Cystic teratomas are rare pluripotent embryonic tumors which most commonly originate in gonadal organs. Extra-gonadal cystic teratomas are exceedingly uncommon, accounting for only 1% of all cystic teratomas, and have been reported in unusual locations including the kidney, mediastinum and liver. These extra-ovarian cystic teratomas have also been known to harbor other neoplasms including carcinoid tumors. In this report, we describe a unique case of a hepatic cystic teratoma occurring as a combined tumor with a carcinoid in a young female. The patient underwent elective laparoscopic resection of her tumor after extensive radiographic and endoscopic work-up for chronic, non-localizable abdominal pain. We believe the carcinoid tumor arose de novo from committed differentiation of a cell line within the teratoma, and not metastatic spread.

Flexible endoscopy has become an integral part of managing many surgical problems that in the past required open or laparoscopic surgical interventions. Stents, clips, suturing devices, glues, and vacuum systems can be used to control perforations, leaks, and fistulas in properly selected patients. Stents have gained place in the treatment algorithm for patients with esophageal perforation from various causes. Endoscopic clips are being used to close perforations in the gastrointestinal tract in addition to their use for bleeding. The technology is slowly evolving and larger clips are available for over-the-scope use. Early perforations and leaks can be managed with clips. Various suturing devices are available for endoscopic suturing mainly for upper gastrointestinal tract. Many of the devices were initially designed for antireflux procedures and are used for closure of perforations and fistulas. The research in closure techniques for enterotomies in natural orifice surgery has expanded its role in the management of iatrogenic perforations. In this article, we review the current literature and describe the role of flexible endoscopy for treatment of leaks and fistulas.

INTRODUCTION:Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition.METHODS:A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy.RESULTS:Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but was converted to open in three. One patient had an open procedure from start to finish. Pathology showed changes compatible with nesidioblastosis with varying degrees of hyperplasia of islets and islet cells. Follow-up ranged from 8-54 (median, 22) months. All patients initially reported marked relief of symptoms. Over time, two patients had complete resolution of symptoms; three patients developed occasional symptoms (once or twice per month), which did not require any medication; two patients developed more frequent symptoms (more than twice per month), which were controlled with medications; and two patients had severe symptoms refractory to medical therapy (calcium channel blockers, diazoxide, octreotide).DISCUSSION:Postprandial hypoglycemia after gastric bypass surgery with endogenous hyperinsulinemia is being increasingly recognized and reported in the literature. Our experience with nine patients is one of the largest. The etiology of this condition is not entirely understood. There may be yet unknown factors involved but increased secretion of glucagon-like peptide 1 and decreased grehlin are being implicated in islet cell hypertrophy. There is no "gold standard" treatment-medical or surgical-but distal pancreatectomy to debulk the hypertrophic islets and islet cells is the main surgical modality in patients with severe symptoms refractory to medical management.

BACKGROUND:Laparoscopic antireflux surgery (LARS) has replaced the open approach in most centers and has become the standard surgical treatment of this disease. One of the controversial technical issues is whether to use a bougie or not at the time of wrap. The aim of the study was to evaluate the long-term consequences of LARS in a series of patients without bougie.METHODS:An institutional review board-approved study was conducted for patients who underwent LARS between 1998 and 2005. Patients were contacted and an SF-12 form was completed. Their charts were reviewed. Patient characteristics, preoperative evaluation, intraoperative details, and postoperative course were studied.RESULTS:Overall, 135 patients were identified who underwent LARS from 1998 to 2005 with no bougie. Only 123 patients could be contacted for the study. Preoperative work-up included EGD in 100%, manometry in 98%, and 24-hour pH study in 25% of patients. Postoperative dysphagia to solids was seen in 11 of 123 (8.9%) patients. One patient (<1%) had dysphagia to liquids. Five patients (4%) had severe dysphagia. EGD and dilatation was required in 5 of 123 (4%) patients. Ten patients (8.1%) had recurrent reflux requiring medication. Also, 4 of 123 (3.2%) patients had bloating symptoms and 2 of 123 (1.6%) patients had difficulty vomiting. The mean follow-up of patients was 38.6 months.CONCLUSIONS:The overall rate of dysphagia in this series following LARS without bougie was 8.9%. Mild to moderate dysphagia was seen in 6 of 123 (4.8%) and 4% patients had severe dysphagia requiring dilatation. Endoscopic dilatation was successful in relieving symptoms in patients with severe dysphagia. The incidence of severe dysphagia reported in the literature is 2-5% and recurrent reflux 5-15%. Rate of dysphagia was comparable to other series reported in the literature, as was the rate of recurrent reflux. Based on our series of patients, LARS without bougie appears to be effective in terms of postoperative dysphagia and recurrent reflux.