Successful Endoscopic Treatment of a Pancreatic Pseudocyst in a Patient with Situs Inversus Totalis and Upper GI Duplication

BACKGROUND Duplication of the gastrointestinal tract is a rare congenital malformation that can develop in any part of the digestive tract. These duplications may be asymptomatic into adult age. Situs inversus totalis is a rare congenital anomaly characterized by a mirror transposition of thoracic and abdominal organs. We present a case of a pancreatic pseudocyst in a patient with a combination of situs inversus totalis and doubling of the esophagus, stomach, and first part of the duodenum. CASE REPORT A 64-year-old woman presented with epigastric pain. Abdominal computed tomography revealed a pancreatic pseudocyst and a previously identified duplication of the esophagus, stomach, and duodenum with situs inversus totalis. The patient underwent esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography for pseudocyst drainage. During EGD, a bifurcation of the esophagus was found. Duplication of the esophagus, stomach, and first part of the duodenum was evident on further advancement. A week later, there was repeated filling of the pseudocyst with a liquid component, and the patient underwent cystogastrostomy with stenting. Five months after discharge, the stent was removed without complications. CONCLUSIONS Duplication of the gastrointestinal tract and situs inversus totalis are very rare congenital malformations that require early diagnosis. While situs inversus totalis does not represent any medical disadvantage, physicians should be aware of abnormal anatomy before procedures to prepare specialists for this in case of the need for special techniques. Endoscopic treatment of pancreatic pseudocysts is safe and effective even in such rare cases. The use of endoscopic methods also minimizes intervention and decreases the length of the patients' stays in the hospital.

[Endosonography in diagnosis of distal biliary stenosis]

Diagnostic validity of endoscopic ultrasonography (EUS) was estimated retrospectively in 34 patients, suffering distal biliary stenosis, revealed during endoscopic retrograde cholangiopancreatography or magnet resonance cholangiopancreatography, in whom the cause of the block was not revealed in accordance to the CT data obtained. Nontumoral stenosis was diagnosed, when normal in layers structure of the biliary ducts walls was safe, not depending on a new tumor presence. In other situations stenosis was considered having tumoral genesis. The definite diagnosis of stenosis was established after morphological investigation in 18 patients--postoperatively and during dynamic follow-up--in 16. Diagnostic validity of EUS while determining the stenosis cause have had constituted: sensitivity--94.1%, specificity--82.3%, accuracy--88.2%. In a tumoral stenosis in accordance to the EUS data there was revealed hypoechogenic mass of irregular form, causing the common biliary duct obstruction and the surrounding tissues infiltration. EUS constitutes an effective method of the biliary stenosis estimation, it permits to determine the diagnosis on the early stages.

[Estimation of endosonography method in the patients with moderate risk for choledocholithiasis]

Efficacy of endoultrasonography application in conditions of moderate risk for choledocholithiasis occurrence was estimated in 33 patients, in whom ultrasonography (US) did not reveal the common biliary duct concrements. Sensitivity, specificity, accuracy, positive and negative prognostic values of the method in suspicion for choledocholithiasis presence while US performance have had constituted 78.6, 94.7, 82.0, 98.2 and 54.5%; vs for endoultrasonography--100, 94.4, 97, 93.8 and 100% accordingly. Endoultrasonography constitutes a safe and highly effective method of investigation in patients in suspicion of the biliary ducts disease presence, it permits to reveal choledocholithiasis in significant part of patients after ineffective US. This diagnostic option permits to reduce the need for performance of diagnostic endoscopic retrograde cholangiopancreaticography.

[The modern approach to endoscopic drainage of pancreatic pseudocysts]

The results of endoscopic surgical procedures performed in 72 patients over postnecrotic pseudocysts (PPC) of the pancreas. Complications occurred in 9 (12.5%) patents, recurrence PPC pancreas after endoscopic procedures were observed in 6 (8.3%).

[Morphologic peculiarities of gastric mucosa before and after bariatric surgery]

Morphological state of gastric mucosa was studied up in patients, suffering morbid obesity before and after gastric banding and gastric shunting operations. According to histologic investigation data gastric mucosa in patients, suffering morbid obesity, is not changed or has moderate inflammatory changes. Gastric banding and gastric shunting did not change gastric mucosa trustworthily morphologically.

[Enteral tube feeding of patients with duodenal ulcer before and after the operation]

The results of treatment of 947 patients, suffering duodenal ulcer stenosis, to whom the enteral nutrition (EN) probe was introduced before and after operation, were analyzed. There was noted a positive impact of EN on metabolic processes, water-electrolyte balance, lowering of operative-anesthesiologic risk, lethality and postoperative complications rate, securing possibility of operative intervention performance in a planned order.

[Estimation of the patients quality of life after gastric banding according to Moorehead-Ardelt II system]

The quality of life estimation according to Moorehead-Ardelt II system was conducted. The sweet-eater syndrome determination was elaborated and introducted in 45 patients, suffering morbid obesity, to whom gastric banding was performed. The investigation was conducted to unify the results and specify indications for some bariatric operations performance.