Pancreaticogastrostomy - an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy - experience from a tertiary care center of Pakistan.

Whipple's pancreaticoduodenectomy has been refined over the years to be a safe operation though the morbidity rate still remains high (30-50%). Pancreatic fistula is the most important cause of mortality following pancreaticoduodenectomy. To prevent it, surgeons have used two anastomotic techniques: pancreaticojejunostomy and pancreaticogastrostomy. Recent studies found that pancreaticogastrostomy is associated with fewer overall complications than pancreaticojejunostomy. This is a retrospective review of patients who underwent Whipple's at Aga Khan University Hospital and had pancreaticogastrostomy as a preferred anastomosis for pancreatic stump. Forty four patients met the inclusion criteria, 27 were male. No patient developed post-operative pancreatic fistula, 13 (31%) patients had morbidities including delayed gastric emptying 4(9.1%), wound infection 3(6.8%), and haemorrhage 6(13.6%). Mortality is reported to be 5 (11.9%). Pancreaticogastrostomy seems to be a safe alternative and easier anastomosis to perform with less post-operative morbidity and mortality. Further data should become available with greater numbers in the future. .

Intramural gas in stomach along with acute calculus cholecystitis: an unusual association.

Intramural gas in stomach is a rare finding, but differential diagnosis of this condition into gastric emphysema and emphysematous gastritis is clinically important because of vastly different aetiologies and prognosis. Emphysematous gastritis is caused by gas producing micro-organisms inside the stomach wall and is a potentially fatal condition, while, on the other hand, gas enters stomach wall through mucosal breach in the case of gastric emphysema and prognosis is usually good with complete resolution. To date, no case has been reported in the literature showing gas in the stomach wall in a patient with acute calculus cholecystitis. We present a case of a young man with upper abdominal pain, and who, upon diagnostic work up was diagnosed with acute calculus cholecystitis with associated intramural gas in the stomach with no known aetiological factors to be positive. Conservative management with close observation resulted in complete symptomatic resolution.

Ileosigmoid knotting- a rare variant of bowel volvulus.

Two patients with acute intestinal obstruction underwent exploratory laparotomy after adequate fluid resuscitation and radiological imaging. A preoperative diagnosis of sigmoid volvulus and an operative diagnosis of ileosigmoid knotting or compound volvulus were established.