Authors L. THIJS (1), M. ASBASBASSI (2), G. LAMBRECHT (3), M.COOL (3), G. DEBOEVER (3) / [1] Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroenterology and Hepatology, [2] AZ Damiaan, Oostende, Belgium, General Surgery,[3] AZ Damiaan, Oostende, Belgium, Gastro-enterology
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Results Introduction Laparoscopic hernia repair is one of the most frequently performed procedures in general surgery. The preferred method is the ‘totally extraperitional’ (TEP) hernia repair [1]. Mesh migration into the gastro-intestinal tract is a rare complication of this procedure. The presenting symptom of mesh migration can be abdominal pain, obstruction, fistula, abscess or hematochezia. Diagnosis is made by CT scan. We present a case mesh migration into the caecal wall detected by colonoscopy.
Case report A 44-year old male patient with a family history of colon cancer was referred for a screening colonoscopy. His previous medical history includes a bilateral totally extraperitoneal inguinal hernia repair in 2014. A lightweight polypropylene mesh was used to repair the hernia. Clips were placed during the surgery to seal a gap in the peritoneum. Since this operation he complained of mild chronic lower abdominal pain, without blood loss or change in bowel habits. On a computed tomography (CT) scan performed in February 2015 no explanation for his symptoms was found. During colonoscopy a mesh-like structure, which could not be removed from the colonic wall, was observed in the caecal region. Further investigation by CT scan of the abdomen confirmed the migration of the mesh through the wall of the caecum. There was also a small amount of free air in the peritoneal cavity, but no abscess was found. The patient was referred for laparoscopic exploration and a caecal resection was performed. The unmigrated portion of the mesh was left in situ and the peritoneal defect was closed.
Discussion There are two groups of groin hernia repair techniques: the open tension-free techniques with mesh and the laparoscopic repair techniques. Laparoscopic inguinal repair techniques involve the transabdominal preperitoneal technique (TAPP) and the totally extraperitional technique (TEP). With the TAPP technique the abdominal cavity is entered, leading to the possibility of injury to the intraperitoneal contents [7]. In TEP, the peritoneal cavity is not entered during the surgery and the hernia is sealed from outside the peritoneum [1]. In English literature only 5 cases of mesh migration into the large intestine after laparoscopic inguinal hernia repair were reported [9-10]. Mesh migration into the intestine can lead to fistula, intestinal obstruction and intra-abdominal abscess. [10] . It can cause chronic abdominal pain, change in bowel habits or hematochezia, but sometimes remains completely asymptomatic. Migration of the mesh can be explained by two mechanisms. Primary mesh migration happens when an inadequately connected mesh traverses the adjacent anatomical paths of least resistance or when a relatively connected mesh is shifted by external forces [2,4,6]. Secondary mesh migration occurs through anatomical borders and is caused by chronic inflammation due to foreign body reaction [5,6] . There are multiple factors that determine the risk of mesh migration [2, 6, 10] , such as: - The type of mesh materials. There is more chronic inflammation and fibrosis with the polypropylene meshes [10]. - Inadequate fixation of the prosthetic device can also lead to migration of the mesh [11] . - Placement of the mesh plug too deep within the inguinal canal also predisposes to migration of the mesh [11] . - Direct contact between the mesh and viscera [9-10] . - Chronic inflammation accompanying diverticular disease could support erosion through the bowel wall. Mesh migration into the colon is generally managed by resection of the involved bowel [9] . Only one report of endoscopic mesh removal was found in literature (table 1). The mesh was intraluminal and adherent to the splenic flexure. An alligator forceps was used to remove the mesh[12] . Endoscopic attempts of mesh removal increase the risk of damage to the colonic wall and surrounding structures and could lead to intra-abdominal infection.
Conclusion Mesh migration into the gastro-intestinal tract is a rare complication of laparoscopic inguinal hernia repair. The presenting symptom can be abdominal pain, obstruction, fistula, abscess or hematochezia. It can also occur completely asymptomatic. Diagnosis is made by CT scan or colonoscopy. The treatment of choice is surgical resection of the affected bowel.
Authors T. DEMARET (1), S. VARMA (1), X. STEPHENNE (1), F. SMETS (1), I. SCHEERS (1), L. VAN MALDERGEM (2), R. REDING (3), E. SOKAL (1) / [1] Cliniques Universitaires Saint-Luc, , Belgium, Pediatric gastroenterology & hepatology, [2] Centre Hospitalier Régional Universitaire de Besançon, Besançon, France, Center for human genetics, [3] Cliniques Universitaires Saint-Luc, , Belgium, Pediatric surgery and abdominal transplantation
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Results Mild Zellweger spectrum disorder, also described as Infantile Refsum disease, is attributable to mutations in PEX genes. Its clinical course is characterized by progressive hearing and vision loss, and neurodevelopmental regression. Supportive management is currently considered the standard of care, since plasmalogen supplementation, low phytanic acid diet, cholic acid, and docosahexaenoic acid have not shown clinical benefits. Liver transplantation (LT) was shown to correct levels of circulating toxic metabolites, partly responsible for chronic neurological impairment, with LT survival currently being >95%. Of three patients having undergone LT for mild ZSD, one died after LT, while the other two displayed significant neurodevelopmental improvement on both the long- (17 years post-LT) and short-term (9 months post-LT) follow-up. We documented a sustained improvement in the biochemical profile, with a complete normalization of plasma phytanic, pristanic and pipecolic acid levels. This was associated with improved clinical evolution, puberty achievement, as well as stabilization of hearing and visual functions, and neurodevelopmental status, which has enabled the older patient to lead a relatively autonomous lifestyle on the long-term. The psychomotor acquisitions have been remarkable. Specially seen in comparison to their affected siblings who did not undergo LT and exhibited a poor neurological outcome with severe disabilities. Based on our short- and long-term follow-up experience, we speculate that LT performed before the onset of severe sensorineural defects in mild ZSD, enables partial metabolic remission and improved long-term clinical outcomes.
Authors C. MOURADIDES (1), I. BORBATH (1), P. DEPREZ (1), T. MOREELS (1) / [1] Cliniques Universitaires Saint-Luc, , Belgium, Hépato-Gastroentérologie
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Results We report the case of a 71 year old female with a pancreatic head adenocarcinoma, previously treated with Whipple resection with pyloric conservation and adjuvant chemotherapy. However, progression to peritoneal carcinomatosis and local recurrence lead to upper GI obstructive symptoms. Initially the obstruction was treated by means of an uncovered metallic enteral stent, which ended up in the afferent limb, obstructing the alimentary limb, leading to gastric outlet syndrome. The uncovered metallic enteral stent could not be removed because of tumor ingrowth. Peritoneal carcinomatosis rendered the patient not suitable for surgical treatment. There was no endoscopic access to the alimentary limb via or beside the metallic enteral stent because of tumor ingrowth. An endoscopic gastrojejunostomy was then performed, using the HotAxios system (XLumina Axios, Boston Scientific), under EUS guidance (linear array echoendoscope GF-UCT 180, Olympus, Japan) and fluoroscopy: the alimentary limb was identified by transgastric EUS, accessed with a 19G needle, and confirmed fluoroscopically by injection of intraluminal constrast dye. Next, a 0.035inch guidewire was placed, allowing smooth introduction of the HotAxios stent deployment system into the alimentary limb. The fully covered HotAxios stent was then deployed under fluoroscopic and endoscopic guidance, with the distal part in the intestinal lumen, and the proximal flange in the stomach. However, upon release, it immediately migrated outside the stomach. So a second metallic esophageal covered stent (Taewoong Medical Niti, 8cm, 22mm) was placed over the guidewire inside the HotAxios stent, with the proximal part protruding into the gastric lumen. After the procedure, the patient was able to resume oral feeding. 3 months later, she was readmitted for recurrent vomiting due to a migration of the esophageal stent into the stomach, whereas the HotAxios stent was still in place. A new fully covered Nagi stent (Taewoong Medical, 20mm and 16mm diameter) was placed inside the HotAxios stent. 3 months later, a control gastroscopy showed the stents were in correct position and the endoscopic gastrojejunostomy was patent. She finally died due to progression of her malignant disease, 7 months after the endoscopic creation of the gastrojejunostomy. This case illustrates the feasibility of the HotAxios sytem to create an endoscopic gastrojejunostomy to treat malignant gastric outlet syndrome in altered anatomy. Endoscopic ulstrasound-guided gastrojejunostomy is an alternative to surgical gastrojejunostomy to treat benign and malignant gastric outlet syndrome, in normal and surgically altered anatomy. Lumen apposing metallic stent placement reduces the risk of stenosis recurrence classically described in uncovered metallic stents, and prevents migration encountered with covered metallic stents. Technical success rate has recently been reported to be 92%, and clinical success 85%.
Authors M. STRUYVE (1), C. LANGMANS (2), G. ROBAEYS (3) / [1] UZ Leuven Gasthuisberg, Leuven, Belgium, Gastroenterology and Hepatology, [2] UZ Leuven Gasthuisberg, Leuven, Belgium, Internal Medicine, [3] Ziekenhuis Oost Limbug, Genk, Belgium, Gastroenterology and Hepatology
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Results A 64-year-old man was seen at the outpatient clinic complaining about progressive dysphagia since the last week. He suffered from a pronounced intent to vomit, an excessive salivation and a vague chest pain. Physical examination was unremarkable. Prior medical history revealed intermittent dysphagia the past two years with an episode of acute dysphagia one year ago due to a food impaction that was endoscopically removed. The esophagogastroduodenoscopy (EGD) at that time showed a benign esophageal stricture in the distal esophagus. Biopsy specimens that were taken from the stricture at that time showed active esophagitis and the presence of mycosis. The patient had been successfully treated with proton pump inhibitors and antimycotics for respectively four and two weeks and there was no recurrence of severe dysphagia until today. Because of a recurrent episode of severe dysphagia today, a new EGD was performed as next step in the evaluation of this case. Endoscopic evaluation showed a stenosis of the distal esophagus that could be passed by the scope. Because of the vague chest pain already present before the procedure, we performed a standard chest X-ray that revealed free air as a sign of a pneumomediastinum (Fig. 1A). We consequently performed a computed tomography (CT) scan of the chest which confirmed the presence of a pneumomediastinum with dominant localization around the esophagus from the level of the gastroesophageal junction to the cervical base (Fig 1B). Small intramural air bubbles in the proximal part of the esophagus were seen on these CT images suggestive for intramural esophageal pseudodiverticulosis (EIPD). The next diagnostic step was to perform an X-ray esophagogram with Telebrix gastro® (joxitalamaat, meglumine) which could not reveal a leakage of contrast but revealed pathognomonic signs of EIPD. It also showed a linear to circular loss of filling probably due to the stenosis in the distal esophagus that was visualized on the EGD (Fig. 2A,B,C,D,E). We admitted the patient in the hospital for transient fasting, proton pump inhibitors and treatment with intravenous antibiotics and total parenteral nutrition. Radiographic control after one week no longer showed the presence of free air as a sign of a pneumomediastinum. Oral feeding was restarted without problems and the patient was discharged out of the hospital. Follow-up consultation was scheduled and a balloon dilatation of the stenosis will be considered.
Dysphagia is a common complaint of patients seen at the outpatient clinic as well as at the emergency room. The differential diagnosis is broad and includes common causes such as gastroesophageal reflux disease, strictures, webs, tumors, foreign bodies, functional disorders etc. that are well known by physicians. We report here EIPD as a cause of dysphagia that is less known by physicians and it is rarely described in the literature. EIPD is characterized by multiple, segmental or diffuse, flask-like outpouchings in the esophageal wall corresponding to dilated and inflamed excretory ducts of the submucosal esophageal glands. The underlying etiology still remains unclear. Symptoms can be various, but the predominant symptom is dysphagia. Esophageal strictures, esophageal candidiasis and gastroesophageal reflux disease are often associated. The diagnosis can be made by upper gastrointestinal endoscopy, but barium esophagography is the modality of choice. Complications of EIPD are rare and include broncho-esophageal and esophagomediastinal fistula, pleural and pericardial effusion, abscesses, gastrointestinal bleeding from a web-like stenosis or esophageal perforation with pneumomediastinum like in our case. The treatment for EIPD should be directed towards treating underlying associated conditions and relieving symptoms rather than the pseudodiverticulosis itself.
Authors L. WAUTERS (1), K. PEETERS (2), A. VAN HOOTEGEM (3), P. GOETSTOUWERS (3), P. DELVAUX (2), J. CALLENS (3) / [1] UZ Leuven, Leuven, Belgium, Gastroenterology, [2] AZ-KLINA, Brasschaat, Belgium, General Surgery, [3] AZ-KLINA, Brasschaat, Belgium, Gastroenterology
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Results Small bowel obstruction due to an enterolith expelled from Meckel’s diverticulum is a rare condition. Diagnosis may be challenging when calculi are not radio-opaque and delayed treatment can lead to complications of bleeding or perforation. We present a case of small bowel obstruction resulting from a Meckel’s enterolith. A 42-year-old man presented to the emergency department (ED) with exacerbation of intermittent and colicky abdominal pain, which he had been experiencing for the past 10 days. His last bowel movement the previous day was normal and he reported nausea with bilious vomiting. He was recently admitted at the same hospital for similar complaints with an episode of non-bloody diarrhea 48h after a barbecue. At that time, there was mild abdominal distention and tenderness without peritoneal signs and a temperature of 38.1°C. C-reactive protein (CRP) level was 119 mg/L (normal range 0 - 5 mg/L) with normal white blood cell (WBC) count and there was radiological evidence of dilated small bowel loops with air fluid levels. The patient was discharged after his symptoms had quickly resolved with intravenous analgesia. An empirical treatment with Azithromycin was prescribed for suspected Campylobacter enteritis, but stool culture was negative. He had a history of Salmonella enteritis with normal ileocolonoscopy and biopsies and no prior abdominal surgery. Upon presentation, physical examination revealed diffuse abdominal pain on palpation. CRP level was 70.7 mg/L and WBC count 25.07 x1000/μL (normal range 3.45 - 9.76 x1000/μL) with no further abnormalities. Abdominal X-rays suggested small bowel obstruction with absence of gas in the colon and rectum. Abdominal CT-scan confirmed a mechanical obstruction due to a well-defined structure (35mm in diameter) with a central high-density component proximal to the caliber change located in the ileum and suggestive of an impacted food bolus. There was no evidence of appendicitis, ileitis or pneumobilia. Following surgical consult, laparoscopy was performed with resection of a large Meckel’s diverticulum located 50cm proximally from the ileocecal valve. Histopathological evaluation showed a Meckel’s diverticulum of 6.0x4.5x1.5 cm with intestinal mucosa and no evidence of malignancy. On the second post-operative day, the patient experienced recurrent abdominal pain and vomiting, with clinical suspicion and radiological evidence of small bowel obstruction. Abdominal CT-scan showed the round structure as previously described that was displaced more distally and similarly located proximally to the transition point. On laparotomy, multiple loops of distended ileum surrounded by non-purulent fluid were seen and an impacted stone or enterolith was removed by longitudinal enterotomy. Biochemical analysis showed a composition of 60% cholesterol, 30% bilirubin and some calcite. A final diagnosis of small bowel obstruction secondary to an expelled Meckel’s enterolith was made. The postoperative course was uneventful and the patient was discharged home with no further episodes of abdominal pain.
