High-resolution manometry features of paraesophageal hernia.

BACKGROUND: Paraesophageal hernias (PEH) can be associated with obstructive symptoms, but high-resolution manometry (HRM) characteristics have not been described in detail. METHODS: HRM studies of confirmed PEH patients (n = 60, 66.3 ± 1.5 years, 76.7% F), axial hernias (n = 125, 56.1 ± 1.1 years, 58.4% F), and healthy controls (n = 20, 27.9 ± 0.7 years, 45% F) were analyzed. Axial hernias (type 1) were compared to PEH subtyped as isolated PEH (type 2), PEH with axial hernia (type 3), PEH with herniated abdominal organs (type 4), and unknown. Distal contractile integral (DCI), esophageal length, lower esophageal sphincter pressures (LESP), EGJ contractile integral (EGJ-CI), and integrated relaxation pressure (IRP) were extracted. Intra-luminal pressures were measured proximal (intrabolus pressure, IBP) and distal (intragastric pressure, IGP) to EGJ. Univariate and multivariate analyses were performed to characterize esophageal and EGJ motor physiology in PEH. KEY RESULTS: PEH patients had LESP and EGJ-CI similar to controls; axial hernia patients had lower LESP. While IRP was within normal limits, PEH had elevated IBP and IGP, and shorter esophageal length compared to axial hernia and normal controls (P ≤ .0001 across groups). Short esophageal length was consistent across PEH subtypes (P = .06). On multivariate regression analysis, IBP remained an independent predictor of PEH (P < .0001). Within PEH subtypes, gastric pressure was higher when axial HH was also present, in contrast to isolated PEH (P = .03); other metrics did not differ. CONCLUSIONS & INFERENCES: Luminal pressure increase both upstream and downstream of the EGJ on HRM likely represents obstructive phenomena in PEH, identification of which may support suspicion of PEH.

Chronic ileitis with transmural migration of ingested foreign body treated by laparoscopy.

BACKGROUND: Ingestion of foreign bodies such as fish bone or chicken bone is relatively common in adults; however, resultant transmural migration is extremely rare. METHODS: We present a case of a 79-year-old woman with chronic low-grade abdominal pain, worsening over the last 4 days. Computed tomography revealed segmental small bowel wall thickening with chronic inflammation suggestive of Crohn's ileitis and oral steroids were commenced; only later, ingestion of a foreign body was suspected. RESULTS AND CONCLUSION: At diagnostic laparoscopy, a linear foreign body resembling a wooden splinter was identified. It had partly migrated through the chronically inflamed bowel wall without causing perforation or abdominal contamination. It was removed laparoscopically without an enterotomy or bowel resection. Microscopy revealed non-viable bone, likely fish or chicken bone. The patient made an uneventful recovery and was discharged 3 days later. Herein we emphasise on the differential diagnosis and presentation of chronically ingested foreign bodies, as well as the feature of chronic ileitis with uncomplicated transmural migration of the ingested foreign body that was treated laparoscopically without an enterotomy.

Endoscopic mucosal resection of a solitary metastatic tumor in the stomach: a case report.

Endoscopic mucosal resection (EMR) is increasingly being utilized in the management of early gastric cancer. Metastatic cancer of the stomach is uncommon. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) that was successfully excised with EMR. A 71-year-old man presented with iron deficiency anemia, he had undergone a radical nephrectomy for RCC 3 years previously. Upper gastrointestinal endoscopy revealed a malignant-appearing 10 × 12 mm polyp in the stomach. Histopathology of the biopsy revealed that it was a metastasis from RCC, confirmed by immunohistochemistry with Vimentin and CAM 5.2 positivity. Computed tomography and bone scanning revealed no other metastases. Simultaneous laparoscopy and upper gastrointestinal endoscopy revealed that the lesion was localized to the gastric mucosa. EMR of the tumor en bloc was performed successfully. Histology confirmed a complete excision. He had an uneventful postoperative course and is well 15 months after surgery, without any tumor recurrence.

Common facial vein: an alternative patch material in carotid angioplasty.

Patch angioplasty is a popular adjunct to carotid endarterectomy to facilitate arteriotomy closure. The long saphenous vein is the common autogenous patch in use. We tested the feasibility of using the ipsilateral common facial vein (CFV), which is usually sacrificed during exposure of the carotid bifurcation. A consecutive series of 17 patients undergoing carotid endarterectomy was examined to show the use of CFV patch in arteriotomy closure in 18 procedures. During exposure of the carotid bifurcation, the facial vein was harvested and distended with heparinized saline to assess the size of the vein. If the vein had an adequate diameter, it was everted and used as a double-layered patch. Patients were followed up postoperatively with serial duplex scanning at 3, 6 and 12 months, and yearly thereafter. The median (range) age of the patients in the series was 66 years (52-72 years). Of the 18 CFV harvested, 2 were rejected because of small calibre. The median (range) length of the vein harvested was 5 cm (4-6 cm). The average diameter of harvested vein was 5 mm. The median (range) time taken for harvesting, distending and everting the vein was 10 min (8-12 min). There were no perioperative deaths or strokes. There was no significant re-stenosis during the follow up of 24 months (18-36 months), with a mean peak velocity of 0.86 m/s (0.58-1.29 ). The use of everted CFV patch in carotid angioplasty is safe, quick, convenient and durable, whereas saphenous veins are spared and lower limb incisions avoided.

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture.

OBJECTIVE: To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures. METHODS: A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency. RESULTS: The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement. CONCLUSIONS: These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.