Gastric diverticulum: a contemporary review and update in management.

BACKGROUND: Gastric diverticula (GD) are the rarest form of gastrointestinal tract diverticulum, with an estimated incidence of 0.013-2.6%. GD are poorly understood and there are no established management guidelines. Only sparse updates have been published since the mid-20th century. This paper reviews the current literature and provides some suggested guidelines for the management of GD. METHODS: A search of Medline via OvidSP and Google Scholar for 'gastric diverticulum' and associated synonyms from the year 1950 onwards was performed. We included randomized controlled trials (RCTs), cohort and case-control studies, and case series. Full text, English language manuscripts on adult populations were included. RESULTS: A total of 103 manuscripts were included in the final selection - 77 individual case studies, 23 case series and three reviews. No RCTs, cohort or case-control studies were found. The case studies represent 305 patients, 50.8% female with average age 49.2 years (range 18-80). The most common symptom was abdominal pain (48.2%). The average maximum diameter was 3.97 cm (range 0.5-9). One hundred and four patients were managed operatively. Despite persistent recommendations in the literature that GD > 4 cm should be considered for resection, there are no data supporting this approach. CONCLUSION: The evidence pertaining to the management of GD is sparse. The decision for operative management should be individualized and based primarily on the presence of symptoms or complications which may be directly attributable to the GD. Where surgery is indicated, a laparoscopic approach, potentially with intra-operative gastroscopy, is appropriate.

How to do mesh-mediated fascial traction for delayed primary closure of the open abdomen.

The open abdomen can be a life-saving resuscitative manoeuvre in patients with catastrophic abdominal pathologies, however, can lead to the need for delayed primary closure. The most recent guidelines released from the European Hernia Society and World Society for Emergency Surgery both suggest mesh-mediated fascial traction in conjunction with negative pressure wound therapy as the preferred method in this situation. We present a detailed 'how to do it' on this technique.

Unique case of metachronous adrenal and hepatic myelolipomas.

We present a unique case of metachronous adrenal and hepatic myelolipomas in a 62-year-old man. Myelolipomas are most commonly found in the adrenal gland, with extra-adrenal sites such as the lung, retroperitoneum and liver reported. They are a form of benign mesenchymal tumour, with only 25 case reports of a hepatic location published to date. The are no guidelines to its management. Our patient underwent resection due to pain, and after a complicated postoperative period is pain free.

Liver resection as a component of en-bloc multivisceral resection for upper abdominal tumors is associated with increased morbidity.

BACKGROUND AND METHODS: Complex en-bloc multivisceral and oncovascular resections for upper abdominal tumors remain rare, but there is increasing interest in their role. We analyze complications and survival for these operations. We performed a retrospective cohort study of patients who underwent en-bloc upper abdominal resections for tumors involving multiple organs. Primary outcomes were complications as per the Clavien-Dindo Classification and Comprehensive Complication Index (CCI). Secondary outcome was overall survival (OS). RESULTS: We identified 60 consecutive patients who underwent resection from 2011 to 2018. Histopathology was heterogeneous, the most common being renal cell carcinoma. Eighteen patients had major complications. Mean (interquartile range) CCI was 29.6 (9.6-43.9). Liver resection was significantly associated with an increased CCI and increased the odds of a major complication (odds ratio: 4.67, 95% confidence interval [CI]: 1.31-16.59; P = .017). Charlson Comorbidity Score was significantly associated with the presence of at least one major complication. Mean OS was 47.1 months (95% CI: 37.6-56.6). CONCLUSION: In appropriately selected patients, and when undertaken in centers with appropriate subspecialist surgical teams and intensive care services, en-bloc multivisceral resection of upper abdominal tumors is safe, but liver resection is associated with an increase in major complications.

Inferior Vena Cava Resection and Reconstruction with Bovine Pericardium for Renal Cell Carcinoma: Complications and Outcomes.

OBJECTIVES: To assess the postoperative complication rate and overall survival when bovine pericardium is used as graft material for inferior vena cava (IVC) reconstructions in patients with renal cell carcinoma (RCC). The ideal graft material is yet to be established, with synthetic grafts widely studied and used in the current literature. METHODS: We performed a retrospective cohort analysis of consecutive patients who underwent IVC reconstructions as part of resection for RCC, using bovine pericardium as either a patch repair or tubular interposition graft. RESULTS: A total of 15 patients underwent resection with IVC reconstruction between 2010 and 2018. Nine patients had tubular interposition grafts and 6 had patch repairs. Three patients had Clavien-Dindo grade 3 or higher short-term complications. There was no difference in Comprehensive Complications Index between those who had interposition grafts and patch repairs. Two patients had a long-term graft-associated thrombus requiring temporary anticoagulation. Overall survival was 46.5 months (95% confidence interval [CI] 36.9-56.1). There were no perioperative deaths. All long-term deaths were due to disease progression. CONCLUSION: Reconstruction of the IVC with a bovine pericardium graft is safe in experienced centers. Bovine pericardium could be considered as the material of choice, given its safety in the immediate postoperative period, ease of use, and patency without routine long-term anticoagulation. Advanced surgical management leads to good overall survival in this cohort with high tumor burden.