sheath tumors which are usually found incidentally while undergoing workup for other conditions. Despite their benign nature, they require surgical resection with negative margins. It is important to differentiate gastric schwannomas from gastrointestinal stromal tumors prior to surgical excision, as this can alter the recommended surgical plan. This can be achieved with endoscopic ultrasound and fine needle aspiration with analysis of the sampled tissue using immunohistochemical stains. We present the case of a 68-year-old female patient with an incidental finding of a gastric fundus schwannoma. Laparoscopic gastric wedge resection was performed with complete excision of the tumor and negative margins. Pathology was confirmed with immunohistochemical stains positive for S-100 and negative for CD117 and DOG1. Post-operative recovery was uneventful without tumor recurrence.

Gastrointestinal stromal tumors (GISTs) are tumors arising from the fourth layer of the stomach. They are the most common form of mesenchymal neoplasms in the gastrointestinal tract. The diagnosis for the aforementioned tumors is made through endoscopic ultrasonography (EUS) with no further inspection through biopsies and aspirations. Regarding the fact that biopsies are not made in these cases, pathological misdiagnoses, however rare and effectless in the final outcome of the surgery, do occur. Here, we present a case of a 35-year-old male diagnosed with GIST through the means of EUS however, the post-op pathology report showed something very interesting. This patient was reported to be a case of perforated peptic ulcer and we found vegetable fiber component in the tissue of this patient. Bearing in mind the finding, misdiagnoses of GIST patients are probable, and careful planning prior to the surgery is recommended.

Bioelectronic medical approaches to control vagus nerve-to-organ signaling have the potential to treat cardiac, respiratory, gastrointestinal (GI) and metabolic diseases, such as obesity. Unlike cervical vagus nerve stimulation (VNS), abdominal VNS could provide specific therapeutic control of the GI tract without off-target effects on thoracic organs; however, surgical approaches for abdominal VNS electrode placement are not well established. Moreover, optimal device configurations and additional placement of GI recording electrodes for closed-loop control are largely unknown. We designed VNS cuff and GI planar serosal electrodes and tested placement of these devices in laparoscopic surgery in two cadavers. We determined that electrode positioning on the ventral abdominal vagus nerve and gastric antrum was feasible but other sites, such as the duodenum and proximal stomach, were more difficult. The current investigation can guide potential placement and design of VNS cuff and GI electrodes for development of closed-loop GI therapeutic devices.

The gastrointestinal stromal tumor (GIST) is the most common type of sarcomatous tumor of the gastrointestinal tract. Many GISTs appear as submucosal tumors with intraluminal protrusion. GISTs with malignant features have a high risk of postoperative recurrence or metastasis, usually to the liver or peritoneum. We present a case of gastric GIST with double rarities: arising completely extraluminally with a pedicle and postoperative metastasis to the pancreas. A woman in her seventies diagnosed with a large extraluminal gastric GIST underwent complete removal of the tumor. Nine months later, a solitary metastatic tumor in the pancreas was detected. Imatinib controlled metastasis well for four years before the tumor became resistant. The patient then had a partial pancreatectomy with splenectomy. She is currently free from recurrence. We genetically analyzed the primary and metastatic GISTs and found known mutations related to poor prognosis and imatinib resistance.

Paracaecal hernia is a rare type of internal hernia usually presenting with a picture of small bowel obstruction. In this report we present a 68-year-old woman who was admitted with colicky lower abdominal pain, vomiting and abdominal distention. A computed tomography scan of her abdomen and pelvis demonstrated multiple dilated small bowel loops with a transition point in the right iliac fossa. After a trial of conservative treatment, the patient was taken to theatre where she underwent laparoscopic reduction of a strangulated paracaecal hernia. The patient had an uneventful post-operative recovery and was discharged home. Despite being a rare cause for small intestinal obstruction, this should be part of the differential diagnosis especially in the absence of previous abdominal operations. Early recognition and prompt surgical treatment is the key to prevent complications. A laparoscopic approach is feasible if expertise is available.

Gastrocutaneous fistulae are traditionally treated with to parenteral nutrition or surgical management. We are presenting a case of a 56-year-old man who underwent a surgical closure of a gastrocutaneous fistula with a trionic (cell alginate activate packing). The fistula recurred on postoperative day 14, after the Bilroth II operation. For the first 8 days after filling the fistula with trionic, we applied total parenteral nutrition. Later, the patient started taking liquid foods through the mouth. The leak of the fistulous liquid was conspicuously reduced, and on the 20th day, it ceased completely.

Bochdalek hernias are usually diagnosed in newborns. However, they can occur in adults. Few reports exist regarding robotic repair of such hernias. We present a case of a female patient with symptomatic Bochdalek hernia, including the spleen. Patient was successfully treated by robotic-assisted surgical mesh with the use of indocyanine green (ICG). An 80-year-old female patient presented with dyspnea, angina and intermittent abdominal pain. She had loss of appetite and 15-kg weight loss within 3 months. Past medical history was unremarkable. Imaging revealed a left Bochdalek hernia. The patient underwent robotic-assisted surgery; hernia contents included stomach, parts of colon, omentum and remarkably the spleen. Sac was dissected free. Patency of organs was assessed with ICG. Diaphragmatic defect was repaired with mesh. Bochdalek hernias should be surgically repaired. Minimally invasive therapy is safe and effective. Intraoperative ICG use can provide excellent results with favorable clinical outcomes.

Bochdalek hernia (BH) is the most common type of congenital diaphragmatic hernia and is usually left-sided. It typically presents in neonates and diagnosis in adults is a rarity. To date only 34 reported cases of right-sided BH have been surgically managed in adults in literature. We review a 21-year-old female with a right-sided BH diagnosed as acute calculus cholecystitis and underwent laparoscopic cholecystectomy. The diagnosis of BH was made incidentally during surgery. The hernia did not have a sac with no hernial contents. It was treated via laparoscopic intracorporeal suturing and patient postoperative period was uneventful. Right-sided BH is rare. Regardless of the symptoms surgical treatment should be done to avoid risk of visceral strangulation.

Giant inguinal hernias are defined as inguinal hernias that extend below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30 cm or a laterolateral diameter of ~50 cm with non-reducibility for >10 years. This article presents a 39-year-old male with a five-year history of a giant left inguinal hernia that was treated with left inguinal hernia repair with mesh, orchiectomy, complicated scrotoplasty, intraoperative ultrasound and aspiration of 3.9 L of fluid from the hernia sac. Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking, or, as in this case, aspiration of the hernia sac and a preperitoneal incision. Although the Lichtenstein tension free repair is commonly used, no standard approach has been accepted.

Jejunogastric intussusception (JGI) is a rare complication of gastrojejunostomy surgery (

Buried bumper syndrome (BBS) is a rare complication associated with percutaneous endoscopic gastrostomy (PEG) tubes. It develops when the internal bumper migrates through the gastric wall, lodging anywhere along the gastrostomy tract leading to overgrowth of gastric mucosa thereby encasing the tube. BBS can lead to bleeding, perforation, peritonitis and intra-abdominal sepsis. Our case is a 71-year-old female presenting with tenderness, erythema and purulent discharge at the PEG tube site 2-weeks post-insertion. Computer tomography scan demonstrated the PEG had dislodged with the internal bumper in the subcutaneous tissue and the distal tip lying within the tract beyond the stomach wall. The PEG was removed by simple external traction. The patient clinically improved and discharged home on day three. Although BBS usually occurs late post-PEG insertion, it can also occur acutely. Preventative measures should be adopted at ward-level and emphasized with appropriate PEG tube care information provided to patients to avoid and recognize such complication.

Complex ventral hernia repair has been a challenging task of difficulty in primary closure of the defects. Transversus abdominis muscle release (TAR) procedure, as a type of posterior component separation, is a new myofascial release technique in complex ventral hernia repair. TAR creates immense retro muscular plane and allows bilaminar ingrowth of the mesh, allowing primary closure of defect. Owing to its favorable outcome, suitability of TAR technique in treatment of complex ventral hernia could be explored further where closure of the primary defect is difficult.

First operated by Claudius Amyand in 1735. Amyand’s hernia is a rare presentation and accounts for only 1% of all inguinal hernias. Amyand’s hernia is described when the appendix is trapped within an inguinal hernia. In most cases, Amyand’s hernia is an incidental finding intra-operatively due to variable clinical manifestations, and features. Amyand’s hernia has variable theories explaining its pathophysiology besides having multiple proposed surgical approaches either via laparoscopic or open repair and with the latter being in a debate of pro and against mesh repair. We present a case of a sliding Amyand’s hernia in which the vermiform appendix and part of the cecum were adherents to the wall of a right inguinal hernial sac. Amyand’s hernia is a rare form of inguinal hernias and its presentation is widely variable. However, in most cases, it is non-complicated and is found as an incidental intraoperative finding. Many studies debate among different diagnostic and management approaches to serve a better outcome with fewer operative complications.

Acute traumatic abdominal wall hernia (TAWH) is a rare type of hernia that occurs after a low or high velocity impact of the abdominal wall against a blunt object with few cases reported. Perforations of the hollow viscera commonly follow abdominal trauma and likely require surgery for hemorrhage and sepsis source control. We report a case where a high velocity impact of the abdominal wall against the stump of a felled tree caused a TAWH with concomitant gastric perforation in a 20-year-old male patient who required exploratory laparotomy with primary repair of the stomach and fascia. The physical examination findings without previous history of abdominal hernia and pneumoperitoneum in the chest X-ray made suspect our diagnosis and it was confirmed intraoperatively. At 3 months postoperatively the patient has a strong abdominal wall. It is imperative to emphasize the importance of the physical examination goal of not losing diagnosis of TAWH.

Intussusception through a prolapsed end colostomy is amongst the rarest of stoma complications. In this case report, we discuss the therapeutic approach to this complication and provide an update of the existing literature. A 66-year-old male presented with a prolapsed colostomy that was ischaemic in appearance. Intraoperatively, a small bowel intussusception within the prolapsed colon was identified. A subtotal colectomy was subsequently performed to prevent further volvulus formation. When patients present with a prolapsing oedematous enterostomy that cannot be reduced, careful clinical examination is required. If there is vascular compromise, exploratory laparotomy is mandatory.

Gastrointestinal stromal tumors (GISTs) occurring outside the gastrointestinal tract are known as extragastrointestinal stromal tumors (EGIST). They share some common histopathologic and molecular characteristics. This report describes two female patients who were suspected of having a mesenteric GIST, but opted for surveillance rather than definitive treatment. Upon reassessment, both patients demonstrated increased tumor mass with no evidence of distant metastasis. The intraoperative findings confirmed the conclusion of clinical and imaging studies performed preoperatively and radical excisions were performed. Histopathological examination (spindle cell neoplasm) and immunohistochemistry (CD117) confirmed EGIST. Both patients underwent Imatinib therapy following surgery with no evidence of disease recurrence or metastasis upon follow up. Although sharing histologic features with GIST, EGIST frequently demonstrates distinct characteristics that facilitate the proper diagnosis and management of EGIST. Since it is a rare and aggressive disease with a poor outcome, early detection and curative surgical resection remains the mainstay of treatment.

Spleen is normally positioned in the left upper quadrant. Abnormal location where it is not found in its normal anatomical position is called wandering spleen (WS). Wandering spleen is a rare medical condition that occurs due to developmental abnormality or acquired laxity of the ligaments that hold the spleen in its normal anatomical position. It affects children and young adults, especially childbearing age women. Patients affected with this condition may present with nonspecific symptoms requiring a high index of suspicion. Here, we are presenting a 20-year-old female known to have WS ended up with infarcted WS requiring emergency splenectomy.

Neuroendocrine tumours (NET) of the small bowel present significant clinical challenges, such as their rate of metastasis at initial presentation, common multifocality and understaging even with gold standard imaging. Here, we present a case of a high-risk surgical patient with a complex medical history initially presenting as an acute abdomen due to an incarcerated incisional hernia. He was found at emergency laparotomy to have three small NET deposits in a 30-cm segment of incarcerated ileum which was resected. Postoperative morphological and functional imaging and biochemical markers were unremarkable, but due to clinical suspicion for undetected residual tumour bulk given the non-systematic palpation of the entire small bowel at initial operation, underwent re-operation where a further 70 cm of ileum was found to harbour multiple tumour deposits (n = 25) and was resected. There was no surgical morbidity and the patient remains tumour-free at 9-month follow-up.

Cowden syndrome is a rare autosomal dominant disorder that is characterized by multiple hamartomatous neoplasms in a variety of tissues and is associated with germline mutations in the PTEN gene. Cowden syndrome does not have increased risk of gastric malignancy; however, complications of benign neoplasm can occur. The authors report a case of a patient with Cowden Syndrome and with gastric polyps that caused severe morbidity and a surgical approach was indicated. An antrectomy with troncular vagotomy was performed with a Billroth I reconstruction. In this case, this was of paramount importance so the duodenum can be revisited.

Hydatidosis or Echinococcosis is a parasitic disease caused by infection with the larval stage of Echinococcus granulosus. Primary isolated pancreatic hydatidosis is very rare even in countries where echinococcosis disease is highly endemic. The objective of this case report is to highlight this unusual and rare hydatid cyst presentation to avoid incorrect diagnosis and management. In our case, preoperative evaluation guided the diagnosis toward cystic pancreatic neoplasms, leading us to contemplate a radical surgical approach (Pancreaticoduodenectomy). Pancreatic hydatid cysts can be confused with cystic pancreatic neoplasms, it should always be considered as a differential diagnosis in endemic areas, to prevent misdiagnosis and inappropriate management.

Omental torsion, a rare cause of acute abdomen in children and adults, is difficult to correctly diagnose before surgery because it mimics the common causes of acute surgical abdomen. We present a case of greater omental torsion that was diagnosed by laparoscopy. A 37-year-old man presented with right lower abdominal pain and was suspected to have appendicitis. Blood tests revealed elevated C-reactive protein and white blood cell count, whereas computed tomography revealed a nodular mass and high-density lesions in the fat tissue. As the patient’s abdominal symptoms were severe and a clear diagnosis could not be made, we performed exploratory laparoscopy. Laparoscopy revealed omental torsion, and an omentectomy was performed. The patient’s pain had significantly reduced post-surgery, and post-operative recovery was uneventful. Thus, laparoscopic examination is useful for accurately diagnosing omental torsion and is less invasive than surgery.

Surgeons in resource-limited settings have adapted to overcome the challenges of the limitations of resources using different available methods and inventions from the local environment. We report four cases of oesophageal cancer palliatively treated with improvised gastrostomy feeding tubes by using 24Fr urinary catheters, to optimize their nutritional status to withstand chemotherapy/radiotherapy. Two patients managed to begin chemo and radiotherapy, but only one out of the four survived. The aim of this report is to appraise the methods used by surgeons to overcome the challenges they face in clinical practice.

Hiatal herniations are most commonly diagnosed during work-up for gastroesophageal reflux disease. Here, we present a patient with retrosternal pain for whom the computed tomography scan showed a lipomatous formation in the lower posterior mediastinum, and further examination indicated the origin to be paraesophageal herniation (PEH) of the greater omentum. This was confirmed by laparoscopy, the herniated part of the greater omentum was repositioned and the hiatal hernia was repaired. During recovery the patient complained of dysphagia, a common and transient postoperative occurrence, but which later proved to be a mechanical obstruction caused by a bolus. This case raises awareness of potential differential diagnoses pre- and postoperatively in conjunction with PEH, and the management of such differential diagnoses is discussed.

Parietal peritoneal lipomas are a rare surgical entity with seven case reports in the published literature. Their aetiology remains nebulous and includes theories such as misplaced embryonic tissue, adipose hyperproliferation, trauma and fat herniation or excessive obesity. This is the first case report in the literature with two parietal peritoneal lipomas incarcerated in an umbilical hernia. We strongly advocate for an international rare tumour registry, given the sparsity of data on these tumours and their possible malignant potential, which we believe would help potentiate an effective treatment protocol for future cases.

A gastrocolonic fistula is a rare surgical presentation, typically in the setting of gastric or colonic malignancy. This report presents the first reported Australian case of a gastrocolonic fistula following upper gastrointestinal surgery. A middle-aged woman presented to emergency with a short history of severe abdominal pain, faeculent vomiting, profuse diarrhoea and weight loss. This was in the setting of a previous pylorus-preserving pancreaticoduodenectomy complicated by marginal ulceration, for which a distal gastrectomy and Roux-en-Y reconstruction was required. The rarity of gastrocolonic fistulae and non-specific presentation with diarrhoea, vomiting and weight loss can make the diagnosis challenging. The mainstay of management is surgical resection in both benign and malignant disease.

We experienced the case of successful conversion to distal gastrectomy for gastric cancer with direct invasion to the pancreatic head after the pre-operative chemotherapy. Esophagogastroduodenoscopy in a 66-year-old man revealed a tumor at the gastric antrum. Abdominal computed tomography (CT) showed that the tumor of the antrum was in contact with the pancreatic head. A biopsy of the tumor confirmed an adenocarcinoma and an overexpression of HER2 (3+). Staging laparoscopy showed the direct invasion of the gastric tumor to the pancreatic head. The patient received S-1, oxaliplatin and trastuzumab. After the pre-operative chemotherapy, CT showed a significantly shrinking tumor detached from the pancreatic head. Subsequently, distal gastrectomy was performed. Intra-operative exploration showed that the gastric tumor separated from the pancreatic head. The accumulation of trials for pre-operative chemotherapy for local advanced gastric cancer is expected.

Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society. Treatment of recurrent disease became more refined, with the study of molecular and hormonal receptors playing a central role. A 76-year-old caucasian woman presented to the emergency department with growing tiredness, and melaena. Past medical history included an endometrioid adenocarcinoma. The patient had undergone a hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy and was disease-free for 2 years. The endoscopy revealed an ulcerated lesion involving the second and third portions of the duodenum. Histopathologic examination confirmed a poorly differentiated adenocarcinoma of endometrial origin. She started palliative chemotherapy, remaining with adequate symptomatic control. Endometrial cancer recurrence typically occurs locally. The liver is the intra-abdominal organ most commonly involved. There are scarce reports of duodenal metastasis of malignancies originated in distant organs. The duodenum remains an uncommon metastization site and is rarely associated with endometrial cancer.

The most common long-term complication post esophagectomy implicating the esophagogastric anastomosis is stricture-induced stenosis leading to late postoperative dysphagia. Herein, we present a case of a male patient readmitted to our Upper Gastrointestinal Department due to a food bolus obstruction through an anastomotic epithelial band arisen from a prior esophagogastric anastomosis performed 5 months earlier. A band transection in between two hemostatic clips placed on both sides of the band, followed by a release and fragmentation of the foreign body into several pieces led to its final transoral removal endoscopically. The patient experienced a direct resolution of his dysphagia and discharged on the same day. At 6 months follow-up, he remains symptom-free. In conclusion, endoscopic state-of-the-art techniques when combined with standard hemostatic surgical principles in a minimally invasive manner are excellent tools for the management of post-esophagectomy syndromes.

A rare case was demonstrated whereby a prophylactic laparoscopic total gastrectomy was performed in a 29-year-old male with a CDH1 gene mutation in the context of rare anatomical anomaly, situs inversus totalis (SIT). This report provides radiological and laparoscopic images detailing the patient’s unique anatomy. We also describe the operative approach and technical challenges whilst accounting for the patient’s anatomical anomaly. This is the first known case of a laparoscopic total gastrectomy for a CDH1 gene mutation in a patient with SIT. With sufficient pre-operative evaluation and meticulous intra-operative caution, this technically complex operation is safe and feasible in patients with mirror-image anatomy as seen in SIT.

Managing traumatic injuries of the gastroesophageal junction (GEJ) is infrequent due to associated lesions of adjacent highly vascularized organs. Its anatomical localization in the upper abdomen makes the repair challenging to perform. A stable 23-year-old male was presented at the emergency department with two thorax gunshot wounds. Computed tomography revealed air in the periesophageal space and right hemopneumothorax with no injury of the major vessels. A chest tube was placed and the patient was transferred hemodynamically stable to the operating. Abdominal exploration identified injuries to the left diaphragm; liver lateral segment; 1-cm transfixing perforation of the GEJ and right diaphragmatic pillar. Primary repair of the GEJ was performed and patched with a partial fundoplication. The diaphragm was repaired and the liver bleeding controlled. Finally, drains and a feeding jejunostomy were placed. The patient had an uneventful early postoperative course and was discharged home on the 12th postoperative day.

A 47-year-old patient presented at our emergency department with acute epigastric pain. A thoracic X-ray showed a partially intrathoracic stomach as well as bowel left sided. A following computed tomography scan diagnosed a diaphragmatic hernia. In the patient’s history, 20 years ago a serious car accident was reported as the presumable traumatic origin. Intraoperatively, the diaphragmatic hernia was repaired with a direct suture and mesh augmentation. The rest of the abdomen was clear. In a thoracic X-ray following chest tube removal, herniated small bowel appeared intrathoracally on the right. Relaparotomy showed an extensive diaphragmatic hernia with parts of the liver, small bowel and colon in the right thoracic cavity. Only a partial direct repair was possible, an inlay mesh repair was performed. The further recovery was uneventful. Bilateral delayed traumatic diaphragmatic hernias are extremely rare, but with a suggestive trauma history thorough intraoperative exploration of the contralateral side should be evaluated.

A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings. We describe a case of a 53-year-old gentleman who presented to our institution with respiratory sepsis and a massive haemopneumothorax on imaging. Uniquely, he was discharged a week prior after a splenectomy for a traumatic fall. Gut flora in the pleural fluid and a subsequent positive dye test suggested an aero-digestive connection. Repeat imaging revealed a fistula between stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm. This is the first GPF in literature presenting in such a fashion. Although rare, a persistent effusion with a history of blunt thoracoabdominal trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.

Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. However, spleen involvement in pancreatitis is rare. We present a patient with a pancreatic tail pseudocyst with splenic extension and rupture. Due to initial stability, conservative management was decided. However, he developed tachycardia with severe abdominal pain associated with signs of peritoneal irritation, requiring an emergency laparotomy. A large pancreatic tail pseudocyst was identified in addition to a ruptured spleen. Splenectomy and double layer hand-sewn gastrocystic anastomosis were performed. The patient had a satisfactory recovery and was discharged on the 11th postoperative day. Conservative management is an option in stable patients but with a high rate of failure. Surgery remains the standard choice in these cases.

We present the case of a 23-year-old patient who developed a severe gastric ischemia after the ingestion of a single dose of sodium polystyrene sulfonate (SPS) orally. Emergency surgery confirmed extensive full thickness gastric necrosis, prompting a total gastrectomy. Histopathology showed kayexalate crystals in the gastric wall, suggesting SPS-related ischemic gastritis. After radical resection of the affected stomach, this young patient was able to fully recover. Although effective, the widespread use of SPS to treat hyperpotassemia remains a debated topic because of rare but serious adverse events like the forming of kayexalate crystal residues in the gastrointestinal tract. These crystal residues are mostly found in the large intestine and can lead to ulceration and necrosis. Physicians need to be aware of this rare but potentially devastating adverse effect of SPS ingestion.