Aortic bifurcation rupture after blunt abdominal trauma in a child: a case report

Blunt trauma to the abdomen resulting in aortic injury is rare in children with only a few case reports in the past 40 years. We describe the diagnosis and management of a 2-year-old boy who survived an aortic bifurcation rupture after blunt trauma.     

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应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法对２例病人采用全麻,在动态数字减影血管造影监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生,结论腹主动脉瘤腔内修复术手术创伤小,病人恢复快,跨肾动支架人工     

Primary aortoenteric fistula

A 78-year-old woman presented with a gastrointestinal hemorrhage and palpable abdominal aortic aneurysm. The computed tomography scan of the abdomen showed a primary aortoenteric fistula. The challenging clinical diagnosis of aortoenteric fistulae and their surgical treatment options are discussed.     

Symptomatic Abdominal Aortic Aneurysm with Inferior Vena Cava Malposition

A 66-year old woman was admitted with an acute symptomatic abdominal aortic aneurysm. After preoperative assessment, she was directly operated on via transperitoneal approach.

Intraoperatively, a left-sided inferior vena cava was diagnosed. The preoperative study of the abdominal computed tomography had not revealed this venous malformation.

Retroperitoneal venous anomalies are a major source of unexpected haemorrhage during aortic reconstruction. Thus, for optimal preoperative preparation, a systematic close examination of the preoperative contrast enhanced CT scan of the abdomen is advised.     

Retained Intra-abdominal Knife in a Self inflicted Stab

It is unusual to encounter a patient who stabbed his abdomen with a kitchen knife. A 25-year-old man was in police custody for 2 days. He stabbed his abdomen with a kitchen knife. He was brought to casualty with a retained knife in his abdomen. The knife had torn gastrocolic omentum and caused contusion on the transverse colon. His postoperative period was fair.     

Surgical treatment of primary aortojejunal fistula

INTRODUCTIONPrimary aortoenteric fistula is a rare clinical situation with a high mortality rate. One should suspect that condition when an abdominal aortic aneurysm is known to be present. We describe the case of a 60 year old man who presented with upper gastrointestinal bleeding as the first and sole manifestation of an abdominal aortic aneurysm, due to the rupture of the aneurysm in the jejunum.PRESENTATION OF CASEThe patient was admitted with hematemesis and melena. He reported no abdominal pain. Upper gastrointestinal endoscopy disclosed no bleeding or lesions of the stomach and duodenum. Bleeding stopped the following day, only to recur 4 days later. The patient was then subjected to abdominal CT scan, which revealed the presence of a subrenal aortic aneurysm, with fistulization to the small intestine. At laparotomy the aortic aneurysm was adherent to the first centimeters of jejunum. The diseased aorta was excised and replaced with a Dacron Y graft in situ.DISCUSSIONPrimary aortojejunal fistulas are only rarely encountered. They usually are the result of a nonspecific aneurysm of the abdominal aorta. They usually manifest with premonitory bleeding, followed by catastrophic hemorrhage few days later. Even with surgery the mortality rate is high.CONCLUSIONDiagnosis of primary aortoenteric fistula requires a high index of suspicion in cases of upper gastrointestinal bleeding, especially when endoscopy is negative and there is no knowledge of the existence of an abdominal aortic aneurysm. CT scan and prompt surgery are crucial to the survival of these patients.     

Early Results after Treatment of Open Abdomen after Aortic Surgery with Mesh Traction and Vacuum-Assisted Wound Closure

ObjectivesThis study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery.DesignProspective clinical study.Material and methodsFrom October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC.ResultsAll wounds could be closed following a median interval of 10.5 (range: 6–19) days after laparostomy. A median of four (range: 2–7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2–36) months.ConclusionVAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.     

Strangulated transmesosigmoid hernia as a late complication of a fall from a height: A case report

IntroductionA transmesosigmoid hernia is defined as small bowel herniation through a complete defect involving both layers of the sigmoid mesentery. Blunt trauma injury to the sigmoid mesocolon has been reported only rarely. We herein report a case of a strangulated transmesosigmoid hernia associated with a history of a fall from a height.Presentation of caseA 43-year-old woman presented to our hospital for evaluation of vomiting. She had no history of abdominal surgery but had sustained a complete spinal cord injury and pelvic fracture secondary to a fall from a height 25 years earlier. A computed tomography scan of her abdomen and pelvis demonstrated a closed loop of small bowel in the pelvis, with a zone of transition in the left lower abdomen. Although the cause of the obstruction was difficult to establish, ischemia was strongly suspected; therefore, the decision was made to perform emergency exploratory laparoscopy. During laparoscopy, a loop of ileum was observed to have herniated through a full-thickness defect in the sigmoid mesocolon, consistent with a transmesosigmoid hernia. The herniated loop was strangulated but not gangrenous and was successfully reduced using laparoscopic graspers. The incarcerated small bowel appeared viable and was therefore not resected. The defect was closed with a running suture. The patient had an uneventful postoperative course with no recurrence.Discussion and conclusionAbdominal blunt trauma can cause sigmoid mesenteric rupture resulting in a transmesosigmoid hernia. In the management of transmesosigmoid hernias, laparoscopic herniorrhaphy has the advantage of facilitating simultaneous diagnosis and surgical intervention.     

Elective Resection of Pheochromocytoma with Concomitant Abdominal Aortic Aneurysm Repair: Report of a Case

We report a rare case of coexistent pheochromocytoma and abdominal aortic aneurysm (AAA). The patient was a 72-year-old man who presented to the Emergency Department with severe dyspnea and hypertension. Physical examination revealed a pulsatile mass in his abdomen. A computed tomography scan, done after pharmacological treatment of his symptoms, showed a thoraco-AAA and a left adrenal mass. His urinary vanylmandelic acid and metanephrine levels were found to be elevated, strongly indicative of a diagnosis of pheochromocytoma. We gave the patient phenoxybenzamine, an α-blocker, preoperatively, then resected the adrenal mass and repaired the AAA. The patient had an uneventful recovery. The diagnosis of pheochromocytoma was confirmed histologically. To our knowledge, this is the first reported case of elective resection of both these lesions.     

Ruptured intracranial aneurysm associated with unruptured abdominal aortic aneurysm--case report

A 61-year-old male with hypertension presented with sudden onset of headache and nausea due to subarachnoid hemorrhage (SAH). He had two siblings with history of SAH due to ruptured intracranial aneurysms. Right carotid angiography on admission showed an anterior communicating artery aneurysm. At that time, the extracranial arteries were not examined. The aneurysm was clipped with no complications. A pulsating mass was palpable in the abdomen 37 days after the onset. Ultrasonography and computed tomography showed an abdominal aortic aneurysm with intraluminal thrombus, measuring 8 x 9 x 8 cm. Normal pressure hydrocephalus had already developed. The patient underwent elective abdominal aortic aneurysm resection before ventriculoperitoneal shunting. After shunting, he recovered fully. The present case indicates that unpredictable sudden enlargement of associated abdominal aortic aneurysm is possible in patients with ruptured intracranial aneurysms.     

Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction—A Novel Technique for Late Closure of the Open Abdomen

Background Open abdomen (OA) treatment often results in difficulties in closing the abdomen. Highest closure rates are seen with the vacuum-assisted wound closure (VAWC) technique. However, we have experienced occasional failures with this technique in cases with severe visceral swelling needing longer treatment periods with open abdomen. Feasibility and short-term outcome of a novel combination of techniques for managing the open abdomen are presented. Methods The VAWC technique was combined with medial traction of the fasciae through a temporary mesh in seven consecutive patients. The VAWC-system was changed and the mesh tightened every 2–3 days. Results Median (range) age in the 7 men was 65 (17–78) years. The diagnoses were ruptured abdominal aortic aneurysm (AAA) (3), operation for juxtarenal AAA (1), iatrogenic aortic lesion (1), trauma (1) and abdominal abscesses (1). Four patients were decompressed due to abdominal compartment syndrome (ACS) or intra-abdominal hypertension, and 3 could not be closed after laparotomy. Intra-abdominal pressure prior to OA treatment was 24 (17–36) mmHg. Maximal separation of the fasciae was 16 (7 –30) cm. Delayed primary closure was achieved in all patients after 32 (12–52) days with OA. No recurrent ACS was seen. No technique-specific complication was observed. Two small incisional hernias, one intra-abdominal abscess and one wound infection occurred in three patients. Conclusions Delayed primary closure in cases with severe visceral swelling and long periods of OA seems feasible with this technique.     

腹腔镜技术在急腹症和腹部外伤中的应用

目的:探讨腹腔镜用于普通外科急腹症和腹部外伤的价值。方法:回顾分析2005年4月至2008年8月作者用腹腔镜诊治急腹症48例患者的临床资料。结果:48例患者中,胃十二指肠溃疡穿孔13例,急性阑尾炎9例,急性胆囊炎17例,腹部闭合性损伤4例,腹部开放性损伤1例,急性盆腔炎2例,肠梗阻2例。48例患者均在腹腔镜下确诊,43例在腹腔镜下完成手术,5例中转开腹。患者均获痊愈,无术后并发症及围手术期死亡。结论:腹腔镜技术集诊断与治疗于一体,是治疗急腹症和腹部外伤的有效方法。     

Raumforderung im Retroperitoneum

Castleman’s disease is presented in the following article in more detail using the case report of a 55-year-old patient with abdominal pain without any significant pre-existing medical conditions. A computer tomography of the abdomen demonstrated a retroperitoneal tumor in the lower abdomen below the aortic bifurcation. Because malignancy of the tumor could not be excluded, surgical extirpation was performed without complications. Histopathological examination revealed the diagnosis of a localized castleman’s tumor. Castleman’s disease is a rare disease of the lymph nodes of unknown etiology. In the prognosis, benign forms can be distinguished from malignant forms.     

The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn

BACKGROUND: Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem. METHODS: From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound. RESULTS: Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up. CONCLUSION: In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.     

Primary omental torsion: A case report

A patient presented with an acute abdomen at the Emergency Department.The patient,a 69-year-old man,was admitted and underwent surgery with a provisional diagnosis of acute appendicitis.During surgery,omental torsion was diagnosed and the involved omentum was removed.The patient had no previous surgical history.Omental torsion is a rare cause of acute abdomen in children and adults who may present with various signs and symptoms;a preoperative diagnosis may therefore be difficult and can usually only be established during surgery.     

Aortic pseudoaneurysm after endarterectomy for small aorta syndrome

IntroductionSmall Aorta Syndrome (SAS) or hypoplastic aorto-iliac syndrome is a rare pathology of the aorta that affects almost exclusively young or middle-aged women and is characterized by smaller dimension of the aorta and iliac axes. Etiopathogenesis is unclear and many factors have been invoked. The smaller caliber of the aorta and iliac arteries may predispose to aorto-iliac occlusive disease development.In the past aorto-iliac endarterectomy (AE) with patch closure was utilized as an alternative to surgical bypass in order to correct steno-obstructive syndromes affecting carriers of SAS. Little is known about long term outcomes of this type of surgery.Presentation of the caseDuring investigations for acute colecystitis, an aortic pseudoaneurysm (PA) was diagnosed by ultrasound in a 73 old year woman. She was submitted twenty-two years ago for SAS with disabling claudication to aortic endarterectomy (AE) with patch graft insertion. Considering all the vascular options available she was submitted to open surgery with replacement of the aortic bifurcation.DiscussionAortic PA is a relatively common complication after bypass surgery but is rarely observed after AE. It requires prompt intervention to prevent subsequent complications such as rupture, thrombosis, distal embolism or aorto-enteric fistula.ConclusionEndovascular treatment for aortic PA should be always considered the treatment of choice but the open surgical option was preferred in this particular case because of the small diameters of the iliac accesses, making them unsuitable for an endovascular approach.     

Primary Omental-Mesenteric Myxoid Hamartoma of the Mesoappendix Incidentally Detected After Abdominal Trauma in a Child: Report of a Case

A 14-year-old boy was brought to our hospital with abdominal pain and nausea after suffering a blow to the abdomen. A mass was felt in the right hypogastrium, and the patient was hospitalized for possible hematoma resulting from the abdominal trauma. Initially, we treated him conservatively and observed his course, but on the 20th day after trauma, enhanced computed tomography showed that the area of strong enhancement in the tumor was unchanged. Superior mesenteric angiography showed findings indicative of a pseudoaneurysm caused by the trauma, and surgery was performed 26 days after the injury. Laparotomy revealed a tumor with a clear boundary, thought to originate in the mesoappendix, without any sign of pseudoaneurysm. Histopathological examination confirmed that the tumor was an omental-mesenteric myxoid hamartoma. The patient had an uneventful postoperative course and was discharged from hospital on the 12th day after surgery. More than 5 years have elapsed since the operation and no sign of recurrence or metastasis has been recognized.     

Giant cystic lymphangioma originating from the lesser curvature of the stomach

Cystic lymphangiomas are rare benign tumors. Most frequently occurring in children and involving the neck or axilla, these tumors are much less common in adults and very rarely involve the abdomen. The known congenital and acquired (traumatic) etiologies result in failure of the lymphatic channels and consequent proliferation of lymphatic spaces. This case report describes a very rare case of a giant mesenteric cystic lymphangioma in an adult male with no clear etiology and successful resolution by standard radical resection. A previously healthy 44-year-old male presented with a 6-wk history of progressive upper abdominal pain, vomiting, anorexia and unintentional weight loss accompanied by rapid abdominal distension. A palpable mass was detected upon physical examination of the distended abdomen and abdominal computed tomography scan showed a giant multilobulated cystic process, measuring 40 cm in diameter. Exploratory laparotomy revealed an enormous cystic mass containing 6 L of serous fluid. The process appeared to originate from the lesser omentum and the lesser curvature of the stomach. Radical resection of the tumor was performed along with a partial gastrectomy to address potential invasion into the adjacent tissues. Histological analysis confirmed the diagnosis of a multicystic lymphangioma. The postoperative recovery was uneventful and the patient was discharged after 6 d. At 3-mo follow-up, the patient was in good health with no signs of recurrence.     

Sinus of Valsalva dilatation after replacement of the ascending aorta and aortic valve

A 52-year-old woman, height, 149 cm; weight, 40 kg, was admitted because of anterior chest discomfort and palpitations. There was no family history of Marfan syndrome. She had undergone replacement of the ascending aorta and aortic valve 10 years prior for DeBakey II aortic dissection. Postoperative pathological examination of the resected aortic wall revealed cystic medionecrosis. Computed tomography(CT) 4 years after the surgery showed moderate enlargement of the preserved sinuses of Valsalva, and CT 10 years after the surgery showed enlargement of the sinus. She consented to a reoperation. The prostheses were explanted, and the aortic root was replaced with a composite graft. The right coronary artery ostium was completely closed, and no graftable portions of the distal right coronary artery were detected. Thus, the left coronary artery alone was reimplanted. The patient required extracorporeal membrane oxygenation for 10 days postoperatively, after which she recovered fully without complications. This case may indicate that the complete aortic root should be replaced during initial surgery of the ascending aorta or aortic valve in patients with potential risk of sinus of Valsalva dilatation.