Intestinal Obstruction Secondary to Multiple Gastrointestinal phytobezoars, A Rare presentation.

INTRODUCTION: Intestinal obstruction considered to be one of the most common surgical presentation. Adhesions secondary to previous operations, hernias, neoplasms, inflammatory bowel disease, intussusception, or volvulus are the usual causes of intestinal obstruction but bezoar can presents in 0.4-4%. Bezoar can be trapped in different locations throughout the gastrointestinal tract and it can be solitary or multiple lesions. CASE PRESENTATION: This is a 37-year-old male, known case of diabetes mellitus, Presented to the Emergency Department complaining of generalized abdominal pain for 2 days duration. Associated with abdominal distention, fever, nausea, vomiting and obstipation. There was a history of persimmon intake. Unremarkable past surgical history. On examination, He was tachycardic, other vital signs were within normal. Abdominal examination showed abdominal distention and Sluggish bowel sound. Abdominal X-ray revealed multiple air-fluid levels. An abdominal CT scan with IV contrast revealed an intra-luminal mass in the ileum and intra-gastric mass with suspicious of bezoars. He underwent exploratory laparotomy, gastrostomy to remove intra-gastric bezoar, and enterotomy to remove the ileal bezoar. CLINICAL DISCUSSION: Intestinal obstruction is considered to be the most common complication of this entity; other possible complications include gastric ulcer, gastritis, and gastric perforation. Due to limitations of endoscopy and barium enema in the diagnosis of bezoar, Abdominal CT-scan is considered to be the gold standard in the diagnosis. The management of phytobezoar can be either conservative or surgical, depends on the lesion size and location. CONCLUSION: Although intestinal obstruction secondary to bezoar is rare, multiple levels of gastrointestinal obstruction should raise the suspicion of bezoar.

Rare gastric neoplasm: Malignant glomus tumor of the stomach. A case report.

INTRODUCTION: Glomus tumors are rare neoplasms that aris-e from neuromyoarterial canal or glomus body. They are mainly found in the peripheral soft tissue, extremities and rarely developed inside the gastrointestinal tract. In the gastrointestinal tract, the stomach is the most common site for the development of glomus tumors, and most often found in the antrum. Usually, the symptoms of gastric glomus tumors are non specific i.e (abdominal pain, GI bleeding and/or perforation) and possibly discovered incidentally during upper GI endoscopy. CASE PRESENTATION: This is a-56-year-old-male, presented to the emergency department with upper GI bleeding i.e (melena), and signs of shock (HR: 110; BP:80/60), Blood tests showed Hemoglobin level: 5 g/dl. Resuscitation was started with IV fluid and transfusion of 4 units of PRBCs. After resuscitation, He gave a 10 days history of passing black tarry stool, palpitation, headache, dizziness, easily fatigability, malaise, and colicky epigastric abdominal pain. His abdomen was soft, lax with no tenderness, there was fullness at the left upper quadrant. Upper GI endoscopy was performed that showed a large gastric ulcer with adherent clots, necrotic base and oozing at the proximal part of the greater curvature, after that the bleeding was managed with a heater probe and epinephrine injections. The histopathological examination of the biopsy revealed a spindle and epithelioid tumor with the top differential diagnosis being GIST, however other submucosal lesions cannot be excluded. After that, He underwent exploratory laparotomy and wedge resection of the tumor. The final histopathology showed a malignant glomus tumor. CLINICAL DISCUSSION: Due to overlapping clinical and radiological features between glomus, GIST and other submucosal lesions, the histopathological examination is considered to be the gold standard for the diagnosis. Surgical resection with negative margin is the treatment of choice for gastric glomus tumors. CONCLUSION: Although gastric glomus tumor is a rare entity and accounts for 1% of all gastric mesenchymal tumors, it should be considered in the differential diagnosis, since preoperative biopsy is difficult and overlapping features with other submucosal lesions. Surgical treatment is the preferred option for gastric glomus tumor and long-term follow-up is required due to high metastatic and recurrence rate in the malignant type.

Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report.

BACKGROUND Achalasia is a rare primary esophageal motility disorder of unknown etiology, with significant negative impact on patient quality of life. Esophageal perforation is the most serious complication after pneumatic dilatation for achalasia, with a high mortality rate of up to 20%. Double-tract reconstruction is used mainly after proximal gastrectomy for gastric cancer, with the advantage of functional preservation of the stomach. We report a case of iatrogenic esophageal perforation after endoscopic pneumatic dilatation for achalasia that was successfully managed by laparoscopic proximal gastrectomy with double-tract reconstruction. CASE REPORT An elderly man started to manifest desaturation during endoscopic dilatation for achalasia, and multiple esophageal perforations were confirmed just above the gastroesophageal junction. During diagnostic laparoscopy, multiple perforations were found 2 cm proximal to the gastroesophageal junction extending 5 cm proximally with multiple linear mucosal tears. A trial of primary repair was difficult and double-tract reconstruction was performed by transection of the distal esophagus above the perforations and proximal gastrectomy. Then, 3 anastomoses were performed: end-to-end esophago-jejunostomy, end-to-side jejuno-jejunostomy, and side-to-side gastro-jejunostomy 15 cm distal to the esophago-jejunostomy site. After a smooth postoperative course, he was discharged home and was followed up regularly. CONCLUSIONS Esophageal perforation is the most serious complication after endoscopic pneumatic dilatation for achalasia. Double-tract reconstruction is a feasible and effective reconstruction modality following esophageal resection that avoids complications of esophago-gastrostomy. This technique deserves to be considered a valid treatment modality for advanced and complicated cases of achalasia, but further research is needed.

Intrathoracic Gossypiboma: An Overlooked Entity.

BACKGROUND During any surgical procedure, there are several factors that may lead to morbidity and mortality. One of those factors is a retained cotton or gauze surgical sponge inadvertently left in the body during an operation, known as gossypiboma. This clinical oversight may cause serious postoperative complications and increase the risk of mortality, particularly if left undiscovered. Furthermore, this issue adds to the economic burden on healthcare systems by increasing the rate of reoperation and rehospitalization. The length of postoperative gossypiboma diagnosis varies greatly, as patients may either present acutely with symptoms such as a palpable mass, pain, nausea, and vomiting, or remain asymptomatic for several years. CASE REPORT We report the case of a 48-year-old man who underwent a thoracotomy after a road traffic accident. The resulting empyema led to the intraoperative discovery of an intrathoracic gossypiboma, which was initially interpreted radiologically as a part of the previous surgical staple line. The causative agent was discovered by the team's nurses during the postsurgical count of instruments and sponges, and who were alerted to a recovered sponge differing in appearance from the sponges used for that procedure. CONCLUSIONS In general, proper counting and adherence to the World Health Organization 'Surgical Safety Checklist' can greatly improve the outcome of any surgery. The diagnosis of gossypiboma is often late or missed entirely and leads to additional interventions that can be avoided or detected early when the material contains a radiopaque marker. In cases under suspicion of any mistakenly left object, the use of intraoperative radiology before skin closure is highly recommended to prevent postoperative complications for the patient and organization.