Localized small-bowel infarction caused by Aspergillus during chemotherapy for acute myeloid leukemia: Report of a case

Aspergillosis is a common fungal infection in immunocompromised patients undergoing chemotherapy. The incidence of invasive fungal infection in these patients has increased dramatically in recent years. We report a case of small-bowel infarction caused by Aspergillus in a 48-year-old man who was receiving chemotherapy for acute myeloid leukemia. On day 20 after the start of chemotherapy, right lower abdominal pain and rebound tenderness developed, with a high fever. A contrast-enhanced computed tomography scan showed a semicircular perfusion defect in the ileum. Thus, we performed partial resection of the ileum with primary anastomosis. Macroscopically, the ileum had mucosal ulcerations. Microscopically, there was transmural necrosis with microperforation and Aspergillus invading necrotic tissue and blood vessels. The patient had an uneventful postoperative course and was discharged 14 days after the procedure. Intestinal aspergillosis is rare and associated with high mortality. Thus, it should be considered in the differential diagnosis of neutropenic patients with sudden abdominal pain and fever.     

The second STEP: the feasibility of repeat serial transverse enteroplasty

Background

Serial transverse enteroplasty (STEP) lengthens and tapers dilated bowel. Redilation of the STEP segment occurs in some patients with intestinal failure. The feasibility of a repeat STEP procedure in a pig model is evaluated.

Methods

Six pigs underwent reversal of an intestinal segment distal to the ligament of Treitz. At 6-week intervals after reversal, each animal had 2 STEP procedures on the bowel proximal to the reversed segment. Necropsy was performed up to 6 weeks after repeat STEP.

Results

Bowel length increased by 11.3 ± 3.9 cm and bowel diameter decreased from a mean of 5.3 ± 0.8 to 1.8 ± 0.4 cm (P < .0001) after the first STEP. After repeat STEP, bowel length increased by 16.7 ± 13.3 cm (P < .01), and the bowel was tapered from a mean of 5.4 ± 0.9 to 2.2 ± 0.4 cm (P < .01). Five pigs did well after repeat STEP, and 1 pig had early necropsy for bowel obstruction. None had histologic evidence of bowel ischemia in the repeat STEP segment.

Conclusions

A second STEP operation is feasible in a pig model and may be considered to optimize bowel length and function in select patients with intestinal failure.     

Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence

Background and Objectives:

The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence.

Methods:

This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis.

Results:

Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month.

Conclusions:

Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.     

The operative management of gallstone ileus

INTRODUCTION

Gallstone ileus is an uncommon entity, which accounts for 1–4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. Despite medical advances over the last 350 years, gallstone ileus is still associated with high rates of morbidity and mortality. The management of gallstone ileus remains controversial. Whilst open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery and lithotripsy. However, controversy persists primarily in relation to the extent of surgery performed.

MATERIALS AND METHODS

A literature review was performed in an attempt to discover the optimal surgical treatment of gallstone ileus, particularly the timing of biliary surgery. Published articles were identified from the medical literature by electronic searches of Pubmed and Ovid Medline databases, using the search terms ‘gallstone ileus’, ‘gallstone/intestinal obstruction’ and ‘gallstone/bowel obstruction’. The related articles function of the search engines was also used to maximise the number of articles identified. Relevant articles were retrieved and additional articles were identified from the references cited in these articles.

RESULTS AND CONCLUSIONS

The literature on gallstone ileus is composed entirely of retrospective analysis of small numbers of patients accumulated over many years. The question as to whether one stage or interval biliary surgery should be performed remains unanswered and it is unlikely that further case series will help decision making in the management of gallstone ileus. Whilst many authors conclude that enterolithotomy alone is the best option in most patients, a one-stage procedure should be considered for low-risk patients.     

联合益生菌的快速肠道准备对结直肠癌术后肠道黏膜屏障功能的影响

目的 观察联合益生菌的快速肠道准备方法的有效性及对结直肠癌术后肠道黏膜屏障功能的影响.方法 将60例行择期结直肠癌根治性手术的患者按硬币法随机化原则分为试验组（30例）和对照组（30例）.对照组采用传统的3 d肠道准备方法,试验组在使用恒康正清快速1 d肠道准备的基础上添加益生菌口服,2g/d,至少5 d.术后接受等氮量等热卡营养支持.术中观察肠道清洁度;光镜下观察肠黏膜形态学变化;免疫组织化学染色检测肠黏膜occludin蛋白和IgA的表达;检测术后第1天和第7天全血细菌DNA片段及术后第7天血清C反应蛋白浓度;观察体温、心率、外周血白细胞计数以及全身炎性反应综合征（SIRS）和吻合口瘘的发生情况.结果 试验组和对照组清肠效果的优、良率分别为90.0%和93.3%（P=0.314）;两组手术标本黏膜形态、绒毛高度、隐窝深度的差异无统计学意义.术后第7天PCR检测全血细菌DNA阳性者试验组2例（3.3%）,对照组有8例（26.67%）,差异有统计学意义（P=0.003）.试验组和对照组手术标本中结肠上皮occludin表达分别为（19.32±2.40）%和（16.21±2.54）%（P=0.025）;IgA表达分别为（7.60±1.48）%和（5.29±-1.57）%（P=0.031）;差异均有统计学意义.两组术后分别有24例（80.0%）和26例（86.7%）出现SIRS,分别各有2例（6.67%）出现吻合口瘘,差异均无统计学意义（P＞0.05）.结论 联合益生菌的快速肠道准备方法有效可行,且有利于结直肠癌术后肠道黏膜屏障功能的保护,减少术后早期炎性反应.     

术前不同肠道准备对结直肠癌术后肠道菌群变化的影响

目的比较传统肠道准备与快速肠道准备对结直肠癌患者术后肠道菌群变化的影响。方法前瞻性人组2010年3月至2011年3月间南方医科大学南方医院收治的60例结直肠癌患者,按抓阄的方法随机分成试验组（33例,术前仅行1d的肠道准备）和对照组（27例,按传统的3d方案进行肠道准备）。分别于肠道准备前和术后第1次排粪时,留取粪便进行肠道菌群分析,并观察术后肠道菌群紊乱及感染性并发症的发生情况。结果两组患者术后均发生不同程度的肠道菌群失调,表现为双歧杆菌、乳酸杆菌等益生菌种计数较术前明显减少（P〈0．05）,且对照组较试验组下降更明显（P〈0．05）;而大肠杆菌、葡萄球菌等致病菌的计数则明显高于术前（P〈0．05）,且对照组明显高于试验组（P〈0．05）。试验组术后感染性并发症发生率为9．1％（3／33）,明显低于对照组的29．6％（8／27）（P〈0．05）。结论快速肠道准备在一定程度上可减轻术后肠道菌群的紊乱程度,并降低术后感染性并发症的发生率。     

Gastroschisis, atresia, dysmotility: surgical treatment strategies for a distinct clinical entity

Purpose

Intestinal atresia (IA) occurs in 10% to 20% of infants born with gastroschisis (GS). We describe a distinct subset of these children with severe dysmotility, without mechanical intestinal obstruction, and with adequate intestinal length for enteral nutrition and propose possible treatment strategies.

Methods

A total of 177 patients with GS managed at a single institution between 1993 and 2007 were retrospectively reviewed.

Results

Twenty-one (12%) patients had IA. Six (29%) did well, with gradual progression to full diet; 1 died at birth because of complete midgut infarction; 1 died of necrotizing enterocolitis; 4 with short bowel syndrome (SBS) (small bowel length, 30-41 cm) died of liver failure because of total parenteral nutrition (3) or sepsis (1). Nine (43%) were felt to have gastroschisis/atresia/dysmotility, defined as adequate small bowel length for survival as measured at time of laparotomy (mean, 146 cm; range, 66-233 cm), massive intestinal dilatation, and stasis. Of 9 patients with gastroschisis/atresia/dysmotility, 5 (56%) survived. All had surgery to “rescue” their dysfunction intestine, at mean age 128 days (range, 52-271 days): 4 had tapering enteroplasties of mean 37 cm (range, 5-115 cm)—all 4 survived; 3 had diverting stomas created for intestinal decompression, followed by stoma closure—1 survived; 1 nonsurvivor had a Kimura “patch”; 1 nonsurvivor underwent redo anastomosis. Survivors weaned off total parenteral nutrition at mean age 331 days after rescue surgery (range, 42-814 days).

Conclusions

More than one third of patients with GS/IA appear to have significant intestinal dysmotility without true SBS nor obstruction. Successful treatment of these infants may be achieved with the use of tapering enteroplasty and/or temporary diverting stomas.     

围手术期不同处理因素对SD大鼠肠道菌群的影响

目的探讨围手术期不同处理因素对SD大鼠肠道菌群数量及比例的影响。方法根据围手术期不同处理因素,将SD大鼠48只分成对照组、抗生素组、肠道准备组、禁食组、抗生素-肠道准备组、抗生素-肠道准备一禁食组、肠道准备-手术处理-抗生素．术后早期进食组（术后早期进食组）及肠道准备-手术处理．抗生素一术后禁食组（术后禁食组）8组。每组6只．处死后取回盲部粪便．采用倍比稀释法分别涂在选择性培养基上,37℃恒温培育48h,对大肠杆菌、类杆菌、双歧杆菌和肠球菌计数。结果与对照组相比,抗生素组大鼠细菌总数、类杆菌、肠球菌和双歧杆菌计数均明显下降（P〈0．05）,而大肠杆菌水平上升（P〈0．05）,杆菌与球菌的比例（杆球比）升高（P〈O．05）：肠道准备组大鼠细菌总数、类杆菌、双歧杆菌和肠球菌计数均明显下降（P〈0．05）,而大肠杆菌无明显变化（P〉O．05）。杆球比下降（P〈0．05）;禁食组细菌总数、类杆菌、肠球菌和双歧杆菌计数均明显降低（P〈0．05）,大肠杆菌计数无明显改变（P〉0．05）,杆球比下降（P〈0．05）。术后早期进食组与术后禁食组相比,大肠杆菌、肠球菌及细菌总数明显升高（P〈0．05）,杆球比下降（P〈0．05）。结论抗生素、肠道准备及禁食均可影响SD大鼠肠道菌群数量和比例的改变,导致肠道菌群失调：术后早期进食对菌群失调有改善作用。     

Unchanged high mortality rates from acute occlusive intestinal ischemia: six year review

Objective Acute intestinal ischemia (AII) is an uncommon surgical emergency that has been increasing in incidence and remains a highly lethal condition with a difficult diagnosis. We undertook this study to evaluate our experience in treating this condition with a view to expand the cumulative information in the literature. Materials and methods Between January 2000 and December 2006, 60 patients with AII caused by thrombotic vascular event underwent surgery at our surgical center. The patients’ medical records including data covering demographic features, comorbid medical conditions, medical risk factors, clinical symptoms, history and physical examination findings, and biochemical and radiologic examinations were reviewed. Operative records, the American Society of Anesthesiology physical status classification (ASA-PS), postoperative complications, duration of hospital stay, and final outcome were also considered. Results Of the 60 patients with primary thrombotic vascular event, 20 patients had embolism and 19 patients arterial thrombosis. In 21 patients, mesenteric venous thrombosis was the etiology of AII. The median age was 73 years (range, 43–96). Higher ASA classification, age >70 years, late presentation, and high serum lactate levels were predictors of adverse outcome. The overall death rate was 60% (36/60), which was within the range of that observed in the published series. Conclusion AII remains a highly lethal condition. Mortality rates remain as high as they did decades ago due in part to advanced presentation and advanced age with multiple associated conditions and risk factors, all of which are independent predictors of adverse outcome.     

Giant Bladder Diverticulum as a Rare Cause of Intestinal Obstruction: Report of a Case

We report a case of intestinal obstruction as an unusual manifestation of bladder diverticulum. To our knowledge, this is the first report of a giant bladder diverticulum causing acute abdomen as a result of mechanical bowel obstruction.     

Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction

BACKGROUND: Many factors are believed to influence the mortality and morbidity after operations for adhesive small bowel obstruction (SBO). METHODS: In a multicenter prospective cohort of 286 patients operated on for adhesive postoperative SBO, we studied the in-hospital and 30-day postdischarge mortality (early mortality) and morbidity as well as long-term mortality using univariate and multivariate analysis. RESULTS: In the present cohort, with a median follow-up of 41 months and 9% patients lost to follow-up at the end of the study, the prevalence of early postoperative mortality was 3%. All deceased patients were over 75 years old with an American Society of Anesthesiologists (ASA) class >/=III. The prevalence of long-term mortality was 7% with the following independent risk factors: age >75 years old (hazards ratio [HR] 6.6 [95% confidence interval [CI], 2.4-18.1]), medical complications (HR 7.4 [CI, 2.2-24.3]), and a mixed mechanism of obstruction (HR 4.5 [CI, 1.5-13.7]). Prevalence of medical and surgical morbidity was 8% and 6%, respectively. Independent risk factors for medical complications were ASA class >/=III (odds ratio [OR] 16.8 [CI, 2.1-133.1]) and bands (OR 14.1 [CI, 1.8-111.5]) and for the surgical complications the number of obstructive structures >/=10 (OR 8.3 [CI, 1.6-19.7]), a nonresected intestinal wall injury (OR 5.3 [CI, 1.5-18.3]), and intestinal necrosis (OR 5.6 [CI, 1.6-19.7]). Otherwise, 3 patients with "apparent" reversible ischemia developed a postoperative intestinal necrosis followed by 2 reoperations and 1 death. CONCLUSION: The early postoperative mortality is strongly linked with the age and the ASA class and the long-term mortality with postoperative complications. More frequent bowel resections might be suggested for patients featuring a number of obstructive structures >/=10 and an intestinal wall injury, especially when associated with a reversible intestinal ischemia.     

Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature

We present a case of neonatal ovarian torsion complicated by bowel obstruction and perforation and review the literature regarding the incidence of bowel obstruction in neonatal ovarian cysts, the presentation, and treatment. A term neonate was prenatally diagnosed with a cystic abdominal mass palpable on physical examination. A postnatal abdominal x-ray showed paucity of gas in the left hemiabdomen with rightward displacement of bowel loops. Exploratory laparotomy on day 2 of life revealed a large cystic mass in the left lower quadrant consistent with a torsed left ovary, an omental band causing strangulation of the bowel mesentery, and a perforation of the distal ileum. Our literature search revealed 19 reported cases of neonatal ovarian cysts resulting in bowel obstruction. Infants may present with a palpable abdominal mass, respiratory distress, as well as signs and symptoms of intestinal obstruction. Two mechanisms exist for bowel obstruction: adhesions caused by a torsed necrotic ovary and mass effect of a large ovarian cyst, often measuring 9 to 10 cm in diameter. Options to treat ovarian cysts include antenatal or postnatal aspiration, laparoscopy, and laparotomy. Cysts less than 4 to 5 cm can be observed, whereas operative intervention is indicated in symptomatic cases and in persistent or enlarging ovarian cysts.     

结直肠癌术前vivonex替代肠道准备的临床研究

目的探讨口服vivonex可否替代结直肠癌术前肠道准备。方法结直肠癌患者40例,分vivonex组(20例)和对照组(20例),手术前后行肠道菌群分析,血浆D-乳酸、血中细菌DNA检测,观察术中肠道清洁情况和术后感染性并发症的发生率。结果两组术前双歧杆菌/大肠杆菌(B/E)比值倒置,对照组术后B/E比值(0.25±0.06)较术前(0.72±0.59)倒置更为明显,P<0.01。vivonex组术后B/E比值(1.36±0.34)较术前(0.76±0.47)显著增加,P<0.05;两组术后B/E比值比较,vivonex组较对照组显著增加(P<0.01)。术后血浆D-乳酸对照组较vivonex组显著增加(P<0.05),血中DNA阳性率(40%)、术后感染性并发症发生率(25%)对照组均高于vivonex组(25%和15%)。结论vivonex用于结直肠癌术前肠道准备可维护肠屏障功能,降低术后感染性并发症发生率。     

Solitary and complicated neurofibroma of small Bowel: A case report

IntroductionNeurofibromatosis is a genetic disorder characterized by tumors and pigmentary changes on the skin, such as spots that color leans to ‘White Coffee’.Neurofibromas of the gastrointestinal tract are commonly associated with neurofibromatosis type I (NF1). Although, digestive involvement can be the single manifestation of the disease and may consequently; represent the only diagnostic element.Presentation of caseWe report here; a case of a patient admitted to the emergency department with a bowel obstruction, for which radiological investigations revealed the presence of intussusception due to an intestinal tumor.The patient underwent a bowel resection with anastomosis, and then, after being examined histologically, the result has identified an intestinal neurofibroma without evidence of malignancy. Then and on the fourth day following the surgery, the patient was discharged with good clinical improvement.DiscussionThe intestinal neurofibroma may be the first and the only manifestation of neurofibromatosis type I. Also, it’s uncommon to present a neurofibroma isolated from the small bowel with an intussusception, which makes the pre-surgical diagnosis very difficult. And until now, only a few case reports of these conditions have been reported.ConclusionWe report this uncommon clinical case of an isolated neurofibroma from the small bowel to raise awareness among the medical team about this exceptional pathology. Nevertheless, its risk of developing serious complications and malignant transformation led us to opt for earlier surgical treatment.Furthermore, it requires a close clinical follow-up to eliminate the neurofibromatosis type I or the multiple endocrine neoplasia type II.     

Bowel Cleansing Before Bowel Surgery: Major Discordance Between Evidence and Practice

Mechanical bowel cleansing (preparation) before colorectal surgery is commonly practiced, and medical care guidelines consent to this regimen. This has been an incontestable routine for surgeons for more than 100 years. However, during the last years, several randomized control trials and three meta-analyses led to the accumulation of enough evidence to conclude that no significant benefit is derived from this practice and thus, elective colorectal surgery can be safely done without mechanical bowel cleansing. Furthermore, several complications are attributed to mechanical bowel cleansing including anastomotic leakage, wound infections, and septic and non-septic complications that sometimes lead to the need for reoperation. Surgeons around the world may have to seriously reconsider the common practice of preoperative mechanical bowel cleansing. Despite the unquestionable practical value of mechanical bowel cleansing for bowel handling during anastomotic confection, we believe that current literature provides strong evidence that passed the line where this time-honored tradition may be finally called into question.     

Small bowel intussusception in adults

Intussusception is the telescoping of a proximal segment of the gastrointestinal tract into an adjacent distal segment. This rare form of bowel obstruction occurs infrequently in adults. We report a case of small bowel intussusception in an adult male patient. We have also performed a literature review of this rare condition.     

母子亲体小肠移植治疗小肠衰竭的方法及疗效探讨：附1例报告

目的：探讨母子亲体小肠移植的方法及其对短肠综合征所致小肠衰竭的疗效。方法：为1名15岁短肠综合征（仅残留小肠8cm）致小肠衰竭的男患者行小肠移植术。供体为患者母亲。取供体带血管蒂回肠中下段1.2m移植于受体腹腔，两端分别造瘘及作人工肛。二期手术于6个月后施行，将受体残余肠中部横断，上下端分别与供肠近、远段行端侧吻合。结果：供、受体手术顺利。受体一期手术后曾发生感染及排斥，经治疗后痊愈。二次术后随访8个月，受体小肠功能逐渐恢复，患者体重明显增加，一般情况好，进食半流质，生活能自理。结论：亲体小肠移植是治疗短肠综合征肠衰竭的有效方法。排斥和感染是威胁小肠移植安全的主要因素。     

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目的 探讨小肠内置管排列术的临床疗效。方法 对1996～2003年采用改良的White手术，即小肠内置管排列术治疗病情较为复杂的肠梗阻35例，包括19例急症手术者。主要原发病为肠粘连和小肠炎性肠病等。结果 随访时间为1个月至3年，远期有效率为96．7％(29／30)，主要并发症为肠漏(25．7％)、低血容量性休克(5．7％)和膀胱损伤(5．7％)。结论 小肠内置管排列术是治疗复杂性肠梗阻的有效方法，正确选择适应证和积极的营养支持有助于减少并发症。肠功能衰竭的机制和诊治方法有待于深入研究。     

腹腔镜结直肠手术两种肠道清洁方法的比较

目的比较腔镜结直肠手术运用聚乙二醇电解质散剂和甘露醇清洁肠道效果,以期为该类疾病的治疗提供参考。方法选取2013年2月至2016年3月拟行腹腔镜结直肠手术病人96例,随机分为观察组和对照组,每组各48例。观察组病人采用聚乙二醇电解质散剂进行术前肠道准备,对照组病人采用口服甘露醇进行术前肠道准备,比较两组病人肠道清洁效果、术后肠蠕动恢复情况和术后不良反应发生情况。结果观察组病人肠道清洁效果与对照组比较,P0.05,差异无统计学意义;观察组病人术后肠鸣音出现时间为(59.74±4.73)h、术后首次排气时间为(80.53±7.37)h、术后首次排便时间为(84.72±9.63)h都短于对照组的(79.64±6.48)h、(99.42±8.93)h和(100.63±10.84)h,两组比较,P0.05,差异均有统计学意义;观察组病人不良反应发生率(16.67%)与对照组(45.83%)比较,P0.05,差异有统计学意义。结论聚乙二醇电解质散剂进行术前肠道准备获得的临床效果与口服甘露醇相当,但其能缩短病人术后肠蠕动恢复时间,降低术后不良反应发生率,值得临床合理选用。     

Bowel ischemia and gangrene—primary true enterolith

Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field.Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made.The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.