Johnson, Kevin N.

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

Abstract Introduction: Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy. Methods: Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized. Results: Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were 19 mm (IQR 17.3, 21) and 4.5 mm (IQR: 4.0, 4.8), respectively. Median time to first full feed was 8.5 hours (IQR: 6.6, 15.6). Twenty-three (69%) patients had postoperative emesis. Median length of stay postoperation was 26.5 hours (IQR: 21.1, 44.7). There were no reoperations for incomplete pyloromyotomy and no infections. On follow-up, 1 patient had prolonged postoperative emesis that resolved without further intervention and 1 patient on peritoneal dialysis before surgery had an incisional hernia that required operation in the setting of bilateral inguinal hernias. Conclusion: In a small series, the top to bottom assessment appears to confirm adequacy of pyloromyotomy.