What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally-invasive approaches including the implementation of robotic PD (RPD). In this key paper evaluation, we discuss the findings of Kalabin et al. whilst evaluating the 'true benefits' of RPD compared to the open approach for the treatment of PDAC.

AREAS COVERED

We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes.

EXPERT OPINION

RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD.In conclusion, RPD allows safe implementation of minimally-invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

The Roles and Interactions of Porphyromonas gingivalis and Fusobacterium nucleatum in Oral and Gastrointestinal Carcinogenesis: A Narrative Review

Epidemiological studies have spotlighted the intricate relationship between individual oral bacteria and tumor occurrence. Porphyromonas gingivalis and Fusobacteria nucleatum, which are known periodontal pathogens, have emerged as extensively studied participants with potential pathogenic abilities in carcinogenesis. However, the complex dynamics arising from interactions between these two pathogens were less addressed. This narrative review aims to summarize the current knowledge on the prevalence and mechanism implications of P. gingivalis and F. nucleatum in the carcinogenesis of oral squamous cell carcinoma (OSCC), colorectal cancer (CRC), and pancreatic ductal adenocarcinoma (PDAC). In particular, it explores the clinical and experimental evidence on the interplay between P. gingivalis and F. nucleatum in affecting oral and gastrointestinal carcinogenesis. P. gingivalis and F. nucleatum, which are recognized as keystone or bridging bacteria, were identified in multiple clinical studies simultaneously. The prevalence of both bacteria species correlated with cancer development progression, emphasizing the potential impact of the collaboration. Regrettably, there was insufficient experimental evidence to demonstrate the synergistic function. We further propose a hypothesis to elucidate the underlying mechanisms, offering a promising avenue for future research in this dynamic and evolving field.

Bile Microbiome Signatures Associated with Pancreatic Ductal Adenocarcinoma Compared to Benign Disease: A UK Pilot Study

Pancreatic ductal adenocarcinoma (PDAC) has a very poor survival. The intra-tumoural microbiome can influence pancreatic tumourigenesis and chemoresistance and, therefore, patient survival. The role played by bile microbiota in PDAC is unknown. We aimed to define bile microbiome signatures that can effectively distinguish malignant from benign tumours in patients presenting with obstructive jaundice caused by benign and malignant pancreaticobiliary disease. Prospective bile samples were obtained from 31 patients who underwent either Endoscopic Retrograde Cholangiopancreatography (ERCP) or Percutaneous Transhepatic Cholangiogram (PTC). Variable regions (V3-V4) of the 16S rRNA genes of microorganisms present in the samples were amplified by Polymerase Chain Reaction (PCR) and sequenced. The cohort consisted of 12 PDAC, 10 choledocholithiasis, seven gallstone pancreatitis and two primary sclerosing cholangitis patients. Using the 16S rRNA method, we identified a total of 135 genera from 29 individuals (12 PDAC and 17 benign). The bile microbial beta diversity significantly differed between patients with PDAC vs. benign disease (Permanova p = 0.0173). The separation of PDAC from benign samples is clearly seen through unsupervised clustering of Aitchison distance. We found three genera to be of significantly lower abundance among PDAC samples vs. benign, adjusting for false discovery rate (FDR). These were Escherichia (FDR = 0.002) and two unclassified genera, one from Proteobacteria (FDR = 0.002) and one from Enterobacteriaceae (FDR = 0.011). In the same samples, the genus Streptococcus (FDR = 0.033) was found to be of increased abundance in the PDAC group. We show that patients with obstructive jaundice caused by PDAC have an altered microbiome composition in the bile compared to those with benign disease. These bile-based microbes could be developed into potential diagnostic and prognostic biomarkers for PDAC and warrant further investigation.

Pancreatic Exocrine Insufficiency and the Gut Microbiome in Pancreatic Cancer: A Target for Future Diagnostic Tests and Therapies?

Pancreatic exocrine insufficiency (PEI) is common amongst pancreatic cancer patients and is associated with poorer treatment outcomes. Pancreatic enzyme replacement therapy (PERT) is known to improve outcomes in pancreatic cancer, but the mechanisms are not fully understood. The aim of this narrative literature review is to summarise the current evidence linking PEI with microbiome dysbiosis, assess how microbiome composition may be impacted by PERT treatment, and look towards possible future diagnostic and therapeutic targets in this area. Early evidence in the literature reveals that there are complex mechanisms by which pancreatic secretions modulate the gut microbiome, so when these are disturbed, as in PEI, gut microbiome dysbiosis occurs. PERT has been shown to return the gut microbiome towards normal, so called rebiosis, in animal studies. Gut microbiome dysbiosis has multiple downstream effects in pancreatic cancer such as modulation of the immune response and the response to chemotherapeutic agents. It therefore represents a possible future target for future therapies. In conclusion, it is likely that the gut microbiome of pancreatic cancer patients with PEI exhibits dysbiosis and that this may potentially be reversible with PERT. However, further human studies are required to determine if this is indeed the case.

The Role of the Multiparametric MRI LiverMultiScanTM in the Quantitative Assessment of the Liver and Its Predicted Clinical Applications in Patients Undergoing Major Hepatic Resection for Colorectal Liver Metastasis

Liver biopsy remains the gold standard for the histological assessment of the liver. With clear disadvantages and the rise in the incidences of liver disease, the role of neoadjuvant chemotherapy in colorectal liver metastasis (CRLM) and an explosion of surgical management options available, non-invasive serological and imaging markers of liver histopathology have never been more pertinent in order to assess liver health and stratify patients considered for surgical intervention. Liver MRI is a leading modality in the assessment of hepatic malignancy. Recent technological advancements in multiparametric MRI software such as the LiverMultiScanTM offers an attractive non-invasive assay of anatomy and histopathology in the pre-operative setting, especially in the context of CRLM. This narrative review examines the evidence for the LiverMultiScanTM in the assessment of hepatic fibrosis, steatosis/steatohepatitis, and potential applications for chemotherapy-associated hepatic changes. We postulate its future role and the hurdles it must surpass in order to be implemented in the pre-operative management of patients undergoing hepatic resection for colorectal liver metastasis. Such a role likely extends to other hepatic malignancies planned for resection.

Advances in Immunotherapeutics in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) accounts for up to 95% of all pancreatic cancer cases and is the seventh-leading cause of cancer death. Poor prognosis is a result of late presentation, a lack of screening tests and the fact some patients develop resistance to chemotherapy and radiotherapy. Novel therapies like immunotherapeutics have been of recent interest in pancreatic cancer. However, this field remains in its infancy with much to unravel. Immunotherapy and other targeted therapies have yet to yield significant progress in treating PDAC, primarily due to our limited understanding of the disease immune mechanisms and its intricate interactions with the tumour microenvironment (TME). In this review we provide an overview of current novel immunotherapies which have been studied in the field of pancreatic cancer. We discuss their mechanisms, evidence available in pancreatic cancer as well as the limitations of such therapies. We showcase the potential role of combining novel therapies in PDAC, postulate their potential clinical implications and the hurdles associated with their use in PDAC. Therapies discussed with include programmed death checkpoint inhibitors, Cytotoxic T-lymphocyte-associated protein 4, Chimeric Antigen Receptor-T cell therapy, oncolytic viral therapy and vaccine therapies including KRAS vaccines, Telomerase vaccines, Gastrin Vaccines, Survivin-targeting vaccines, Heat-shock protein (HSP) peptide complex-based vaccines, MUC-1 targeting vaccines, Listeria based vaccines and Dendritic cell-based vaccines.

Graphene Sensor Arrays for Rapid and Accurate Detection of Pancreatic Cancer Exosomes in Patients' Blood Plasma Samples

Biosensors based on graphene field effect transistors (GFETs) have the potential to enable the development of point-of-care diagnostic tools for early stage disease detection. However, issues with reproducibility and manufacturing yields of graphene sensors, but also with Debye screening and unwanted detection of nonspecific species, have prevented the wider clinical use of graphene technology. Here, we demonstrate that our wafer-scalable GFETs array platform enables meaningful clinical results. As a case study of high clinical relevance, we demonstrate an accurate and robust portable GFET array biosensor platform for the detection of pancreatic ductal adenocarcinoma (PDAC) in patients' plasma through specific exosomes (GPC-1 expression) within 45 min. In order to facilitate reproducible detection in blood plasma, we optimized the analytical performance of GFET biosensors via the application of an internal control channel and the development of an optimized test protocol. Based on samples from 18 PDAC patients and 8 healthy controls, the GFET biosensor arrays could accurately discriminate between the two groups while being able to detect early cancer stages including stages 1 and 2. Furthermore, we confirmed the higher expression of GPC-1 and found that the concentration in PDAC plasma was on average more than 1 order of magnitude higher than in healthy samples. We found that these characteristics of GPC-1 cancerous exosomes are responsible for an increase in the number of target exosomes on the surface of graphene, leading to an improved signal response of the GFET biosensors. This GFET biosensor platform holds great promise for the development of an accurate tool for the rapid diagnosis of pancreatic cancer.

Cancer cell-derived extracellular vesicles activate hepatic stellate cells in colorectal cancer

Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths worldwide, primarily due to the development of metastatic disease. The liver is the most frequently affected site. The metastatic cascade relies on a complex interaction between the immune system, tumor, and distant organs. Communication between the tumor and the metastatic site can be mediated by tumor-derived extracellular vesicles (EVs) and their cargo. The mechanisms underlying this process are starting to be understood through research that has rapidly expanded over the past 15 years. One crucial aspect is the remodeling of the microenvironment at the site of metastasis, which is essential for the formation of a premetastatic niche and the subsequent establishment of metastatic deposits. In the evaluated study, the authors use cellular experiments and a mouse model to investigate how tumour derived extracellular vesicles and their microRNA contents interact with hepatic stellate cells (HSCs). They demonstrate how this may lead to remodelling of the microenvironment and the formation of colorectal liver metastasis using their experimental model. In this mini review, we examine the current evidence surrounding tumour derived EVs and their effect on the tumour microenvironment to highlight potential areas for future research in CRC and other malignancies.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Gastric outlet obstruction secondary to a wandering spleen: systematic review and surgical management of a case

INTRODUCTION

A wandering spleen occurs when laxity or absence of the suspensory ligaments allows migration throughout the abdomen. Gastric outlet obstruction resulting from this abnormality is rare. We present a systematic literature search and a case that was managed successfully with surgical intervention at our centre.

METHODS

A systematic search of the PubMed, Embase™, Medline^® and Google Scholar™ databases was carried out employing the combined search terms "gastric outlet obstruction" AND "wandering spleen". Six results were included for final analysis.

RESULTS

All six search results described a single case each. Patients underwent surgical management (open or laparoscopic) after initial investigation utilising a range of modalities. There were no mortalities reported at 90 days. The single case we present was complicated by gastric perforation; the patient made a successful recovery following open splenopexy and stapled wedge resection of the stomach.

CONCLUSIONS

A wandering spleen is a rare diagnosis and there are only six reported cases of gastric outlet obstruction secondary to a wandering spleen in the literature. None report associated gastric perforation. There are a variety of presenting symptoms, intraoperative findings and operative techniques used to address the gastrosplenic abnormality. The case reported by our centre adds to this limited evidence base and demonstrates a successful outcome from definitive surgical management. We highlight the need to seek early gastro-oesophageal expertise if any gastric pathology is found together with anatomical abnormality of the spleen.

Herpes simplex oesophagitis leading to perforation and mediastinal collection: a case report and review of literature

Herpes simplex oesophagitis is rare, especially in immunocompetent patients. A 78-year-old man presented with sepsis on the background of several months of retrosternal chest pain and fatigue. Computed tomography of the chest abdomen and pelvis revealed a large mediastinal collection and an oesophago-gastro-duodenoscopy demonstrated a healed mucosal scar from a spontaneously healed perforation. The collection was successfully drained with an ultrasound-guided drain and the patient made a full recovery. Spontaneous oesophageal perforation from herpes simplex oesophagitis has been reported five times in the literature, with only two occurrences in immunocompetent individuals.

699 Does Pre-Operative Imaging Improve Negative Appendicectomy Rate?

Aim

Appendicectomy is one of the most commonly performed emergency operations. There is no set guideline for an acceptable negative appendectomy rate (NAR) in the UK. Based on previous studies, a NAR of 15-30% is typically accepted. We sought to define our local practice NAR in our initial audit, introduced an appendicitis pathway based on this initial data, and then re-audited to assess whether there had been an improvement in the NAR.

Method

All emergency appendicectomies carried out over a 1-year period from April 2018 – April 2019 were initially analysed. The subsequent audit analysed data from August 2020 - November 2020, after the pathway had been introduced. Histological analysis was used to determine positive or negative appendicectomy.

Results

A total of 207 patients had an appendicectomy over the initial 1-year time frame. In our re-audit, 38 patients had an appendicectomy. Demographics were similar in both groups. The NAR increased from 17% to 18%.

Conclusions

On first glance, the NAR does not seem to have improved. On a closer look, all patients over the age of 18 in our re-audit had a pre-operative CT, and there were no negative appendicectomies in these patients. The issue arises with younger patients, in whom justifying the radiation associated with a CT scan may be difficult. Although ultrasound does not carry the same radiation risk, previous audits at our trust have shown both its sensitivity and specificity for appendicitis is below 50%. We may have to explore alternative imaging modalities in the paediatric population or accept the higher NAR.

416 Prospective Multicentre Study of Impact of COVID-19 on Colorectal Cancer Resections

Introduction

COVID-19 pandemic has posed a major challenge to healthcare systems globally. In NHS, around 36,000 cancer operations have been estimated to be cancelled during the peak time alone. This regional study evaluated the risk of COVID-19 in patients undergoing surgery for colorectal cancer during the peak time.

Method

This prospective multicentre observational study conducted in four busy district hospitals included 52 patients with colorectal cancer who underwent surgery during the COVID lockdown period (23^rd March to 5^th May). PCR swab testing was used to detect COVID. Data was collected from patient notes, MDT files and pathology results.

Results

73% (38/52) underwent elective procedures, 90% with curative intent. Overall, mean (SD) age was 70 (12.2) years, 50% were female. 60% (32/52) had left sided cancers and a total of 48% (25/52) patients had stage 3 or above. 27% (14/52) had post-operative complications, with 4% (2/52) being Grade 3 Clavien-Dindo. Total mortality was 6% (3/52) of which 1 was elective patient. Only one patient developed COVID infection during the inpatient stay.

Conclusions

Data suggests, local policies to prevent COVID spread have been effective. Local lockdown in case of second peak may be a reasonable option. Improvement in COVID testing could have major impact on outcomes.

Idiopathic retroperitoneal haematoma causing duodenal obstruction: a case report and review of literature

Idiopathic retroperitoneal haematoma is a rare clinical entity; resulting duodenal obstruction is even more occult. It can pose a diagnostic challenge due to variable presentations. Timely management requires a high index of suspicion and a multidisciplinary approach. Surgery is indicated in patients refractory to conservative treatment and failure of endoscopic or interventional radiology options. We report an interesting case illustrating the rarity and severity of this condition, with a review of the literature.

A case report and review of the literature of Bouveret syndrome

Bouveret syndrome is a rare variant of gallstone ileus causing gastric outlet obstruction. It results from the formation of either a cholecystoduodenal or a cholecystogastric fistula and subsequent migration of gallstone into the duodenum or pylorus of stomach, causing obstruction. The first case was reported by Leon Bouveret in 1896. We report a case illustrating the rarity and severity of this condition, together with a review of the literature of the different methods of endoscopic and surgical treatment.

Design of a Proficiency-Based Skills Training Curriculum for Our Newly Validated 3-Dimensional (3D) Laparoscopic Models, Using MISTELS

Aim: There are presently no courses or training curricula for surgical simulation that include training with 3-Dimensional (3D) laparoscopic platforms. Our aim is to create an expert led design of a proficiency-based skills training curriculum for our newly validated 3D laparoscopic models, using MISTELS compensating speed for precision and accuracy. Method: In this study, 5 tasks were performed by 12 expert surgeons of different specializations on low-cost, portable models designed for 3D display. The competence level for each task was devised by using a target performance time (within the cutoff limit), maximum allowable error score and penalty error score, allowing real time instant scoring and feedback. The results were evaluated by MISTELS scoring system. Results: Out of the 12 experts, the top 3 with the shortest mean time with no errors would be chosen to design a proficiency curriculum. The final aim of developing such curriculum is to shorten learning curve and to improve technical skills of 3D laparoscopy. The curriculum provides a benchmark level for each task, indicating the cutoff and the target performance time, a list of the allowable errors and the number of repetitions. Conclusion: Our future plan is to investigate the cost and effectiveness of the curriculum and to reveal if practice and repetition will lead to mastering 3D skills among novices (medical students and junior doctors).

Eye-tracking technology in medical education: A systematic review

BACKGROUND

Eye-tracking technology is an established research tool within allied industries such as advertising, psychology and aerospace. This review aims to consolidate literature describing the evidence for use of eye-tracking as an adjunct to traditional teaching methods in medical education.

METHODS

A systematic literature review was conducted in line with STORIES guidelines. A search of EMBASE, OVID MEDLINE, PsycINFO, TRIP database, and Science Direct was conducted until January 2017. Studies describing the use of eye-tracking in the training, assessment, and feedback of clinicians were included in the review.

RESULTS

Thirty-three studies were included in the final qualitative synthesis. Three studies were based on the use of gaze training, three studies on the changes in gaze behavior during the learning curve, 17 studies on clinical assessment and six studies focused on the use of eye-tracking methodology as a feedback tool. The studies demonstrated feasibility and validity in the use of eye-tracking as a training and assessment method.

CONCLUSIONS

Overall, eye-tracking methodology has contributed significantly to the training, assessment, and feedback practices used in the clinical setting. The technology provides reliable quantitative data, which can be interpreted to give an indication of clinical skill, provide training solutions and aid in feedback and reflection. This review provides a detailed summary of evidence relating to eye-tracking methodology and its uses as a training method, changes in visual gaze behavior during the learning curve, eye-tracking methodology for proficiency assessment and its uses as a feedback tool.

Eye-Tracking Technology in Surgical Training

The aim of this review was to amalgamate literature on the use of eye tracking methodology as an adjunct to surgical training. The PRISMA Guidelines were used to undertake this systematic review. Our review studies has shown that recording a surgeon's eye movements; time to first fixation and gaze pattern through the use of eye tracking technology would be beneficial for surgical training.

A case report on a rare presentation of solitary rectal ulcer syndrome

We describe a highly unusual case of solitary rectal ulcer syndrome (SRUS) that presented as a large polyp protruding from the anal canal. A 67-year-old man presented with rectal bleeding and mucus discharge. At examination under anaesthesia, a large pedunculated polypoidal lesion was found, measuring 25 × 20 mm, arising posterolaterally from the anorectal junction and protruding externally 50 mm in size. SRUS can be a misnomer as the condition can present in a number of different ways and only a minority of patients has a solitary ulcer. Other findings include multiple ulcers, hyperaemic mucosa or a broad-based polypoidal mass. In this case, a rare presentation of SRUS in the form of a large polyp was confirmed by histology. A key learning point is to remember that although less common than other causes of rectal symptoms, it should be considered as part of the differential diagnosis once sinister causes have been excluded.

Paraneoplastic polymyositis presenting as a clinically occult breast cancer

Paraneoplastic syndrome affects less than 1% of cancer patients. Diagnosis of paraneoplastic syndrome with neurological presentation requires screening for an underlying malignancy, including a complete history, physical examination and imaging studies. Treatment often results in symptom stability, rather than improvement. Paraneoplastic polymyositis can precede or instantaneously occur at diagnosis or treatment of a primary tumour, while neurological symptoms can persist even following cancer treatment. We report a rare case of metaplastic breast carcinoma with an unusual presentation of paraneoplastic polymyositis.

Laparoscopic endoloop technique - A novel approach of managing iatrogenic caecal perforation and literature review

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With our case we have adopted an innovative approach of using endolooping for an early perforation that was within a short distance of the appendicular base, applied proximal to the site of the perforation.

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In our surgery, the area of ischemic injury can be easily visualized through the laparoscopy and including fresh and healthy tissue margins in the loop is the hallmark of safety for this simple technique.

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The endoloop technique described, undertaken during a laparoscopy is a novel approach. It is a simple and effective method, reminding clinicians to adapt techniques when necessary.

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Nevertheless, it is only limited to perforations around the appendicular base. The endolooping technique may not be suitable for late presentation, large perforations with ischemic or friable tissue, and severe peritonitis. In such cases, the use of other methods, such as wedge resection or stapling would be safer.

Introduction

An iatrogenic caecal perforation is rare, but a serious complication associated with significant morbidity and mortality. We present a 4 min and 50 s video on a new improvisation undertaken during laparoscopic management of post-polypectomy caecal perforation.

Presentation of case

Our patient presented with an acute abdomen following endoscopic polypectomy. At surgery, the site of caecal perforation was close to the appendicular base with devitalization tissue, secondary to diathermy usage. The hallmark of safety within this novel technique included fresh healthy tissue margins within the endoloop (detachable snare ligation) and ensuring no ischemic tissue was gathered. Complete freeing of the appendix and meso-appendicular base was required and securing three endoloops proximal to the site of perforation. The post-operative course was uneventful.

Discussion

The World Society of Emergency Surgery (WSES) 2013 guidelines suggested an early laparoscopic approach is a safe and effective treatment for colonoscopy-related colonic perforation. There are no national guidelines and the management is dictated by the clinical condition of the patient, co-morbidity, size and site of perforation as well as the scale of bowel preparation, and surgical experience.

Conclusion

The endoloop technique described, undertaken during a laparoscopy is a novel approach. It is a simple and effective method, reminding clinicians to adapt techniques when necessary. Nevertheless, it is only limited to perforations around the appendicular base.

Non-healing gastro-duodenal ulcer: A rare presentation of primary abdominal tuberculosis

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This case has illustrated the difficulty of promptly diagnosing an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease, in the absence of pulmonary involvement in an immunocompetent patient.

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A high index of clinical suspicion with a multidisciplinary team approach is required.

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The first line of treatment for gastrointestinal tuberculosis is medical treatment, indicating that 6 months of an anti-tuberculosis regime is satisfactory. Surgical treatment should be sought for patients who develop complications such as obstruction, perforation, and stricture formation.

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In the absence of positive pathological (polymerase chain reaction or acid-fast bacilli staining) and radiologic tests, the diagnosis is often established by obtaining a surgical histopathology specimen.

INTRODUCTION

We present a case of primary gastrointestinal tuberculosis that has culminated in ulcer formation, in the absence of pulmonary involvement in an immunocompetent patient.

PRESENTATION OF CASE

A 28-year-old Asian male presented to casualty with a 1-week history of epigastric cramping abdominal pain and several episodes of non-bilious vomiting. The patient deteriorated clinically, becoming more cachectic and given his unexplained weight loss, an oesophageal-gastro-duodenal endoscopic imaging confirmed a duodenal ulcer. The biopsy of the non-healing ulcer was the hallmark of the disease, revealing evidence of granulomatous inflammation consistent with tuberculosis bacilli.

DISCUSSION

Gastrointestinal tuberculosis with ulceration is rare with respect to the oesophagus, stomach and duodenum. This case proves to be unique, as our patient had experienced primary isolated gastric tuberculosis in the absence of pulmonary tuberculosis in a healthy individual. Immunohistochemical staining, histopathology and radiological investigations have demonstrated their importance in confirming abdominal tuberculosis and the extent of bowel involvement.

CONCLUSION

This case has illustrated the difficulties associated with a prompt diagnosis of an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease in an immunocompetent patient.

An innovative repair for a re-recurrence of an incarcerated inguinal hernia

A patient presented with a recurrent incarcerated inguinoscrotal hernia requiring urgent surgery. The defect was through the gap in the mesh left originally for the cord structures. As a result, a modified funnel repair was performed. An innovative approach was adopted that was best suited to tackling and reducing the risk of recurrence.