Discordant intestinal malrotation in adult monozygotic twins discovered incidentally during laparoscopic gastric bypass: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Intestinal Malrotation is an uncommon entity in the adult population; more so in monozygotic twins, where concordance is expected. In literature, discordant intestinal Malrotation has only been discovered when one twin became symptomatic, and the other was screened. To the best of our knowledge, this is the first documented case of discordant adult type intestinal Malrotation in otherwise asymptomatic monozygotic twins discovered incidentally during Laparoscopic Roux-en-Y Gastric bypass (LRYGB). CASE PRESENTATION: Twins A and B met the NIH criteria for bariatric surgery, neither having symptoms of acute or chronic volvulus or history of intraabdominal surgery. Twin A had a LRYGB performed by a trained bariatric surgeon, noting no anatomic anomalies. 5 months later, Twin B had LRYGB and intestinal Malrotation was diagnosed incidentally. CLINICAL DISCUSSION: Diagnosis of Intestinal Malrotation is rare in adults, usually discovered after becoming symptomatic or during abdominal imaging for another indication. Two cases of discordant intestinal Malrotation in monozygotic twins have been documented, both discovered when one twin became symptomatic due to acute volvulus, suggesting epigenetic phenomena. When discovered incidentally during surgery, patients can safely undergo their intended procedure, but literature suggests prophylactic division of Ladd's bands, while appendectomy is left to the discretion of the surgeon. CONCLUSIONS: Intestinal Malrotation appears to be associated with epigenetic phenomena and if discovered incidentally during surgery, the proposed procedure can be carried out by an experienced surgeon, in addition to division of Ladd's bands and appendectomy.

Minimally invasive oesophagectomy: The first case report of a thoracolaparoscopic oesophagectomy done in the Caribbean.

INTRODUCTION: Minimally invasive oesophagectomy is one of the options in the armamentarium of a modern surgeon when faced with treating oesophageal cancer. Trinidad and Tobago has successfully treated a patient using this method. This case report adds to the rich surgical history in the Caribbean. CASE PRESENTATION: Our patient presented with progressive dysphagia, and after being worked up was diagnosed with oesophageal cancer. He underwent neoadjuvant chemotherapy and had a minimally invasive McKeown oesophagectomy done by a fellowship trained, advanced laparoscopic oesophageal and gastric surgeon. CONCLUSION: The patient had an uneventful recovery and was tumor free with excellent quality of life at 4 years, showing that the Caribbean is keeping up with the rest of the surgical world.

The caged bird sign of achalasia: A case series describing a new radiologic sign that can be reliably used in a resource-poor setting to diagnose achalasia.

INTRODUCTION: Achalasia is an uncommon oesophageal motility disorder caused by failed relaxation of a hypertensive lower oesophageal sphincter in response to swallowing. It often manifests clinically with symptoms such as dysphagia, regurgitation, and weight loss. Manometry is considered the gold standard diagnostic test in diagnosing this condition. However, it is not always accessible, especially in the resource-limited setting. Other radiological adjuncts, such as barium oesophagram, often show features that are highly suggestive of achalasia: the bird-beak appearance of the distal oesophagus, and a dilated oesophagus (megaoesophagus) containing food residue, which may then progress to become tortuous (sigmoid) or aperistaltic. Thus, the use of these tests play a significant role in the identification of this condition. CASE PRESENTATION: Three patients were diagnosed with achalasia at the San Fernando General Hospital, Trinidad and Tobago. Together with characteristic symptoms, barium oesophagrams demonstrated features of achalasia, bearing a close resemblance to those of a caged bird. The barium oesophagrams were scrutinized by a fellowship trained, upper GI advanced laparoscopic surgeon, and the consistent features described were noted. CONCLUSION: In the setting where manometry is not accessible, barium oesophagram plays an important role. We propose that recognition of easily identifiable features such as the "caged bird sign of achalasia" on this imaging modality can assist in the diagnosis of this entity.

A Giant Gallstone: The Largest Gallstone Removed Laparoscopically in the World.

Trinidad and Tobago, a small twin island republic off the coast of Venezuela, is leading the Caribbean in laparoscopic surgery. While giant gallbladders are usually difficult to operate on and have a high conversion rate from laparoscopic to open procedure, in Trinidad and Tobago a laparoscopic cholecystectomy involving a giant gallbladder and the largest gallstone ever removed laparoscopically was performed uneventfully.

Totally Laparoscopic Whipple's Operation: Initial Report from the Caribbean.

Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple's operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple's operation to be performed in the Caribbean.

Mature Cystic Teratoma Hiding in the Retroperitoneum of an Adult.

We report a rare case of a mature cystic teratoma found in the retroperitoneum of a 28-year-old woman with vague symptomatology. We review the radiologic and pathologic features of this rare lesion.