Proximal small bowel intussusception occurring in an adolescent Crohn’s disease patient is an extremely rare entity. It is usually primary without a lead point and quite often a transient phenomenon. We report such transient and intermittent jejunal intussusception in a 16-year-old male, developing immediately in a postoperative period after a stoma reversal for jejunal stricture perforation peritonitis.

No abstract

Introduction Choledochal cysts (CCs) are uncommon biliary lesions. Considering the evolution of imaging, we describe our experience with the presentation and management of choledochal cysts. Methods A review of the records of all patients with choledochal cyst managed in our institute were retrospectively analyzed. The study analyzed clinical presentation, diagnosis, treatment and postoperative outcomes. Results Between 2015 and 2019, 30 CCs (male/female: 7/23) were operated. We observed more adults compared to children (17 vs. 13). The median age at surgery was 18.5 years (4-67 years). The presentation included abdominal pain (90%), pancreatitis (17%0, cholangitis (13%), and incidental diagnosis in (7%). Anomalous union of the bile duct and the pancreatic duct was seen in 17%. Two patients had synchronous cholangiocarcinoma. The cysts were classified (Todani’s): I: 26; IV:3; and V: 1. The patients underwent complete excision of the cyst and Roux-en-Y hepaticojejunostomy - 27; pancreaticoduodenectomy - 1; hepaticoduodenostomy - 1; and cholecystectomy with T-tube drainage - 1 patient. The operative complications were observed in 10 (33.3%) patients: biliary leaks (four), superficial surgical site infections (four), and cholangitis (three). Only one patient developed a major complication; required re-operation for bile leak peritonitis. There was no operative mortality. One patient with cholangiocarcinoma died with the disease at three months of surgery. The remaining 29 patients are doing well at a mean follow-up of 29.5 months (12-56). Conclusion Adults CCs now far outnumber children at the time of presentation. The majority were symptomatic Todani’s type I cyst. Complete cyst excision and bilio-digestive anastomosis is the best treatment for type I and IV CCs, thus eliminating the risk of malignancy with an excellent operative outcome.

Objective. With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. Methods. This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. Results. Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg’s type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. Conclusion. With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

Although peptic ulcer disease (PUD) is a common entity, the rate of its complication has decreased with the advent of proton pump inhibitors. We present a case of complicated PUD in a 49-year-old male patient having a rare combination of bleeding, gastric outlet obstruction, and a large choledochoduodenal fistula (CDF) who presented with shock. After resuscitation and investigations, ligation of bleeder via duodenotomy, Roux-en-Y choledochojejunostomy, and gastrojejunostomy was done for ulcer bleeding, CDF, and pyloric stenosis respectively. The patient improved after surgery. As with other emergency surgery, minimizing morbidity and mortality remains the principle of management. The best treatment in this situation irrespective of hemodynamic stability is surgery, which is a one-time and best treatment for bleeding, obstruction, and CDF.