Peptic ulcer disease complicated with choledocho-duodenal fistula and gastro-intestinal bleeding: a case report and review of the literature.

Peptic ulcer disease (PUD) is a very common condition, with an annual incidence ranging from 0.1% to 0.3% and a lifetime prevalence ranging from 5% to 10%. If not treated, it can lead to severe complications such as gastro-intestinal bleeding, perforation, or entero-biliary fistula. Entero-biliary fistulas and especially choledocho-duodenal fistula (CDF) are a rare, but relevant and important diagnosis, which can lead to several complications such as gastric outlet obstruction, bleeding, perforation, or recurrent cholangitis. In this article, we present the case of an 85-year-old woman with PUD complicated with gastro-intestinal bleeding and a CDF. We also performed a review of the literature to search for pre-existing cases with this atypical clinical presentation. The aim was to raise awareness among surgeons and clinicians by offering a summary of different types of entero-biliary and especially CDF, existing diagnostic investigations, and management.

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review.

INTRODUCTION: Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. METHODS: Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021). RESULTS: One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years. CONCLUSION: The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

BACKGROUND: Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS: All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS: Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION: The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

A 56-Year-Old Woman with Acute Cholecystitis and a Moynihan's Hump, or Caterpillar Configuration, of the Right Hepatic Artery Identified During Laparoscopic Cholecystectomy.

BACKGROUND When performing a cholecystectomy, several variations can be encountered by the surgeon. The "Moynihan's hump" or "caterpillar configuration" of the right hepatic artery are the terms used to describe a tortuous right hepatic artery running proximal or parallel to the cystic duct, resulting in a small or short cystic artery and occupying most of Calot's triangle. This report is of a 56-year-old woman with acute cholecystitis and a Moynihan's hump or caterpillar configuration identified at laparoscopic cholecystectomy. CASE REPORT A 56-year-old woman presented herself to the Emergency Department with abdominal pain in the right upper quadrant for a week, associated with nausea, vomiting, and abnormal warm and cold sensation. Acute cholecystitis was diagnosed with ultrasound, and a laparoscopic cholecystectomy using a 4-port technique was performed. During the dissection of Calot's triangle, a large pulsatile vessel forming a loop was found, which turned out to be the right hepatic artery. The anatomic variation that was observed during the procedure is called Moynihan's hump or caterpillar configuration of the right hepatic artery. The surgery was uneventful, and the patient was discharged the next day. CONCLUSIONS The Moynihan's hump or caterpillar configuration of the right hepatic artery is a rare anomaly, with an incidence reported to be between 1.3% and 13.3%. This report has shown that although a Moynihan's hump or caterpillar configuration of the right hepatic artery is rare, the surgeon should be aware of this anatomic anomaly when performing gallbladder surgery to prevent arterial damage and operative complications.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one-anastomosis gastric bypass? A systematic review and meta-analysis of randomized-controlled trials.

OBJECTIVE: This study aimed to determine which bariatric procedure allows patients to obtain the best weight-loss outcomes and a remission of type 2 diabetes. METHODS: Databases were searched for randomized-controlled trials comparing Roux-en-Y gastric bypass (RYGB) with sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB). The mean difference (MD) or the relative risk was determined. RESULTS: Twenty-five randomized-controlled trials were analyzed. Excess weight loss (EWL, percentage) was greater for RYGB patients at 3 years (MD: 11.93, p < 0.00001) and 5 years (MD: 13.11, p = 0.0004). Higher excess BMI loss (percentage) was found in RYGB at 1 year (MD: 11.66, p = 0.01). Total weight loss (percentage) was greater for RYGB patients after 3 months (MD: 2.41, p = 0.02), 6 months (MD: 3.83, p < 0.00001), 1 year (MD: 6.35, p < 0.00001), and 5 years (MD: 3.90, p = 0.005). No difference in terms of remission of type 2 diabetes was seen between RYGB and SG. EWL was significantly more important after OAGB than after RYGB after 1 year (MD: -10.82, p = 0.003). CONCLUSIONS: RYGB is more efficient than SG in the midterm. OAGB offers greater EWL than RYGB after 1 year, but further evidence is needed to confirm this result.

Cell-free DNA liquid biopsy for early detection of gastrointestinal cancers: A systematic review.

BACKGROUND: Gastrointestinal tumors are among the most common cancer types, and early detection is paramount to improve their management. Cell-free DNA (cfDNA) liquid biopsy raises significant hopes for non-invasive early detection. AIM: To describe current applications of this technology for gastrointestinal cancer detection and screening. METHODS: A systematic review of the literature was performed across the PubMed database. Articles reporting the use of cfDNA liquid biopsy in the screening or diagnosis of gastrointestinal cancers were included in the analysis. RESULTS: A total of 263 articles were screened for eligibility, of which 13 articles were included. Studies investigated colorectal cancer (5 studies), pancreatic cancer (2 studies), hepatocellular carcinoma (3 studies), and multi-cancer detection (3 studies), including gastric, oesophageal, or bile duct cancer, representing a total of 4824 patients. Test sensitivities ranged from 71% to 100%, and specificities ranged from 67.4% to 100%. Pre-cancerous lesions detection was less performant with a sensitivity of 16.9% and a 100% specificity in one study. Another study using a large biobank demonstrated a 94.9% sensitivity in detecting cancer up to 4 years before clinical symptoms, with a 61% accuracy in tissue-of-origin identification. CONCLUSION: cfDNA liquid biopsy seems capable of detecting gastrointestinal cancers at an early stage of development in a non-invasive and repeatable manner and screening simultaneously for multiple cancer types in a single blood sample. Further trials in clinically relevant settings are required to determine the exact place of this technology in gastrointestinal cancer screening and diagnosis strategies.

Caecal diverticulitis can be misdiagnosed as acute appendicitis: a systematic review of the literature.

AIM: Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management. METHODS: This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD. RESULTS: Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%). CONCLUSION: CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.