Magnetic resonance imaging patterns and perfusion changes of posterior reversible encephalopathy syndrome in children with clinical outcome correlation.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) in children has a propensity towards atypical features on magnetic resonance (MR) imaging, with limited literature on perfusion changes and clinicoradiological correlation. OBJECTIVE: We aimed to comprehensively study MR imaging patterns of pediatric PRES, including cerebral blood flow variations on arterial spin labeling, and looked for any MR biomarkers of poor clinical outcome. MATERIALS AND METHODS: In this retrospective observational study conducted in a tertiary hospital setting, MR records over a 4-year period (May 2019 to May 2023) were systematically searched along with their clinical details. Patients with an age less than 18 years and a clinicoradiological constellation consistent with PRES were included. MR scans were analyzed by two neuroradiologists with 8 years' and 10 years' experience. Association was sought with poor clinical outcome (defined as modified Rankin Scale score at discharge of > 2). RESULTS: A total of 45 patients (29 boys) were included in the study, with a mean age (± standard deviation) of 11.19 (± 4.53) years. On MR imaging, 95.6% of patients (n = 43) showed atypical features and/or atypical areas of involvement. The superior frontal sulcus (n = 18) was the most predominant MR pattern, and cerebellar involvement was not uncommon (n = 15). Unilateral involvement (n = 3), isolated central pattern (n = 1), and spinal cord involvement (PRES-SCI: n = 1) were also encountered. Brainstem involvement (n = 4) showed a characteristic "V-sign" of anterior medullary hyperintensity. Patchy restricted diffusion (46.6%), punctate hemorrhages (37.7%), and leptomeningeal contrast enhancement (36%) were not uncommon. Arterial spin labeling sequence (available in 24 patients) showed increased cerebral blood flow in the involved areas in 79.2% of patients. Univariate analysis showed a significant association of the presence of hemorrhage (P = 0.003), involvement of brainstem (P = 0.007), deep white matter (P = 0.008), and thalamus (P = 0.026) with poor clinical outcome. Multivariate regression analysis found that hemorrhage on MRI (P = 0.011, odds ratio 8) was an independent factor associated with poor clinical outcome. CONCLUSIONS: The conventionally described atypical features in PRES are common in children and therefore may no longer be considered exceptions. Raised perfusion on arterial spin labeling sequence was seen in the majority of cases. Hemorrhage on MRI was an independent predictor of poor clinical outcome in pediatric PRES.

Circulating miRNA-21 Levels in Breast Cancer Patients Before and After Chemotherapy and Its Association with Clinical Improvement.

Breast cancer is the most frequent type of cancer in women, many patients experience recurrences and metastasis. miR-21 (microRNA-21) as biomarker is under investigation for breast cancer. At present, there is very limited information available regarding effect of chemotherapy on miR-21 expression in breast cancer and its correlation with the clinical improvement. Hence, this study was planned to evaluate the effect of chemotherapy on miR-21 in metastatic breast cancer and its relationship with the clinical outcome. Females, aged-18-90 years diagnosed with Invasive Ductal Carcinoma of breast and candidate of neoadjuvant chemotherapy including Adriamycin (60 mg/m2), Cyclophosphamide (600 mg/m2) with or without Taxane (75-175 mg/m2) were included in the study. Before and after 42 days of staring of chemotherapy sample was collected for circulatory miR-21 and RECIST 1.1 criteria was applied to assess the clinical status. Blood samples for routine clinical biomarkers including liver function test and renal function tests was also collected. miR-21 expression before and after chemotherapy was assessed using standard method based on real time PCR. Expression of miR-21, RECIST criteria and other liver and kidney related biomarkers were compared before and after chemotherapy. After neoadjuvant chemotherapy expression of miR-21 was significantly increased by 5.65-fold. There was significant improvement in clinical scores based on RECIST criteria (0.046). No significant correlation was observed between miR-21 expression and difference in RECIST score (r = - 0.122, p = 0.570). Neoadjuvant chemotherapy causes clinical improvement in breast cancer patients however it is not correlated with the miR-21 expression which significantly increased after chemotherapy.

Comparison of neuraxial acoustic target window of the spine among rider sitting, cross leg, hamstring stretch, and classical sitting position: An observational study.

Background and Aims: To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions. Material and Methods: This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions. Results: The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001). Conclusions: There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.

Cutoff values of body fat composition to predict metabolic risk factors with normal waist circumference in Asian Indian population.

OBJECTIVES: The aim of the study is to see if visceral fat volume (VFV), subcutaneous fat volume (SFV), and visceral-subcutaneous fat ratio (VSR) can be used to detect metabolically obese normal weight individuals in Asian Indian population. METHODS: This is a single center prospective cross-sectional study and 80 cases having either hypertension, diabetes, or hyperlipidemia with normal waist circumference and 80 controls having normal metabolic parameters with normal waist circumference were evaluated. Visceral and subcutaneous fat volumes and visceral to subcutaneous fat ratios were determined by computed tomography (CT) at L4-L5 level with a slice thickness of 5 mm. RESULTS: Visceral fat volume, subcutaneous fat volume, and VSR are significantly higher in patients with metabolic risk factors as compared to those without risk factors. Volume of subcutaneous fat is significantly higher in females as compared to males. VSR is higher in males in our study. The cutoff values for VFV, SFV, and VSR to predict at least one metabolic syndrome are 8.5 cm3, 15.7 cm3, and 0.61 in males and 7.0 cm3, 16.5 cm3, and 0.44 in females. CONCLUSIONS: For individuals with normal waist circumference, VFV, SFV, and VSR can effectively predict the presence of one metabolic risk factor. KEY POINTS: • Visceral fat volume, subcutaneous fat volume, and visceral-subcutaneous fat ratio can predict individuals at risk of metabolic syndrome having normal waist circumference. • Higher VSR in Indian population is due to low reservoir of primary adipose tissue fat compartment which leads to diversion of adipocytes into the secondary adipose tissue fat compartment. • This data can be used as a screening tool in preventive radiology for identifying individuals at risk of developing metabolic syndrome.

An evaluation of the three-component pubic symphyseal human age estimation method: a CT-based exploration in an Indian population.

Age estimation constitutes an important facet of human identification within forensic, bioarchaeological, repatriation, and humanitarian contexts. Within the human skeletal framework, the pubic symphysis comprises one of the more commonly utilized structures for age estimation. The present investigation was aimed at establishing the applicability of the McKern-Stewart pubic symphyseal age estimation method in males and females of an Indian population, an aspect previously unreported. Three hundred and eighty clinical CT scans of the pubic symphysis were collected and scored in accordance with the McKern-Stewart method. An overall accuracy of 68.90% was obtained on applying the method to males, demonstrating a limited applicability of the method in its primal form. Subsequently, Bayesian analysis was undertaken to enable accurate age estimation from individual components in both sexes. Bayesian parameters obtained with females suggest that McKern-Stewart's components fail to accommodate for age-related changes within the female pubic bone. Improved accuracy percentages and reduced inaccuracy values were obtained with Bayesian analysis in males. With females, the error computations were high. Weighted summary age models were utilized for multivariate age estimation, and furnished inaccuracy values of 11.51 years (males) and 17.92 years (females). Error computations obtained with descriptive analysis, Bayesian analysis, and principal component analysis demonstrate the limited applicability of McKern-Stewart's components in generating accurate age profiles for Indian males and females. The onset and progression of age-related changes within the male and female pubic bone may be of interest to biological anthropologists and anatomists involved in exploring the underlying basis for aging.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report.

Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.

MDCT evaluation of Dorsal Pancreatic Artery and Intrapancreatic arcade anatomy.

OBJECTIVE: The purpose of the study was to analyze the anatomy and variations in the origin of the dorsal pancreatic artery, greater pancreatic artery and to study the various types of arterial arcades supplying the pancreas on multidetector CT (MDCT). METHODS: A retrospective analysis of 747 MDCT scans was performed in patients who underwent triple phase or dual phase CT abdomen between December 2020 and October 2022. Variations in origin of Dorsal pancreatic artery (DPA), greater pancreatic artery (GPA), uncinate process branch were studied. Intrapancreatic arcade anatomy was classified according to Roman Ramos et al. into 4 types-small arcades (type I), small and large arcades (type II), large arcades (type III) and straight branches (type IV). RESULTS: The DPA was visualized in 65.3% (n = 488) of cases. The most common origin was from the splenic artery in 58.2% (n = 284) cases. The mean calibre of DPA was 2.05 mm (1.0-4.8 mm). The uncinate branch was seen in 21.7% (n = 106) with an average diameter of 1.3 mm. The greater pancreatic artery was seen in 57.3% (n = 428) predominantly seen arising from the splenic artery. The most common arcade anatomy was of Type II in 52.1% (n = 63) cases. CONCLUSION: Pancreatic arterial variations are not very uncommon in daily practice. Knowledge of these variations before pancreatic surgery and endovascular intervention procedure is important for surgeons and interventional radiologist.

Age estimation from iliac auricular surface using Bayesian inference and principal component analysis: a CT-based study in an Indian population.

Age estimation constitutes one of the pillars of human identification. The auricular surface of the ilium presents as a durable and robust structure within the human skeletal framework, capable of enabling accurate age estimation in older adults. Amongst different documented auricular age estimation methods, the Buckberry-Chamberlain method offers greater objectivity through its component-based approach. The present study aimed to test the applicability of the Buckberry-Chamberlain method in an Indian population through a CT-based examination of the auricular surface. CT scans of 435 participants undergoing CT examinations following the advice of their treating physicians were scrutinized for different age-related auricular changes. Three of the five morphological features described by Buckberry-Chamberlain could be appreciated on CT scans, and thus further statistical analysis was restricted to these features. Transition analysis coupled with Bayesian inference was undertaken individually for each feature to enable age estimation from individual features, while circumventing age mimicry. A Bayesian analysis of individual features yielded highest accuracy percentages (98.64%) and error rates (12.99 years) with macroporosity. Transverse organization and apical changes yielded accuracy percentages of 91.67% and 94.84%, respectively, with inaccuracy computations of 10.18 years and 11.74 years, respectively. Summary age models, i.e. multivariate age estimation models, derived by taking this differential accuracy and inaccuracy into consideration yielded a reduced inaccuracy value of 8.52 years. While Bayesian analysis undertaken within the present study enables age estimation from individual morphological features, summary age models appropriately weigh all appreciable features to yield more accurate and reliable estimates of age.

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients?

Both apixaban and enoxaparin are Food and Drug Administration-approved standard therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the other is still controversial. With an objective to observe efficacy and safety outcomes of apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA) arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Efficacy outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were found to be equally efficacious in preventing venous thromboembolism; however, apixaban had a better safety profile. The apixaban group had nonsignificant higher tendency for wound discharge, atrial fibrillation and transient ischaemic attack. Enoxaparin had nonsignificant greater tendency for bleeding, wound dehiscence and pulmonary complications. Apixaban is a safe alternative to conventionally used enoxaparin for chemoprophylaxis in patients undergoing THA or TKA.

Computed tomographic evaluation of the acetabulum for age estimation in an Indian population using principal component analysis and regression models.

The acetabulum presents as a well-preserved evidence, resistant to taphonomic degradation changes and can thus aid in the age estimation process. A CT-based examination of the acetabulum can further help simplify the process of age estimation by overcoming the time-consuming process of maceration and by doing away with the interference resulting from tissue remnants. The aim of the present study was to evaluate the role of the acetabulum for age estimation in an Indian population through a CT-based examination, using principal component analysis and regression models. CT images of 400 individuals aged 10 years and above were evaluated according to the features defined in the San-Millán-Rissech method of age estimation. Five of the seven morphological features defined by San-Millán-Rissech were appreciable on CT scans, and, to enable further statistical analysis, a cumulative score was computed using these five features. A significant correlation of 0.835 and 0.830 for the right and left acetabulum, respectively, was obtained between computed cumulative scores and chronological age of individuals. No significant sex differences were observed in the scoring of different age-related morphological changes. Regression models were generated using individual features and cumulative scores. Regression models derived using the cumulative score yielded inaccuracy values of 9.67 years for the right acetabulum and 9.15 years for the left acetabulum. Inaccuracy and bias values were computed for each individual feature, as well as for each decade, using mean point ages established within the original study. Amongst the various features, acetabular rim porosity was seen to have the lowest values of inaccuracy (11.50 years) and bias (2.32 years) and activity on outer edge of acetabular fossa the highest (inaccuracy and bias values of 22.36 years and 21.50 years, respectively). Taking into consideration this differential contribution towards age estimation, weighted coefficients and mean point ages for different morphological features were determined using principal component analysis. Subsequently, summary age models were generated from the obtained weighted coefficients and mean age values. Summary age models derived in the present study yield lower estimates of inaccuracy of 7.60 years for the right acetabulum and 7.82 years for the left acetabulum. While regression models derived in the present study allow for age estimation using even a single appreciable feature, summary age models take into account the contribution of each feature and generate more accurate estimates of age. Both statistical computations yield reduced error rates and thus can render greater applicability to the acetabulum in forensic age estimation.

CT-based evaluation of the acetabulum for age estimation in an Indian population.

Age estimation constitutes an important aspect of forensic research, investigation and human identification. For the purpose of age estimation, various markers within the skeletal framework are employed. Degenerative morphological changes in the skeleton can be used for age estimation in adults. Amongst the various bones, age-progressive changes in the innominate bone are of particular significance in age estimation. Within the pelvis, the acetabulum presents as a durable and well-preserved evidence, characteristic manifestations of which can be employed for age estimation. The present study aimed at a CT-based evaluation of acetabular changes for the purpose of age estimation in an Indian population. CT images of 250 individuals aged 10-88 years were scrutinized according to the features defined in the Calce method of acetabular age estimation. Scores were allotted to the various features and a cumulative score was calculated. No significant bilateral and sex differences were observed. Significant correlation was obtained between the scores for these defined characteristics and the chronological age of individuals. Population-specific regression models were generated for age estimation. The scoring method devised in the present research requires further validation as it represents a new tool for age estimation in medico-legal cases.

Management options for post-esophagectomy chylothorax.

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Vanishing aneurysms in Behcet's disease - A case series.

Behçet's disease is a systemic vasculitis with a wide spectrum of manifestations. Although pulmonary involvement is typical, the presence of pulmonary arterial aneurysms is associated with a high incidence of mortality and morbidity. We report two cases of Behçet's disease with pulmonary arterial involvement who presented with hemoptysis, showed significant treatment response, thus, highlighting the importance of early diagnosis and therapeutic management.

MDCT evaluation of pancreatic contour variations in head, neck, body and tail: surgical and radiological significance.

OBJECTIVE: The purpose of the study was to investigate the incidence of pancreatic contour variations on multidetector CT (MDCT) for abdominal examinations. METHODS: A retrospective analysis of 700 MDCT scans was performed in patients who underwent triple phase CT abdomen between October 2018 and January 2021. After excluding 176 patients, finally total of 524 patients were included in the study. For simplification, we classified the pancreatic contour variations as classified by Ross et al. and Omeri et al. Pancreatic head-neck variations was classified into Type I-anterior, Type II-posterior and Type III-horizontal variety. Pancreatic body-tail variation was divided into Type Ia-anterior projection; Ib-posterior projection and Type IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail. RESULTS: The most common type of variation in the head was Type II (n = 112, 21.3%) followed by Type III (n = 37, 7%) and Type I (n = 21, 4%). The most common type of variation in the body of pancreas was Type Ia (n = 33, 6.2%) followed by Type Ib (n = 13, 2.4%). In the tail region of pancreas, the most common variation was Type IIb (n = 21, 4%) followed by Type IIa (n = 19, 3.6%). CONCLUSION: Pancreatic contour variations are not very uncommon in daily practice. Knowledge of these variations is important for surgeons, radiologists and avoids misjudgement of normal pancreatic tissue as tumor or lymph node especially on unenhanced or single phase MDCT.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision.

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

Retrograde radial arteriovenous fistula, post coronary artery intervention.

BACKGROUND: Radial arteriovenous fistula (AVF) post coronary artery intervention is rare. METHODS AND CONCLUSION: Here we describe an extremely rare case of radial AVF with retrograde filling through the deep palmar arch and presenting as early ischemic changes.

Large sternal exostoses presenting as stridor: A surgical and anesthetic challenge.

BACKGROUND AND AIMS: Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. METHODS: Here we present a case of large chest wall osteochondroma as a part of hereditary multiple exostoses in a 9-year-old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. RESULTS: The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia before the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.

Laparoscopic retrieval of impacted and broken dormia basket using a novel approach.

We encountered a 73-year-old patient who presented with right upper abdominal pain and jaundice. On evaluation, he was found to have cholelithiasis with choledocholithiasis. Endoscopic retrograde cholangiography was attempted, but during the procedure, the wire snapped and the dormia basket got retained in the common bile duct (CBD). Laparoscopic CBD exploration was performed and the basket with calculus was found impacted in the lower CBD. The basket was disengaged by holding its tip through another dormia introduced through choledochoscope and basket with all calculi retrieved. Clearance of CBD was ascertained with choledochoscopy and CBD was closed primarily. He did well in the post-operative period and was discharged on the 5th post-operative day. At 1-year follow-up, the patient was doing well. Laparoscopic CBD exploration is a feasible and safe option for the retained dormia basket. We utilised the 'dormia with dormia technique' to retrieve the impacted basket which has not been reported before.

Combined hyperdense gallbladder wall-lumen sign: new computed tomography sign in acute gangrenous cholecystitis.

PURPOSE: The objective of our study was to evaluate the combined hyperdense gallbladder wall-lumen sign on computed tomography (CT) in diagnosing gangrenous cholecystitis. MATERIAL AND METHODS: We retrospectively reviewed the unenhanced CT scans of surgically proven cases of acute gangrenous (GCh) and non-gangrenous cholecystitis (nonGCh). Eleven cases of pathologically proven acute gangrenous cholecystitis and 12 consecutive cases of surgically proven acute non-gangrenous cholecystitis that underwent CT at our institute were included in the study so as to have 1 : 1 control. The Hounsfield unit (HU) value of the gallbladder wall and intraluminal bile was measured. Interobserver variability for individual CT findings was also assessed. RESULTS: The gangrenous cholecystitis group had significantly higher HU values of wall and bile (median value of 33 HU vs. 21 HU and median value of 21 HU vs. 8.5 HU, respectively, p < 0.05). The area under the receiver operator characteristic curve for HU lumen was 0.80 (95% CI: 0.62-0.98, p = 0.014) with an ideal cut-off at 31.5 HU, where the sensitivity was 54.5% and specificity was 91.7%. HU lumen has an even better assessment for gangrenous cholecystitis with AUC of its ROC as 0.92 (95% CI: 0.80-1.00, p = 0.001) with an ideal cut-off at 12.5 HU, where the sensitivity was 81.8% and specificity was 91.7%. The combined wall-lumen cut-off is 35 HU with sensitivity of 100% and specificity of 75%. CONCLUSION: A cut-off CT density value of the gallbladder wall of more than 31.5 HU, intraluminal bile more than 12.5 HU, and combined wall-lumen HU of more than 35 can predict GCh.

Thoracoscopic oesophagectomy for end-stage achalasia.

Achalasia cardia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of the lower oesophageal sphincter. The management is predominantly palliative with focus on addressing the sphincter that involves either pneumatic dilatation or Heller myotomy which relieves dysphagia in the majority of the cases. End-stage achalasia (ESA) is characterised by failed myotomy, massively dilated and tortuous oesophagus with nutritional deterioration due to progressive dysphagia and vomiting. In these subgroups of patients, oesophagectomy may be the last resort. While oesophagectomy has been described for ESA before, thoracoscopic oesophagectomy has not been reported previously. Hereby, we report our experience of performing minimally invasive oesophagectomy (thoracoscopic) with the gastric pull-up.