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Rapunzel syndrome, defined by the presence of a trichobezoar extending from the stomach to the small intestine, is a rare cause of intestinal obstruction. It usually presents with vague symptoms; however, it can also present with complications such as perforation, peritonitis and obstructive jaundice. We report a rare case of a 37-year-old woman with Rapunzel syndrome complicated by acute cholangitis and pancreatitis and analyse the diagnosis and management of this complicated pathology. Although she reported a history of trichotillomania and trichophagia, she had been asymptomatic for ten years. We review the steps of diagnosis, highlighting the importance of a thorough clinical history and detailed examination, with supporting evidence from the contrast-enhanced computed tomography (CECT) scan. She was successfully managed with gastrotomy and trichobezoar removal. She had an uneventful postoperative recovery and was discharged after psychiatric counselling. To our knowledge, this is the first case of Rapunzel syndrome in a young female presenting with both cholangitis and pancreatitis., (© 2020 Rajendran Vellaisamy et al., published by De Gruyter.)

Management of gastroesophageal junction (GEJ) adenocarcinoma is a controversial topic. The rising incidence of this cancer requires a clear consensus to ensure proper management. Application of oncological principles for tumors of the esophagus or stomach is not possible because of comparative differences in the biology of GEJ adenocarcinoma, leading to different therapeutic options. Staging work-up with endoscopy, endosonography, and PET is essential to inform the choice of neoadjuvant treatment and surgical approach to GEJ adenocarcinoma. Surgery remains the only curative treatment and should be undertaken in specialized centers., (© 2018 New York Academy of Sciences.)

Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH-impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux-symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD., (© 2018 New York Academy of Sciences.)

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy., (© 2018 New York Academy of Sciences.)

Background: The purpose of this study was to examine the face and construct validity of a custom-developed bimanual laparoscopic force-skills trainer with haptics feedback. The study also examined the effect of handedness on fundamental and complex tasks., Methods: Residents (n = 25) and surgeons (n = 25) performed virtual reality-based bimanual fundamental and complex tasks. Tool-tissue reaction forces were summed, recorded, and analysed. Seven different force-based measures and a 1-time measure were used as metrics. Subsequently, participants filled out face validity and demographic questionnaires., Results: Residents and surgeons were positive on the design, workspace, and usefulness of the simulator. Construct validity results showed significant differences between residents and experts during the execution of fundamental and complex tasks. In both tasks, residents applied large forces with higher coefficient of variation and force jerks (P < .001). Experts, with their dominant hand, applied lower forces in complex tasks and higher forces in fundamental tasks (P < .001). The coefficients of force variation (CoV) of residents and experts were higher in complex tasks (P < .001). Strong correlations were observed between CoV and task time for fundamental (r = 0.70) and complex tasks (r = 0.85). Range of smoothness of force was higher for the non-dominant hand in both fundamental and complex tasks., Conclusions: The simulator was able to differentiate the force-skills of residents and surgeons, and objectively evaluate the effects of handedness on laparoscopic force-skills. Competency-based laparoscopic skills assessment curriculum should be updated to meet the requirements of bimanual force-based training.

Gastric cancer remains fifth most common cancer often diagnosed at an advanced stage and is the second leading cause of cancer-related death worldwide. Long non-coding RNAs (lncRNAs) involved in various cellular pathways are essential for tumor occurrence and progression and they have high potential to promote or suppress the expression of many genes. In this study, we profiled 19 selected cancer-associated lncRNAs in thirty gastric adenocarcinomas and matching normal tissues by qRT-PCR. Our results showed that most of the lncRNAs were significantly upregulated (12/19). Further, we performed bioinformatic screening of miRNAs that share common miRNA response elements (MREs) with lncRNAs and their downstream mRNA targets. The prediction identified three microRNAs (miR-21, miR-145 and miR-148a) and five gastric cancer-specific target genes (EGFR, KLF4, DNMT1 and AGO4) which also showed strong correlation with lncRNAs in regression analysis. Finally, we constructed an integrated lncRNA-miRNA-mRNA interaction network of the candidate genes to understand the post-transcriptional gene regulation. The ceRNA network analysis revealed that the differentially regulated miR-21 and miR-148a were playing as central candidates coordinating sponging activity of the lncRNAs analyzed (H19, TUG1 and MALAT1) in this study and the overexpression of H19 and miR-21 could be a signature event of gastric tumorigenesis that could serve as prognostic indicators and therapeutic targets., Competing Interests: CONFLICTS OF INTEREST The authors declare no competing financial interests.

Background: Most of the commercially available virtual reality-based laparoscopic simulators do not effectively evaluate combined psychomotor and force-based laparoscopic skills. Consequently, the lack of training on these critical skills leads to intraoperative errors., Objectives: To assess the effectiveness of the novel virtual reality-based simulator, this study analyzed the combined psychomotor (i.e., motion or movement) and force skills of residents and expert surgeons. The study also examined the effectiveness of real-time visual force feedback and tool motion during training., Design: Bimanual fundamental (i.e., probing, pulling, sweeping, grasping, and twisting) and complex tasks (i.e., tissue dissection) were evaluated. In both tasks, visual feedback on applied force and tool motion were provided. The skills of the participants while performing the early tasks were assessed with and without visual feedback. Participants performed 5 repetitions of fundamental and complex tasks. Reaction force and instrument acceleration were used as metrics., Setting: Surgical Gastroenterology, Government Stanley Medical College and Hospital; Institute of Surgical Gastroenterology, Madras Medical College and Rajiv Gandhi Government General Hospital., Participants: Residents (N = 25; postgraduates and surgeons with <2 years of laparoscopic surgery) and expert surgeons (N = 25; surgeons with >4 and ≤10 years of laparoscopic surgery)., Results: Residents applied large forces compared with expert surgeons and performed abrupt tool movements (p < 0.001). However, visual + haptic feedback improved the performance of residents (p < 0.001). In complex tasks, visual + haptic feedback did not influence the applied force of expert surgeons, but influenced their tool motion (p < 0.001). Furthermore, in complex tissue sweeping task, expert surgeons applied more force, but were within the tissue damage limits. In both groups, exertion of large forces and abrupt tool motion were observed during grasping, probing or pulling, and tissue sweeping maneuvers (p < 0.001)., Conclusions: Modern day curriculum-based training should evaluate the skills of residents with robust force and psychomotor-based exercises for proficient laparoscopy. Visual feedback on force and motion during training has the potential to enhance the learning curve of residents., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Presently, there is no scientific evidence supporting a definite role for follow-up after gastrectomy for cancer, and clinical practices are quite different around the globe. The aim of this consensus conference was to present an ideal prototype of follow-up after gastrectomy for cancer, based on shared experiences and taking into account the need to rationalize the diagnostic course without losing the possibility of detecting local recurrence at a potentially curable stage., Methods: On June 19-22, 2013 in Verona (Italy), during the 10th International Gastric Cancer Congress (IGCC) of the International Gastric Cancer Association, a consensus meeting was held, concluding a 6-month, Web-based, consensus conference entitled "Rationale of oncological follow-up after gastrectomy for cancer.", Results: Forty-eight experts, with a geographical distribution reflecting different health cultures worldwide, participated in the consensus conference, and 39 attended the consensus meeting. Six statements were finally approved, displayed in a plenary session and signed by the vast majority of the 10th IGCC participants. These statements are attached as an annex to the Charter Scaligero on Gastric Cancer., Conclusion: After gastrectomy for cancer, oncological follow-up should be offered to patients; it should be tailored to the stage of the disease, mainly based on cross-sectional imaging, and should be discontinued after 5 years.

Background: In laparoscopic surgery, no external feedback on the magnitude of the force exerted is available. Hence, surgeons and residents tend to exert excessive force, which leads to tissue trauma. Ability of surgeons and residents to perceive their own force output without external feedback is a critical factor in laparoscopic force-skills training. Additionally, existing methods of laparoscopic training do not effectively train residents and novices on force-skills. Hence, there is growing need for the development of force-based training curriculum., Objective: As a first step towards force-based laparoscopic skills training, this study analysed force perception difference between laparoscopic instrument and finger in contralateral bimanual passive probing task., Methods: The study compared the isometric force matching performance of novices, residents and surgeons with finger and laparoscopic instrument. Contralateral force matching paradigm was employed to analyse the force perception capability in terms of relative (accuracy), and constant errors in force matching., Results: Force perception of experts was found to be better than novices and residents. Interestingly, laparoscopic instrument was more accurate in discriminating the forces than finger. The dominant hand attempted to match the forces accurately, whereas non-dominant hand (NH) overestimated the forces. Further, the NH of experts was found to be most accurate. Furthermore, excessive forces were applied at lower force levels and at very high force levels., Conclusions: Due to misperception of force, novices and residents applied excessive forces. However, experts had good control over force with both dominant and NHs. These findings suggest that force-based training curricula should not only have proprioception tasks, but should also include bimanual force-skills training exercises in order to improve force perception ability and hand skills of novices and residents. The results can be used as a performance metric in both box and virtual reality based force-skills training.

Introduction: Glomus tumour (GT) of the stomach is a rare submucosal mesenchymal tumour. Gastric glomus tumours are clinically recognized as benign. Nevertheless, some show biological behaviour similar to that of malignant lesions and presurgical confirmation is often impossible., Presentation of Case: A 32 year old female who presented with epigastric pain and was subsequently investigated for a antral tumour of the stomach and Wedge resection of tumour was done. Immunohistochemistry demonstrated strong positivity of smooth muscle actin and vimentin with low rate of mitosis studied by ki-67., Discussion: We discuss the preoperative investigation, the diagnostic problems and the surgical treatment of the patient with gastric glomus tumour., Conclusion: Glomus tumours should be considered as differential diagnosis for submucosal tumours of stomach., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Although stapling is an alternative to hand-suturing in gastrointestinal surgery, recent trials specifically designed to evaluate differences between the two in surgery time, anastomosis time, and return to bowel activity are lacking. This trial compared the outcomes of the two in subjects undergoing open gastrointestinal surgery. Adult subjects undergoing emergency or elective surgery requiring a single gastric, small, or large bowel anastomosis were enrolled into this open-label, prospective, randomized, interventional, parallel, multicenter, controlled trial. Randomization was assigned in a 1:1 ratio between the hand-sutured group (n = 138) and the stapled group (n = 142). Anastomosis time, surgery time, and time to bowel activity were collected and compared as primary endpoints. A total of 280 subjects were enrolled from April 2009 to September 2010. Only the time of anastomosis was significantly different between the two arms: 17.6 ± 1.90 min (stapled) and 20.6 ± 1.90 min (hand-sutured). This difference was deemed not clinically or economically meaningful. Safety outcomes and other secondary endpoints were similar between the two arms. Mechanical stapling is faster than hand-suturing for the construction of gastrointestinal anastomoses. Apart from this, stapling and hand-suturing are similar with respect to the outcomes measured in this trial.

Corrosive strictures of the gastrointestinal tract are a surgical challenge. We describe a previously undescribed condition called gastrocoele, a rare condition caused by combined oesophageal and antral strictures and review our results. We present our experience with nine cases of gastrocoele due to combined corrosive strictures of oesophagus and antrum between 1993 and 2005. The age group was 21-65 years with female preponderant (66%) sex distribution. The presentation was at a median of 110 days (range 45-400 days) following the corrosive ingestion. The standard investigations included barium swallow, endoscopy, jejunostomy tubogram and barium enema. The surgical procedures performed were antrectomy and coloplasty in six (one staged), antrectomy and oesophageal dilatation in two and gastrojejunostomy and coloplasty in one. There was no major morbidity or mortality with a median follow-up of 3 years. Gastrocoele is a rare entity where good results can be achieved with surgery, however, prevention of corrosive injuries by public education is the best cure!

Objective: Dysphagia due to tuberculosis is rare in both the developing countries with high prevalence rates and the western population following the recent upsurge linked to the AIDS and immigration., Aim: To study tuberculosis as an aetiological factor in the causation of dysphagia and to evaluate the outcome of anti-tubercular treatment and surgical results in these patients., Methods: Retrospective review of experience with 14 cases of dysphagia due to tuberculosis encountered between 1996 and 2003., Results: The duration of symptoms ranged between 3 and 18 months. All of them underwent oesophagogastroscopy, barium swallow, fiberoptic bronchoscopy and CT scan of the chest. The aetiology was subcarinal node enlargement in seven, tracheo-oesophageal fistula in four, oesophageal ulcer in two and cervical node suppuration in one. Tuberculous involvement was confirmed by pathological examination in all patients. All of them received anti-tuberculous therapy. Seven patients required surgery, transthoracic repair of tracheo-oesophageal fistula in four patients, one patient required subcarinal node excision and two needed abscess drainage. There were no mortalities and there was complete relief of dysphagia in all of them., Conclusions: Tuberculosis as a causative factor for dysphagia should be considered in regions with high incidences of tuberculosis and in immunocompromised patients. Treatment with anti-tuberculous therapy is effective. Surgery is required only for complications of tuberculosis.

We report a case of surgically treated splenic abscess in a HIV patient. The patient presented with fever and splenomegaly. The diagnosis was based on ultrasonography and computed tomography. Surgical experience with clinically overt splenic abscess remains limited more so in a HIV patient.