EP.FRI.988Life threatening recurrent bleeding gastric fundus Dieulafoy lesion: A case report

Introduction Dieulafoy lesion is a rare but significant cause of upper gastrointestinal tract (GIT) bleeding. Over 75% of Dieulafoy lesions are located in the stomach and they tend to be responsible for recurrent upper GIT bleeding. Endoscopic therapy is the first line intervention to achieve haemostasis. Patient A 49-year old normally fit man known to have a gastric Dieulafoy lesion since 2008 presented with a history of collapse on the street and significant melaena. He was tachycardic, with a heart rate of 116, and hypotensive, blood pressure 109/68 mmHg on admission. He had significant upper GIT bleeding from the gastric fundus Dieulafoy lesion in April 2008, requiring a massive blood transfusion. At the time, the attempted endoscopic therapy was unsuccessful, resulting in an emergency surgery and under-running of the bleeding vessels. For the recent admission, he underwent an urgent therapeutic oesophagogastroduodenoscopy, with 3 endoscopic clips applied, but this failed to maintain haemostasis. Four units of packed red cell were transfused and he was transferred immediately to the operating theatre. He underwent an emergency laparotomy, adhesiolysis, gastrostomy and wedge resection of the bleeding gastric fundus Dieulafoy lesion using a linear cutter 75mm stapler. He had an uneventful post-operative recovery and was discharged home on day four after surgery. The histology of the wedged gastric specimen confirmed an area of gastric mucosa ulceration with a network of mixed dilated, thin and thick-walled tortuous vessels in the adjacent submucosal layer. The histologic features are consistent with a bleeding gastric Dieulafoy lesion.

Effect of different pancreatic stump closure techniques after distal pancreatectomy on frequency and severity of acute postoperative pancreatitis

Objective: to study the effect of different pancreatic stump closure techniques and diameter of the main pancreatic duct on frequency and severity of acute postoperative pancreatitis after distal pancreatectomy. Material and Methods. Distal pancreatectomy was performed on 126 patients with neoplasms of body and/or tail of the pancreas. Patients were distributed among four groups based upon the pancreatic stump closure technique applied after distal pancreatectomy: group 1 (control) included the patients with isolated suturing of the main pancreatic duct in the pancreatic stump with its subsequent sealing by the gastrocolic omentum or hemostatic sponge; group 2 patients underwent isolated suturing of the main pancreatic duct in the pancreatic stump with its subsequent sealing with 2-octyl cyanoacrylate biological glue; group 3 patients had their pancreatic stump closure performed with endoscopic linear cutter stapler; group 4 was composed of the patients with external transduodenal transnasal drainage of enlarged (D>3 mm) main pancreatic duct in the pancreatic stump. Results. The occurrence of acute postoperative pancreatitis in the control group amounted to 45.8%, while, in groups 2, 3 and 4, the frequencies were 44.4, 9.7 and 15.0(%), correspondingly. Besides, the control group was characterized by declined occurrence of the moderately severe form of acute postoperative pancreatitis. Use of endoscopic linear cutter stapler and external transduodenal transnasal drainage of the enlarged main pancreatic duct caused lower acute postoperative pancreatitis frequency in the patients with main pancreatic duct in their pancreatic stumps below 5 mm in diameter. Conclusion. Use of proposed pancreatic stump closure techniques after distal pancreatectomy resulted in lower frequencies of occurrence and severity of acute postoperative pancreatitis.

A Band Lifting Assisted Method for Laparoscopic Resection of Gastrointestinal Stromal Tumors on the Posterior Wall of the Stomach

Laparoscopic surgical techniques are beneficial for the wedge resection of gastrointestinal stromal tumors (GISTs). We have developed a new technique of laparoscopic transgastric resection for GISTs of the posterior wall of the stomach, a band lifting wedge resection method that has been confirmed to ensure sufficient surgical margins around the resected specimen in 21 cases. GISTs located at the posterior wall of the stomach were collected for this study. Laparoscopic anterior gastrotomy was performed and a 9-Fr rubber band was looped around the base of the tumor, allowing it to be lifted up through the anterior gastrotomy. The lesion was transected using a laparoscopic linear cutter and the gastrotomy was then closed by sequential application of the linear cutter. Surgical specimens were examined immunohistochemically All GISTs were successfully and completely resected using the laparoscopic technique. The resected tumors were ellipse-shaped or round. Macroscopic examination of the resected specimens showed complete tumor excision with negative surgical margins in all patients. A band lifting method for transection of GISTs on the posterior wall of the stomach easily allows for sufficient surgical margins of GISTs. The technique is reliable and feasible for laparoscopic treatment of GISTs in the stomach.