Adult intussusception induced by invagination of the side to side jejuno-jejunostomy after previous total gastrectomy with Roux-en-Y oesophago-jejunostomy

Aim-Background

Adult intussusception (AI) is an unusual and challenging condition that presents a diagnostic preoperative dilemma. It is expected to be found in 1/30.000 of all hospital admissions, 1/1.300 of all abdominal operations, 1/30–1/100 of all cases operated for intestinal obstruction, and in one of 20 cases in children.

Case report

A 72-year-old woman presented with a 2-month history of colicky abdominal pain, vomiting and constipation. She had undergone a total gastrectomy with Roux-en-Y oesophago-jejunostomy for gastric carcinoma 10 years earlier. An erect abdominal X-ray displayed a dilated small bowel loop, whereas urgent abdominal computerized tomography (CT scan) raised the suspicion of a volvulus. She underwent emergency laparotomy which revealed intussusception of the side-to-side entero-enterostomy of the Roux-en-Y loop into the adjacent small bowel (jejuno-jejunal). The intussusception was carefully reduced and a segmental small bowel resection due to ischaemia was performed. No malignant disease (local, regional or distant) was identified. It is believed that the intussusception was secondary to the presence of the previous side-to-side jejuno-jejunostomy. No other clear nidus or trigger was found on histological examination of the resected bowel segment.

Conclusions

AI remains a rare cause of persistent or intermittent chronic abdominal pain. Although intussusception per se has a favourable prognosis, the definitive prognostic factor lies in the nature of the lesion leading to the process. Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small bowel intussusception, providing the segment involved is viable and malignancy is not suspected or found.     

Profiling adult intussusception patients: comparing colonic versus enteric intussusception

Background

Adult intussusception is a rare entity representing 1% of all adult bowel obstruction, hospital admissions secondary to intussusception historically has ranged between .003% and .02%. There is limited knowledge regarding enteric and colonic surgical intussusception patients and their associated conditions.

Methods

A retrospective study was conducted using data from the National Inpatient Sample from 1998 to 2006. The inclusion criteria were surgical patients with intussusception.

Results

A total of 1,178 cases of intussusception requiring surgery were isolated from the database. The mean patient age was 49.57 years, about 58% were females, 99.43% of this population was insured, and the overall mortality rate was 1.70%. Colonic resection was associated with greater mortality compared with the enteric resection group (P = .018).

Conclusions

This was a large study on surgical adult intussusception patients conducted in the United States. We show differences in demography, comorbidities, and potential causes between colonic and enteric intussusception.     

Acute surgical abdomen as presentation of undiagnosed midgut malrotation in adults

Aim-Background

Acute presentation in adulthood of the indolent developmental midgut malformations constitutes a diagnostic problem and emergent surgery may result to an operative surprise.

Methods

In the last five years two women (case I: 46 years, case II: 88 years) and two men (case III: 42 years, case IV: 50 years) underwent urgent laparotomy for acute abdomen due to bowel obstruction (all cases) and peritonitis (cases II, III). Right colon volvulus in cases I, II and IV, ileocolonic intussusception in case II, gaseous distension of bowel loops and abdominal abscess in case III, and enlargement of the entire colon and megasigmoid in case IV were revealed by preoperative imaging. Symptoms of severe abdominal pain, abdominal distension with tenderness, vomiting and complete constipation were evident in all cases. At surgery, features of malrotation, mainly lack of fixation of the right colon which was volvulised, were found in all cases. Right-sided small intestine and Meckel’s diverticulum abscess were found in case III, and an incompletely volvulised megasigmoid coexisted in case IV. We performed resection of peritoneal bands, right hemicolectomy with ileotransversostomy in cases I, II and IV, and enterectomy and right colon fixation in case III. A Hartmann’s sigmoidectomy completed the operation in case IV.

Results

All cases had uneventful outcome, except for some delay in wound healing in a diabetic patient. Histology revealed ischaemia in all segments excised, ileocolonic intussusception associated with a caecal adenocarcinoma in case II, and inflammed Meckel’s diverticulum in case III.

Conclusions

Adult bowel malrotation complicated with right colon volvulus and/or ileocolonic intussusception requires emergent surgery.

     

Laparoscopic resolution of intussusception after Roux-en-Y gastric bypass

Introduction

Roux-en-Y gastric bypass (RYGB) has been the most common surgical operation used to treat obesity and its inherent co-morbidities. Intussusception with bowel obstruction after RYGB is a rare complication and its physiopathology remains unclear. The diagnosis is generally based on typical image of computed tomography (CT) scan and a surgical exploration is generally recommended.

Appendicitis and Benign Appendiceal Mucocele Presenting as Large Bowel Obstruction

Introduction

Appendiceal mucocele is most commonly encountered incidentally during appendectomy.

Methods

We report a case of large bowel obstruction presenting as a closed loop with an appendiceal mucocele as the lead point, superimposed on a chronic ileal stricture that had been misdiagnosed as irritable bowel syndrome.

Results

The patient underwent ileocecal resection and primary anastomosis. She did well postoperatively, and her irritable bowel syndrome disappeared.

Conclusions

Appendiceal mucocele can present in a variety of ways, and surgeons should be alert for atypical presentations. Moreover, some patients with intermittent abdominal pain deserve anatomic investigation before being dismissed as having irritable bowel.     

Robot-assisted triple neurectomy for iatrogenic inguinal pain: a technical note

Background

Painful neuromas are a relatively common complication of hernia and abdominal wall surgery.

Objective

Surgical neurectomy has the potential to to provide durable relief for chronic pain; however, current surgical approaches are not without morbidity or anatomical challenges.We sought a surgical alternative.

Methods

In the treatment of a case of incapacitating inguinal pain, we performed an anterior transperitoneal approach using a surgical robot.

Results

This approach was facile and provided elegant anatomical visualization.

Conclusion

This case describes the first known robot-assisted laparoscopic triple neurectomy and details a simplified, transperitoneal approach.     

Intussusception secondary to endometriosis of the cecum

INTRODUCTION

Intussusception in adults is a rare cause of bowel obstruction. Endometriosis of the bowel is also a rare entity that can be the cause of bowel obstruction. Here, we report a rare case of intussusception secondary to endometriosis of the cecum.

PRESENTATION OF CASE

A 40-year-old woman presented to the hospital with a one-week history of intermittent epigastric pain. On physical examination, there was a soft, round non-tender palpable mass in the right flank and abdominal computed tomography scan revealed an intussusception. We made the diagnosis of ileo-colic intussusception and performed ileocecal resection. The surgical specimen revealed a round submucosal cystic mass in the cecum and the histology showed endometriosis of the cecum.

DISCUSSION

Intussusception in adults is a rare entity present in just 1% of all patients with bowel obstruction, and 5% of all intussusceptions. In general, intussusception in adults has a pathologic lesion as the lead point and the lesion is a malignancy in 20–50% of the cases. Thus, the treatment of an intussusception in adults should be operative. Endometriosis of the bowel is a rare cause of intussusception. Small endometriosis lesions of the bowel are unlikely to cause symptoms; however, in patients presenting with bowel obstruction, urgent treatment is indicated.

CONCLUSION

Intussusception in an adult is a rare cause of bowel obstruction and intussusception caused by endometriosis is also rare. Although rare, the diagnosis of endometriosis as a cause of intussusception must be considered as part of the differential diagnosis.     

Transmural migration of surgical sponge into the stomach with outlet obstruction: Rare Case

Aim

To highlight the unusual postoperative clinical presentation of a retained sponge.

Background

Recognition of postoperatively retained foreign bodies is essential but often delayed, either because of medicolegal implications or because of a confusing clinical presentation and non-specific imaging features. In contrast to radio-opaque materials which are detected at follow-up imaging, radiolucent objects like sponges create problems in identification.

Case Report

A 30-year-old lady presented with intermittent non-bilious vomiting, epigastric pain and fever. Contrast-enhanced computed tomography of the abdomen showed a heterogeneous mass in the duodenum with multiple air pockets. Surgical exploration revealed a full-size surgical sponge with one end embedded in the gallbladder fossa and the other perforating the antrum of the stomach, thus causing an obstruction. The sponge was retrieved, and distal gastrectomy with Billroth II anastomosis was performed. The postoperative course was uneventful.

Conclusion

A high degree of suspicion and awareness of non-specific symptomatology associated with retained sponges after surgery is essential for early diagnosis and correct treatment.     

Significance of Computed Tomography Finding of Intra-Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Background

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective

The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods

During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results

A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion

Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.     

Gefäßchirurgische Therapieoption beim Wilkie-Syndrom

Background

Superior mesenteric artery syndrome, also known as Wilkie syndrome or arteriomesenteric obstruction of the duodenum, is a rare condition. The third part of the duodenum is compressed by the overlying, narrow-angled superior mesenteric artery (SMA) against the posterior structures. Typical symptoms are early satiety, recurrent vomiting, abdominal distention, weight loss with anorexia, and postprandial fullness. A gastrojejunostomy, duodenojejunostomy or Roux-en-Y reconstruction for reconstruction of the intestinal passage are usually the first surgical choices.

Material und methods

Four patients (37, 28, 23, and 24 years old) with typical symptoms of Wilkie syndrome who were treated with transposition of the superior mesenteric artery into the infrarenal aorta are reported. Postoperative upper gastro-intestinal series and abdominal computed tomography scans showed normal morphology with no signs of duodenal obstruction and a normal aortomesenteric angle. During follow-up, all patients’ physical conditions had improved.

Results

The vascular surgery approach to treat SMA syndrome is an alternative treatment option. Compression of the SMA is eliminated and it avoids contact and compression of the duodenum. Transposition of the SMA in the infrarenal aorta is the standardized vascular surgical procedure and a valuable treatment option in patients with chronic visceral ischemia.

Conclusion

Wilkie syndrome can be successfully treated by transposition of SMA without disrupting the continuity of the small bowel.     

Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery

Background and purpose

Postoperative bowel dysfunction is still a major unsolved problem following transperitoneal abdominal aortic surgery. We conducted this study to establish if gum chewing during the postoperative period promotes recovery of bowel function following abdominal aortic surgery.

Methods

The subjects were 44 patients who underwent elective abdominal aortic surgery. The patients were allocated to a control group (n?=?21), who received standard postoperative care, or a “gum group” (n?=?23), who received standard postoperative care and were also given gum to chew three times a day from postoperative day (POD) 0–5.

Results

The patient characteristics, intraoperative, and postoperative care were equivalent in both groups. Flatus was passed on POD 1.49 in the gum group and on POD 2.35 in the control group (P?=?.0004) and the time to oral intake was 3.09?days in the gum group and 3.86?days in the control group (P?=?.023). The number of days to full mobilization in the hospital room was 3.35 versus 5.59 for the gum and control groups, respectively (P?Conclusions Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery. Moreover, it is a physiologically sound, safe, and an inexpensive part of the postoperative care.     

Combined spinal and epidural anaesthesia for major abdominal surgery in infants

Purpose

Subarachnoid anaesthesia is becoming increasingly popular in neonates and infants. However, single dose spinal anaesthesia is of limited value for major abdominal surgery in infants due to its short duration of action and inability to provide analgesia in the post operative period. A new technique of combined spinal and epidural anaesthesia for major abdominal surgery in the infant is described.

Methods

Data were gathered prospectivety from 19 infants presenting for upper and lower abdominal surgery. Anaesthesia was induced with a subarachnoid injection of tetracaine. After the subarachnoid block was established, an epidural catheter was placed for further intraoperative and postoperative management. Data collected included age and weight of the patients, type and duration of the surgical procedure. Doses of local anaesthetics as well as the need for intraoperative and postoperative supplements were recorded. An illustrative case report is provided.

Results

Infants studied represented a wide range of weights (1520–7840 g). Spinal anaesthesia was successful in all 19 patients. A variety of extensive surgical procedures including small bowel resections and various genitounnary procedures were successfully performed. In 17 patients a functioning epidural catheter was in place postoperatively. In these patients effective analgesia was maintained with dilute solutions of epidural bupivacaine. Only three doses of narcotic were required for pain control. No patient required postoperative mechanical ventilation or tracheal intubation.

Conclusion

Combined spinal and epidural anaesthesia is a potential option to general anaesthesia for major abdominal surgery in infants.     

Dünndarmruptur nach stumpfem Abdominaltrauma bei vorbestehender Inguinalhernie

Background

Intestinal perforation following blunt trauma to the abdomen is a rare but life-threatening complication in patients with pre-existing inguinal hernia.

Material and methods

We examined retrospective case series of patients with intestinal perforation following blunt abdominal trauma.

Results

Within 2 years, three patients with pre-existing inguinal hernia were referred to our clinic following simple falls while cross-country skiing. Upon signs of abdominal tenderness and radiographic evidence of free air, explorative laparotomy with revision of the affected bowel segments was performed. The postoperative course was uneventful in two patients. One developed adhesive ileus and incisional hernia within 1 year.

Conclusions

Intestinal perforation must be suspected in patients with inguinal hernia and signs of diffuse abdominal tenderness following blunt trauma. Urgent explorative laparotomy with revision of the affected bowel segments is mandatory in patients with free abdominal air. Secondary hernia repair may represent the safest and most reliable approach and should be delayed until full recovery from the initial surgery.     

Eviszeration von Darm nach Stichverletzung des Abdomens

Study aim

The aim of the study was an estimation of the incidence and clinical aspects of emergency room (ER) parameters of penetrating abdominal injury patients with bowel evisceration.

Study design and methods

The study involved a retrospective cohort analysis of ER data from the Chris Hani Baragwanath Academic Hospitals, Soweto, Johannesburg, South Africa between September 2000 to May 2005.

Results

Out of 9,010 ER patients, 4,390 suffered penetrating injuries with 8 out of 71 eviscerations due to a single gunshot wound, 60 out of 71 eviscerations due to single stab wounds and 3 further patients suffered multiple injuries. The ER mortality was 1 out of 71(1.6 %) with an average ER mortality of 4.2 %. The only death seen was a single abdominal gunshot wound with vascular injury. The causative mortality due to abdominal stab wounds with evisceration of the bowels was therefore zero. The heart rate in patients with abdominal stab wounds with and without bowel evisceration showed no significant difference, thus mesentery tearing or vagal overstimulation could not be seen, neither with bradycardia nor hypotension.

Conclusion

Evisceration itself is not a cause for increased mortality or cardiovascular instability seen in the ER. There is ample time for diagnostic procedures before laparotomy is performed.     

Fetoscopic management of gastroschisis in a lamb model

Background

Gastroschisis is a malformation consisting of an abdominal wall defect with eviscerated bowel. Its standard treatment is postnatal repositioning or temporary prosthetic bag placement. The aim of our study is to evaluate the feasibility of its fetoscopic management in a lamb model.

Methods

At mid-gestation (day 75), gastroschisis was created in eight German blackhead sheep. A second fetoscopic procedure was performed on day 105, assessing the viability, extension, and potential for repositioning of eviscerated bowel. The fetus was retrieved by Cesarean section on day 132 and evaluated.

Results

In six fetuses gastroschisis could be successfully created and assessed with fetoscopy. Two fetuses were lost due to technical complications. Primary repair by repositioning the intestine into the abdomen was not possible because it grew into an inflammatory conglomerate too large for the small fetal abdominal cavity.

Conclusions

Although technically demanding, we were able to produce and reassess six cases of gastroschisis by fetoscopy. As primary repositioning appears unfavorable, fetoscopic prosthetic bag placement may become an alternative.     

Perinephric abscesses in the pediatric population: case presentation and review of the literature

Background

Perinephric abscesses in children are rare. Infection can come from various areas, and clinical signs overlap with more common etiologies, such as pyelonephritis. Imaging modalities and laboratory investigations help lead to a definitive diagnosis.

Case-diagnosis/treatment

We present a case of a 5-month-old infant presenting with a febrile illness and eventual diagnosis of a perinephric abscess causing abdominal compartment syndrome. The infant had no known risk factors, i.e., congenital genitourinal abnormalities or immunosuppression, and was treated successfully following initial resuscitation, appropriate antibiotics, and open surgical drainage. Cultures obtained from the abscess and peritoneal fluid were positive for S. aureus, while blood and urine cultures were negative.

Conclusions

A literature review found 13 studies looking at diagnosis and/or treatment of idiopathic perinephric abscess. With non-specific clinical signs and symptoms, diagnosis can be delayed and rests heavily on clinical suspicion and appropriate imaging. Treatment includes antibiotics alone, or in conjunction with percutaneous or open surgical drainage. In summarizing these studies, a suggestion for diagnosis and basic treatment approach is outlined.     

Contemporary Management of Adult Intussusception: Who Needs a Resection?

Background

Surgical resection is often recommended in adults with intestinal intussusception (AI) because of its potential association with malignancy. We provide a contemporary algorithm for managing AI by focusing on the probability of discovering a lead point.

Methods

This is a retrospective study of adult patients with computed tomography (CT)-confirmed intussusception who underwent operative management of AI between 1996 and 2011 at a single academic institution.

Results

Sixty-four patients were diagnosed with AI by CT scan and then managed operatively. The incidence of colonic (CI), small bowel (SBI), and retrograde intussusception (RI) was 14, 55, and 31 %, respectively. All patients with CI had a lead point, whereas none were found among patients with RI. Some 46 % of patients with SBI had a lead point. The probability of discovering a lead point in SBI was increased by past history of malignancy (RR, 3.7, p < 0.001), a mass seen on preoperative CT scan (RR, 2.9, p = 0.005), and age over 60 years (RR, 2.2, p = 0.07).

Conclusions

A pathologic lead point is likely with CI but not with RI. Patients with SBI who are over the age of 60 years and have a history of malignancy or a mass noted on CT scan have a higher likelihood of harboring a pathologic lead point.     

A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children

Background

Postoperative ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children is extremely rare, and no reports of this special type of postoperative small bowel intussusception have been found in the literature.

Methods

We retrospectively reviewed the clinical charts of 6 infants and children with postoperative ileoileal intussusception that occurred after surgical reduction of ileocolic intussusception between January 1994 and December 2006. Clinical features, diagnostic strategy, operative findings, and outcome were analyzed.

Results

All 6 cases of postoperative ileoileal intussusception after surgery for ileocolic intussusception occurred within 1 week after the initial operation. The clinical manifestation was intestinal obstruction without abdominal palpable mass or bloody stool. Abdominal ultrasound examination revealed the target sign in 5 cases. Manual reduction of the intussusception was performed successfully at reoperation in each instance.

Conclusions

The clinical symptoms of postoperative ileoileal intussusception after operations for ileocolic intussusception are not typical. A second postoperative (ileoileal) intussusception should be kept in mind after surgical reduction of the first (ileocolic) intussusception in children. In any atypical postoperative ileus, a sonographic study should be done to rule out the diagnosis of postoperative intussusception. Once this condition is diagnosed, surgical treatment should be performed as soon as possible.     

Laparoscopic Resection of a Small Bowel Lipoma with Incidental Intussusception

Background:

Small bowel tumors are rare entities that often present with nonspecific symptoms. The diagnosis is more likely in patients with occult gastrointestinal bleeding of unknown origin or in adults with small bowel intussusception. Even with exhaustive diagnostic testing, small bowel tumors are often not diagnosed preoperatively. Because 60% to 70% of small bowel tumors are malignant, surgical excision is always recommended.

Methods:

We report the case of a 73-year-old man with occult gastrointestinal bleeding. A small bowel tumor was discovered only after video capsule endoscopy, computed tomography, and multiple endoscopies were performed.

Results:

The patient underwent laparoscopic exploration. An incidental intussusception made the tumor simple to identify. By extending the umbilical port, the tumor was easily removed. The final pathology demonstrated a submucosal lipoma.

Conclusions:

Small bowel lipomas can cause intussusception and gastrointestinal bleeding. When diagnosed preoperatively, laparoscopic resection is feasible.     

Vorkommnismeldungen bei Klammernahtinstrumenten

Background

The study was initiated to evaluate the risks of surgical staplers.

Methods

In the years 2002–2007, a total of 165 reports of incidents or corrective actions from 3 manufacturers were registered and retrospectively analyzed with respect to the prevalent product default appearance, the results of the manufacturer’s investigations and the severity of the consequences for patient.

Results

Severe patient consequences occurred in only 35.2%. In the majority of the cases no patient injury resulted from the reported malfunction and the investigations revealed no product error (52.7%).

Conclusion

The surgical staplers are predominantly safe for application in thoracic and abdominal surgery. The incident reports are important for risk assessment and improvement of the surgical staplers.