We report the case of a 79-year-old man with a giant gastric diospyrobezoar (50 × 30 mm) who presented with epigastric pain. Two weeks of cola dissolution therapy at home was ineffective. During endoscopy, alligator forceps were used to create grooves on the hard, smooth surface of the bezoar, enabling a 30-mm polypectomy snare to fragment the bezoar into pieces smaller than 1 cm. Residual fragments passed spontaneously, and complete resolution was confirmed by follow-up endoscopy three weeks later. The patient was discharged on postprocedure day 3 without complications. This case demonstrates that the sequential use of alligator forceps and a polypectomy snare can be an effective endoscopic technique for giant gastric bezoars with hard, smooth surfaces, potentially avoiding surgical intervention even in high-risk elderly patients.

Gastroparesis, a chronic motility disorder, is a diagnosis of exclusion that necessitates careful evaluation for structural and surgically correctable causes. Although the medical differential diagnosis emphasizes functional etiologies, anatomic abnormalities are often under-recognized despite guideline recommendations for thorough endoscopic and structural assessment. Symptoms such as nausea, vomiting, early satiety, and delayed gastric emptying may be indistinguishable from true motility disorders. We present two patients initially diagnosed with gastroparesis whose symptoms were ultimately driven by surgical pathology. Case 1 describes a 70-year-old woman with persistent nausea and vomiting, weight loss, epigastric abdominal pain, and delayed gastric emptying on scintigraphy, initially scheduled for gastric peroral endoscopic myotomy (G-POEM) for presumed gastroparesis. Intraoperative endoscopy revealed gastric volvulus as the underlying etiology, prompting conversion to definitive surgical repair. Gastric volvulus, while rare, may be complicated by ischemia or perforation, highlighting the importance of timely differentiation from gastroparesis. Case 2 describes a 53-year-old woman with intractable nausea, vomiting, and inability to tolerate oral intake following a Roux-en-Y gastric bypass (RYGB). Surgical exploration revealed a Roux-en-O configuration with twisted limbs causing impaired drainage, ultimately requiring bypass reversal and pyloroplasty. The Roux-en-O configuration is a rare but serious complication of RYGB involving misplaced anastomoses that create a blind loop, resulting in obstruction and gastroparesis-like symptoms. Clinicians should maintain heightened suspicion for structural pathology in patients with atypical presentations, previous surgery, or refractory symptoms, as delayed diagnosis can lead to life-threatening complications.

Colorectal cancer is the second-leading cause of cancer death in the United States. Locally advanced invasion into an adjacent organ (T4b) occurs in 10%-20% of colon cancers. A 65-year-old man presented with weakness and abdominal pain. The abdomen was soft, moderately distended, and severely tender in the epigastric region. Laboratory studies showed leukocytosis and lactic acidosis. Computed tomography of abdomen demonstrated intra-abdominal free air and splenic abscess. During emergent laparotomy, a perforated splenic flexure mass involving the pancreatic tail and spleen was identified. En bloc resection was performed with temporary abdominal closure. Following hemodynamic improvement, the abdomen was closed with creation of a transverse end colostomy. Pathology revealed moderately differentiated adenocarcinoma with transmural invasion into the pancreatic tail. Multimodal therapy is the standard approach for locally advanced colon cancer. An en-bloc resection of involved organs to achieve an R0 margin remains the cornerstone of surgical management.

Necrobiosis lipoidica (NL) is a granulomatous disease presenting as plaques with potential for progression to chronic ulcerating lesions. Breast involvement of the disease is rare. There are currently no FDA-approved medical therapies, and surgical treatment is controversial due to concerns for disease recurrence. Limited historical cases of surgical management demonstrate success when excision is taken to deep fascia. No prior reconstruction of NL manifesting on the breast has been documented in the literature. In this report, we present a patient with isolated ulcerated NL of the right breast refractory to medical management who was treated with resection to deep fascia and free flap reconstruction utilizing a deep inferior epigastric perforator flap. The patient initially presented with right breast implant rupture and underwent implant removal. After a 7-month monitoring period without disease progression, the patient elected for resection of her right breast NL with reconstruction by deep inferior epigastric perforator flap. The diseased tissue of the right breast was resected down to pectoralis fascia and immediately reconstructed with a deep inferior epigastric perforator flap. Although her postoperative course was complicated by infection, she subsequently recovered well with no NL recurrence and viable flap reconstruction at 10 months postoperatively. The patient was satisfied with her aesthetic outcome. To our knowledge, this is the first report describing reconstruction of NL of the breast and demonstrates the feasibility of resection to deep fascia and coverage without disease recurrence in refractory cases of NL.

Celiac disease (CeD) is a common autoimmune disease of the small intestine triggered by ingesting gluten-containing foods. Chronic symptoms are characteristic of functional dyspepsia (FD), including chronic epigastric pain and burning. The clinical and genetic overlap between FD and CeD is currently being investigated in a large-scale comorbidity and genetic predisposition study. In this study, causal connections between CeD and FD were evaluated using Mendelian randomization (MR) methods, including the inverse variance weighted, MR-Egger regression, and the weighted median methods. Cochran Q test was used to examine heterogeneity among the causal effects. MR-Egger regression indicates the average pleiotropic effect of instrumental variables. MR pleiotropy residual sum and outlier analysis was conducted to detect outlier instruments and remove pleiotropy. CeD was associated with a modestly increased risk of FD, with an estimated effect size of 3.2% (odds ratio = 1.032 [1.008-1.056], P = .019). The reverse MR analysis provided no significant evidence supporting a causal effect of FD on CeD risk (odds ratio = 1.173 [0.989-1.390], P = .099). In addition, no substantial heterogeneity or horizontal pleiotropy was detected in either the forward or reverse MR analyses. These findings highlight the need for routine FD screening among patients with CeD and indicate that optimizing CeD management may help reduce the burden of FD in this population.

Ball-valve syndrome (BVS) is a rare condition characterized by intermittent gastric outlet obstruction caused by a mobile gastric lesion. Large gastric lipomas associated with BVS have traditionally been managed surgically; however, minimally invasive endoscopic treatment may be feasible in selected cases. We report a case of a 52-year-old woman presenting with a 1-month history of postprandial epigastric discomfort and nausea. Contrast-enhanced computed tomography revealed a well-defined, low-attenuation mass extending from the gastric antrum to the duodenal bulb. Esophagogastroduodenoscopy demonstrated a broad-based subepithelial lesion exceeding 50 mm in diameter that repeatedly prolapsed through the pylorus, consistent with BVS. Endoscopic ultrasound showed a homogeneous hyperechoic lesion arising from the submucosa. Based on these imaging findings, a lipoma was strongly suspected, although liposarcoma could not be completely excluded. Therefore, endoscopic submucosal dissection (ESD) was performed as a diagnostic and therapeutic approach. Using a clip-with-line traction method, en bloc resection was successfully achieved without adverse events. The resected specimen measured 103 × 41 × 20 mm, and histopathological examination confirmed a gastric lipoma. The patient's symptoms resolved completely after the procedure, with no recurrence at 1-year follow-up. In conclusion, ESD can be a safe and effective minimally invasive treatment for large gastric lipomas causing BVS, particularly when a confident preoperative diagnosis can be established.

The introduction of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors has significantly altered the treatment paradigm for hormone receptor-positive, HER2-negative breast cancer. Increasingly, surgeons encounter patients receiving these agents at the time of breast reconstruction, yet there is no published evidence on the safety of free tissue transfer in this context. We present the first series examining post-operative outcomes in patients exposed to CDK4/6 inhibitors undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction and outline a pragmatic management approach. We report a retrospective, consecutive cohort series of all unilateral DIEP breast reconstructions undertaken between January 2024 and January 2026 at our institution. We include 232 patients, 9 of whom (4%) underwent peri-operative CDK4/6 inhibition. The median age was 51 years. Overall, 18% of patients were obese (BMI ≥ 30), 7% had a smoking history, and 2% had diabetes. CDK4/6 inhibitors administered were Abemaciclib (n=6), Ribociclib (n=2) and Palbociclib (n=1), and patients were recommended a median of 2 weeks off treatment pre-operatively. Pre-operative haemoglobin, white cell, neutrophil and lymphocyte counts were all significantly lower in the CDK4/6 inhibitor group (p<0.05). No minor complications occurred in CDK4/6 patients compared with 11% in non-exposed patients (p=0.6). Major complications were rare, occurring in 0% of CDK4/6 inhibitor patients and 2.2% of non-exposed patients (p=1.0). In this early series, CDK4/6 inhibition did not adversely affect surgical outcomes. We advocate for close coordination with oncology regarding temporary treatment interruption. Larger, multi-centre studies are needed to fully assess the risk profile of peri-operative CDK4/6 inhibitors in autologous reconstruction.

Pancreatic involvement in paraesophageal hernias is rare and can precipitate acute pancreatitis through mechanical compression or ischemia. We report an 82-year-old woman who presented with epigastric pain and an elevated lipase level. Imaging demonstrated a large type IV paraesophageal hernia containing the stomach, transverse colon, and pancreatic body and tail, with inflammatory changes localized to the pancreatic tail. Common causes of pancreatitis were excluded. The patient improved with conservative management and was referred for elective hernia repair after resolution of pancreatitis. This case highlights an uncommon mechanical cause of acute pancreatitis and the importance of anatomic evaluation in atypical presentations.

Gastric ectopic pancreas is an uncommon congenital anomaly that is usually asymptomatic but can mimic gastric malignancy when inflamed. We report the case of a 33-year-old previously healthy woman who presented with acute severe epigastric pain and inability to tolerate oral intake. Endoscopy demonstrated annular thickening of the gastric antrum, congested and friable mucosa, and poor gastric distensibility. Contrast-enhanced computed tomography demonstrated irregular circumferential antral wall thickening with an enhancing endoluminal mass, perigastric lymphadenopathy, and minimal free intraperitoneal fluid, raising a strong suspicion for gastric malignancy. Fibroblast activation protein inhibitor positron emission tomography demonstrated a tracer-avid gastric antral lesion. Endoscopic ultrasound showed a large hypoechoic mural lesion with loss of normal wall-layer architecture and perigastric lymph nodes. Conventional biopsy showed Helicobacter pylori-associated chronic gastritis without malignancy, while endoscopic ultrasound-guided sampling revealed spindle cells with eosinophilic inflammatory infiltrate and only mild cytological atypia. Immunohistochemistry helped exclude gastrointestinal stromal tumour, schwannoma, carcinoma, and inflammatory myofibroblastic tumour. Following H. pylori eradication therapy and conservative management, symptoms resolved completely. Repeat endoscopy at three months demonstrated resolution of antral thickening and a residual centrally umbilicated subepithelial lesion, supporting the presumed inflamed gastric ectopic pancreas. This case highlights that fibroblast activation protein inhibitor avidity should be interpreted as a marker of fibroblast activation rather than proof of malignancy and that interval reassessment can prevent unnecessary radical surgery in clinically stable patients with discordant imaging and histology.