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1.  Post traumatic acquired multiple mesenteric defects 
Internal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.1 Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.2
In this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.
In the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.11 Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.
In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. 16
The diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.
PMCID: PMC3650254  PMID: 23624198
Mesenteric defect; Internal hernia; Intestinal obstruction
2.  Intestinal Injury from Blunt Abdominal Trauma: A Study of 47 Cases 
Oman Medical Journal  2009;24(4):256-259.
To determine the cause, presentation, anatomical distribution, diagnostic method, management and outcome of intestinal injuries from blunt abdominal trauma.
The study included 47 patients who underwent laparotomy for intestinal injuries from blunt abdominal trauma over a period of 4 years. A retrospective study was conducted and the patients were analyzed with respect to the cause, presentation, anatomical distribution, diagnostic methods, associated injuries, treatment and mortality.
47 patients with 62 major injuries to the bowel and mesentery due to blunt abdominal trauma were reviewed. The male to female ratio was 8.4: 1 and the average age was 34.98 years. There were 44 injuries to the small intestine including 1 duodenal injury, 11 colonic injuries and 7 injuries to the mesentry. 26 patients were injured in road traffic accidents. Out of 29 patients with intestinal perforation, free peritoneal air was present on plain abdominal and chest radiography in 23 patients. 18 patients underwent laparotomy on the basis of clinical findings alone. The commonest injury was a perforation at the antimesentric border of the small bowel. Treatment consisted of simple closure of the perforation, resection and anastomosis and repair followed by protective colostomy for colonic perforations. 3 (6.38%) deaths were recorded, while 8 (17.02%) patients developed major complications.
Although early recognition of intestinal injuries from blunt abdominal trauma is difficult, it is very important due to its tremendous infectious potential. Intestinal perforations are often associated with severe injuries which are probably be the determining factors in survival.
PMCID: PMC3243872  PMID: 22216378
3.  Peritonitis secondary to traumatic duodenal laceration in the presence of a large pancreatic pseudocyst: a case report 
A pancreatic pseudocyst is a common sequela of severe acute pancreatitis. Commonly, it presents with abdominal pain and a mass in the epigastrium several weeks after the acute episode and can be managed conservatively, endoscopically or surgically. We report a patient with a pancreatic pseudocyst awaiting endoscopic therapy who developed a life-threatening complication following a rather innocuous trauma to the abdomen.
Case presentation
A 23-year-old Asian male student presented as an emergency with an acute abdomen a week after a minor trauma to his upper abdomen. The injury occurred when he was innocently punched in the abdomen by a friend. He experienced only moderate discomfort briefly at the time. His past medical history included coeliac disease and an admission four months previously with severe acute pancreatitis. He was hospitalized for 15 days; his pancreatitis was thought to be due to alcohol binge drinking on weekends. Ultrasound scanning showed no evidence of gallstone disease. Five days after the trauma, he became anorexic, lethargic and feverish and started vomiting bilious content. Seven days post-trauma, he presented to our emergency department with severe abdominal pain. An emergency laparotomy was performed where a transverse linear duodenal laceration was found at the junction of the first and second part of his duodenum, with generalized peritonitis. His stomach and duodenum were stretched over a large pancreatic pseudocyst posterior to his stomach. It was postulated that an incomplete duodenal injury (possibly a serosal tear) occurred following the initial minor trauma, which was followed by local tissue necrosis at the injury site resulting in a delayed presentation of generalized peritonitis.
This is the first reported case of a traumatic duodenal laceration following minor blunt trauma in the presence of a large pancreatic pseudocyst. Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury. In the presence of a large pseudocyst, however, the stretching of the duodenum over the pseudocyst had probably predisposed the duodenum to this injury. Patients awaiting therapeutic interventions for their pancreatic pseudocysts should be warned about this unusual but life-threatening risk following minor blunt abdominal trauma.
PMCID: PMC3215995  PMID: 22029762
4.  Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report 
BMC Surgery  2015;15:37.
Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.
Case presentation
A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.
While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.
PMCID: PMC4392740  PMID: 25885337
Non-occlusive mesenteric ischemia; Hepatic portal venous gas; Delayed stricture; Stenosis
5.  Aberrant Mucin Assembly in Mice Causes Endoplasmic Reticulum Stress and Spontaneous Inflammation Resembling Ulcerative Colitis 
PLoS Medicine  2008;5(3):e54.
MUC2 mucin produced by intestinal goblet cells is the major component of the intestinal mucus barrier. The inflammatory bowel disease ulcerative colitis is characterized by depleted goblet cells and a reduced mucus layer, but the aetiology remains obscure. In this study we used random mutagenesis to produce two murine models of inflammatory bowel disease, characterised the basis and nature of the inflammation in these mice, and compared the pathology with human ulcerative colitis.
Methods and Findings
By murine N-ethyl-N-nitrosourea mutagenesis we identified two distinct noncomplementing missense mutations in Muc2 causing an ulcerative colitis-like phenotype. 100% of mice of both strains developed mild spontaneous distal intestinal inflammation by 6 wk (histological colitis scores versus wild-type mice, p < 0.01) and chronic diarrhoea. Monitoring over 300 mice of each strain demonstrated that 25% and 40% of each strain, respectively, developed severe clinical signs of colitis by age 1 y. Mutant mice showed aberrant Muc2 biosynthesis, less stored mucin in goblet cells, a diminished mucus barrier, and increased susceptibility to colitis induced by a luminal toxin. Enhanced local production of IL-1β, TNF-α, and IFN-γ was seen in the distal colon, and intestinal permeability increased 2-fold. The number of leukocytes within mesenteric lymph nodes increased 5-fold and leukocytes cultured in vitro produced more Th1 and Th2 cytokines (IFN-γ, TNF-α, and IL-13). This pathology was accompanied by accumulation of the Muc2 precursor and ultrastructural and biochemical evidence of endoplasmic reticulum (ER) stress in goblet cells, activation of the unfolded protein response, and altered intestinal expression of genes involved in ER stress, inflammation, apoptosis, and wound repair. Expression of mutated Muc2 oligomerisation domains in vitro demonstrated that aberrant Muc2 oligomerisation underlies the ER stress. In human ulcerative colitis we demonstrate similar accumulation of nonglycosylated MUC2 precursor in goblet cells together with ultrastructural and biochemical evidence of ER stress even in noninflamed intestinal tissue. Although our study demonstrates that mucin misfolding and ER stress initiate colitis in mice, it does not ascertain the genetic or environmental drivers of ER stress in human colitis.
Characterisation of the mouse models we created and comparison with human disease suggest that ER stress-related mucin depletion could be a fundamental component of the pathogenesis of human colitis and that clinical studies combining genetics, ER stress-related pathology and relevant environmental epidemiology are warranted.
Michael McGuckin and colleagues identify two mutations that cause aberrant mucin oligomerization in mice. The resulting phenotype, including endoplasmic reticulum stress, resembles clinical and pathologic features of human ulcerative colitis.
Editors' Summary
Inflammatory bowel diseases (IBD) are common disorders in which parts of the digestive tract become inflamed. The two main types of IBD are Crohn's disease, which mainly affects the small bowel, and ulcerative colitis (UC), which mainly affects the large bowel (colon). Both types tend to run in families and usually develop between 15 and 35 years old. Their symptoms include diarrhea, abdominal cramps, and unintentional weight loss. These symptoms can vary in severity, can be chronic (persistent) or intermittent, and may start gradually or suddenly. There is no cure for IBD (except removal of the affected part of the digestive tract), but drugs that modulate the immune system (for example, corticosteroids) or that inhibit “proinflammatory cytokines” (proteins made by the immune system that stimulate inflammation) can sometimes help.
Why Was This Study Done?
Although the clinical and pathological (disease-associated) features of Crohn's disease and UC are somewhat different, both disorders are probably caused by an immune system imbalance. Normally, the immune system protects the body from potentially harmful microbes in the gut but does not react to the many harmless bacteria that live there or to the food that passes along the digestive tract. In IBD, the immune system becomes overactive for unknown reasons, and lymphocytes (immune system cells) accumulate in the lining of the bowel and cause inflammation. In this study, the researchers use a technique called random mutagenesis (the random introduction of small changes, called mutations, into the genes of an organism using a chemical that damages DNA) to develop two mouse models that resemble human UC and that throw new light on to how this disorder develops.
What Did the Researchers Do and Find?
The researchers establish two mutant mouse strains—Winnie and Eeyore mice—that develop mild spontaneous inflammation of the colon and chronic diarrhea and that have more proinflammatory cytokines and more lymphocytes in their colons than normal mice. 25% and 40% of the Winnie and Eeyore mice, respectively, have severe clinical signs of colitis by 1 year of age. Both strains have a mutation in the Muc2 gene, which codes for MUC2 mucin, the main protein in mucus. This viscous substance (which coats the inside of the intestine) is produced by and stored in intestinal “goblet” cells. Mucus helps to maintain the intestine's immunological balance but is depleted in UC. The researchers show that the manufacture and assembly of Muc2 molecules is abnormal in Winnie and Eeyore mice, that less mucin is stored in their goblet cells than in normal mice, and that their intestinal mucus barrier is reduced. In addition, an incompletely assembled version of the molecule, called Muc2 precursor, accumulates in the endoplasmic reticulum (ER; the cellular apparatus that prepares newly manufactured proteins for release) of goblet cells, leading to overload with abnormal protein and causing a state of cellular distress known as the “ER stress response.” Finally, the researchers report that MUC2 precursor also accumulates in the goblet cells of people with UC and that even the noninflamed intestinal tissue of these patients shows signs of ER stress.
What Do These Findings Mean?
These findings indicate that mucin abnormalities and ER stress can initiate colitis in mice. Results from animal studies do not always reflect what happens in people, but these findings, together with those from the small study in humans, suggest that ER stress-related mucin depletion could be a component in the development of human colitis. The results do not identify the genetic changes and/or environmental factors that might trigger ER stress in human colitis, but suggest that once initiated, ER stress might interfere with MUC2 production, which would lead to a diminished mucus barrier, expose the lining of the intestine to more toxins and foreign substances, and trigger local mucosal inflammation. The release of inflammatory cytokines would then damage the intestine's lining and exacerbate ER stress, thus setting up a cycle of intestinal damage and inflammation. Clinical studies to look for genetic changes and environmental factors capable of triggering ER stress and for ER-stress related changes in human UC should now be undertaken to test this hypothesis.
Additional Information.
Please access these Web sites via the online version of this summary at
The MedlinePlus Encyclopedia has pages on Crohn's disease and on ulcerative colitis (in English and Spanish)
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information on Crohn's disease and ulcerative colitis
Information and support for patients with inflammatory bowel disease and their caregivers is provided by the Crohn's and Colitis Foundation of America and by the UK National Association for Colitis and Crohn's Disease
Wikipedia has pages on mucins and on mucus (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
PMCID: PMC2270292  PMID: 18318598
6.  Ischemic Necrosis of Small Bowel Following Laparoscopic Surgery 
Background and Objective:
Small bowel ischemia following laparoscopy was described recently as a rare fatal complication of the CO2 pneumoperitoneum. Of the 8 cases reported in the surgical literature, 7 were fatal, 1 was not. In this report, we describe the first gynecological case.
A 34-year-old woman who underwent laparoscopy with extensive adhesiolysis and myolysis was re-admitted with an acute abdomen on postoperative day 4. Immediate laparotomy revealed acute peritonitis, extensive adhesions, and a 3-cm defect in the small bowel. Tissue examination showed ischemic necrosis of edematous, but essentially normal, bowel mucosa. The postoperative course was extremely complicated. She was discharged after a 2-month hospital stay in the intensive care unit for rehabilitation.
Data are available on 7 patients (including ours). All procedures were described as uneventful. The intraabdominal pressure was set at 15 mm Hg when specified. Some abdominal pain occurred in all, nausea and vomiting in 4, diarrhea in 2, abdominal distention in 1, fever in none. Quick reintervention laparotomy was performed in 2 and delayed in 5 (up to 4 days).
The CO2 pneumoperitoneum is a predisposing factor for intestinal ischemia as it reduces cardiac output and splanchnic blood flow. However, critical ischemia relies on underlying vasculopathy or an inciting event.
Patient selection, maintaining intraabdominal pressure at 15 mm Hg or less, and intermittent decompression of the gas represent the best options for preventing this complication.
PMCID: PMC3015534  PMID: 15119662
Small bowel ischemia; Pneumoperitoneum
7.  Sclerosing mesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: a case presentation and review of the literature 
Sclerosing mesenteritis is a rare disease resembling a mesenteric tumour. We present here a case of sclerosing mesenteritis that affected both the large and the small intestine of the patient. Therapeutic and diagnostic issues are discussed.
Case presentation
A 62-year-old man with a history of non-Hodgkin lymphoma presented with fatigue, a palpable tender abdominal mass and clinical signs of progressing intestinal obstruction. The preoperative evaluation failed to prove recurrence of the lymphoma or any other definite diagnosis. A laparotomy was performed through a midline incision. The mesentery resembled a tumour-like thickened and fibrotic mass. Abundant, rigid intestinal loop adhesions were observed. Diffuse fibrotic infiltration of the ileum and of the sigmoid colon, which obviously affected the intestinal vascular supply, were identified. A right colectomy and partial sigmoidectomy were performed. Pathological evaluation revealed extensive myofibroblastic reaction of the mesentery with accompanying loci of fat necrosis and areas of inflammation. A diffuse fibrotic infiltration that focally showed a ground-glass appearance was observed. The post-operative course was complicated by respiratory insufficiency and infections and the patient died 2 months after the operation.
Sclerosing mesenteritis that affects both the small and the large intestine is extremely rare. The disease is characterized by myofibroblastic reaction, fat necrosis and diffuse fibrosis of the mesentery. Pathological confirmation may be required for definite diagnosis. If the disease is characterized by severe and diffuse fibrosis, then the application of surgical therapy may be problematic.
PMCID: PMC2615039  PMID: 19091063
8.  Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden 
Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital.
This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.
The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.
Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals.
PMCID: PMC4237946  PMID: 25124882
Abdominal injuries; Low trauma volume hospital; Non-operative management
9.  Do Patients with Penetrating Abdominal Stab Wounds Require Laparotomy? 
Archives of Trauma Research  2013;2(1):21-25.
The optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge.
Until the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds.
Patients and Methods
This retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also, diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant.
During the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients’ (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases.
All in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.
PMCID: PMC3876513  PMID: 24396785
Anterior Abdominal Stab Wound; Patients; Urgent Laparotomy
Purpose: The purpose of this study was to assess the incidence of peritoneal adhesions leading to small intestinal obstruction after laparotomy in children in a tertiary paediatric surgical centre.
Methods: A retrospective review of 430 children aged <15 years who had trans-abdominal procedures over a 7 year period.
Results: Four hundred and fifty nine abdominal procedures were performed in 430 children during the study period. The follow up period ranged from 4 months – 7 years (Median 33 months). 22 (4.8%) had intra-operative confirmation of small intestinal obstruction. Their ages ranged from 21 days – 14 years (median 7 years). Postoperative adhesions due to laparotomy for typhoid perforation were the commonest, occurring in 10 (45%). Children undergoing emergency laparotomy were more likely to develop post operative small intestinal obstruction compared to elective laparotomy (p<0.025). Six (27.3%) children had bowel gangrene at laparotomy requiring bowel resection and anastomosis. Post-operative small intestinal obstruction developed in 6 (27.3%). One child died due to sepsis from intestinal gangrene. Conclusion: Small bowel obstruction due to adhesions requiring operative intervention in children in our setting is not un-common. Bowel gangrene is a common complication of postoperative small intestinal obstruction in children in our setting and should be suspected to avoid serious postoperative mortality and morbidity.
PMCID: PMC4170251  PMID: 25452942
Adhesions; Intestinal obstruction; children
11.  Traumatic rupture of a type IVa choledochal cyst in an adult male 
Choledochal cyst (CC) is a rare, congenital anomaly of the bile ducts. We describe a 26-year-old male patient who was transferred to our hospital with a reported traumatic rupture of cystic liver lesions following a fall. At the time of injury, the patient experienced severe abdominal pain. He was found to have peritonitis and abdominal hemorrhage, which is quite rare. Laparotomy revealed 3000 mL fluid consisting of a mixture of blood, bile and inflammatory effusion in the peritoneal cavity. The liver, gallbladder, spleen, stomach, duodenum, small intestine, and colon appeared normal. A large cystic mass was discovered near the porta hepatis. This mass, which connected to the hepatic bifurcation and gallbladder had a 5 cm rupture in the right wall with active arterial bleeding. Abdominal computed tomography (CT) and emergency laparotomy revealed rupture of a huge type IVa CC. The patient was successfully managed by primary cyst excision, cholecystectomy, and Roux-en-Y end-to-side hepaticojejunostomy reconstruction. The postoperative course was uneventful and the patient was discharged on the 12th day of hospitalization. Four weeks after surgery, abdominal CT scan showed pneumatosis in the intrahepatic bile duct, and intrahepatic dilatation which decreased following adequate biliary drainage. The patient has remained well in the close follow-up period for 9 mo.
PMCID: PMC3699050  PMID: 23840134
Biliary tract; Choledochal cyst; Trauma; Rupture; Peritonitis; Hemorrhage
12.  Acute phlegmonous gastritis complicated by delayed perforation 
Here, we report on a case of acute phlegmonous gastritis (PG) complicated by delayed perforation. A 51-year-old woman presented with severe abdominal pain and septic shock symptoms. A computed tomography scan showed diffuse thickening of the gastric wall and distention with peritoneal fluid. Although we did not find definite evidence of free air on the computed tomography (CT) scan, the patient’s clinical condition suggested diffuse peritonitis requiring surgical intervention. Exploratory laparotomy revealed a thickened gastric wall with suppurative intraperitoneal fluid in which Streptococcus pyogenes grew. There was no evidence of gastric or duodenal perforation. No further operation was performed at that time. The patient was conservatively treated with antibiotics and proton pump inhibitor, and her condition improved. However, she experienced abdominal and flank pain again on postoperative day 10. CT and esophagogastroduodenoscopy showed a large gastric ulcer with perforation. Unfortunately, although the CT showed further improvement in the thickening of the stomach and the mucosal defect, the patient’s condition did not recover until a week later, and an esophagogastroduodenoscopy taken on postoperative day 30 showed suspected gastric submucosal dissection. We performed total gastrectomy as a second operation, and the patient recovered without major complications. A pathological examination revealed a multifocal ulceration and necrosis from the mucosa to the serosa with perforation.
PMCID: PMC3964411  PMID: 24696618
Phlegmonous gastritis; Gastric perforation; Streptococcus pyogenes
13.  Operative management of biliary peritonitis complicating blunt hepatic trauma using partial hepatectomy and trans-hepatic biliary stenting 
Biliary peritonitis complicating blunt hepatic trauma is a rare but potentially lethal condition.
A 17-year old male patient who sustained a complex grade IV blunt hepatic trauma presented with severe haemorrhagic shock after an initial laparotomy in another hospital. An urgent exploratory laparotomy revealed a shattered posterior section of the right liver and suture haemostasis of the lacerated liver surface was performed. Postoperatively, the patient developed generalized biliary peritonitis and another laparotomy with peritoneal lavage and drainage was performed on postoperative day 12. However, ongoing manifestations of peritonitis and sepsis necessitated a third laparotomy 6 days later. This revealed ongoing biliary peritonitis due to major intra-hepatic bile duct injury. A partial hepatectomy with intra-operative trans-hepatic biliary stenting was undertaken. Postoperative recovery was uneventful and the biliary fistula healed completely by the end of the second postoperative week.
Major intra-hepatic bile duct injury following blunt hepatic trauma is an extremely rare cause of biliary peritonitis.
The combination of partial hepatectomy with intra-operative trans-hepatic biliary stenting proved to be a safe and effective method for treatment of biliary peritonitis due to major intra-hepatic bile duct injury following blunt hepatic trauma when non-operative management fails.
PMCID: PMC4008861  PMID: 24717813
Biliary peritonitis; Hepatic trauma; Hepatectomy; Trans-hepatic biliary stenting
14.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
15.  Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy 
Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy.
Materials and methods
All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed.
Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula.
The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.
PMCID: PMC2931502  PMID: 20727181
16.  Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report 
Axial torsion and necrosis of Meckel’s diverticulum causing simultaneous mechanical small bowel obstruction are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel’s diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and retention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography (CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral contrast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proximal to the obstruction, and a large (12 cm × 14 cm) Meckel’s diverticulum at the site of obstruction. Meckel’s diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel’s diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel’s diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; delay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.
PMCID: PMC4208045  PMID: 25346803
Meckel’s diverticulum; Axial torsion; Gangrene; Bowel obstruction; Emergency surgery
17.  Management of small bowel volvulus in a patient with simultaneous pancreas-kidney transplantation (SPKT): a case report 
There are several surgical complications which can occur following simultaneous pancreas-kidney transplantation (SPKT). Although intestinal obstruction is known to be a common complication after any type of abdominal surgery, the occurrence of small bowel volvulus, which is one of the rare causes of intestinal obstruction, following SPKT has not been published before. A 24-year-old woman suffering from type I diabetes mellitus with complications of nephropathy resulting in end stage renal disease (ESRD), neuropathy and retinopathy underwent SPKT. On the postoperative month 5, she was brought to the emergency service due to abdominal distention with mild abdominal pain. After laboratory research and diagnostic radiological tests had been carried out, she underwent exploratory laparotomy to determine the pathology for acute abdominal symptoms. Intra-operative observation revealed the presence of an almost totally ischemic small bowel which had occurred due to clockwise rotation of the mesentery. Initially, simple derotation was performed to avoid intestinal resection because of her risky condition, particularly for short bowel syndrome, and subsequent intestinal response was favorable. Thus, surgical treatment was successfully employed to solve the problem without any resection procedure. The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7. According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.
PMCID: PMC2117004  PMID: 17903265
18.  Giant primary angiosarcoma of the small intestine showing severe sepsis 
World Journal of Gastroenterology : WJG  2014;20(43):16359-16363.
Primary malignant tumors of the small intestine are rare, comprising less than 2% of all gastrointestinal tumors. An 85-year-old woman was admitted with fever of 40  °C and marked abdominal distension. Her medical history was unremarkable, but blood examination showed elevated inflammatory markers. Abdominal computed tomography showed a giant tumor with central necrosis, extending from the epigastrium to the pelvic cavity. Giant gastrointestinal stromal tumor of the small intestine communicating with the gastrointestinal tract or with superimposed infection was suspected. Because no improvement occurred in response to antibiotics, surgery was performed. Laparotomy revealed giant hemorrhagic tumor adherent to the small intestine and occupying the peritoneal cavity. The giant tumor was a solid tumor weighing 3490 g, measuring 24 cm × 17.5 cm × 18 cm and showing marked necrosis. Histologically, the tumor comprised spindle-shaped cells with anaplastic large nuclei. Immunohistochemical studies showed tumor cells positive for vimentin, CD31, and factor VIII-related antigen, but negative for c-kit and CD34. Angiosarcoma was diagnosed. Although no postoperative complications occurred, the patient experienced enlargement of multiple metastatic tumors in the abdominal cavity and died 42 d postoperatively. The prognosis of small intestinal angiosarcoma is very poor, even after volume-reducing palliative surgery.
PMCID: PMC4239530  PMID: 25473196
Angiosarcoma; Small intestine; Prognosis; Sepsis; Immunohistological marker
19.  Retained intra-abdominal artery forceps – An unusual cause of intestinal strangulation 
Surgical instruments and materials continue to be retained in the peritoneal cavity despite precautionary measures. Even though uncommon it is also under-reported and carries serious medico-legal consequences. Gauzes and sponges (gossypiboma) are the most commonly retained materials and intra-abdominal retained artery forceps are much rarer but when they do occur lead to chronic abdominal pain and can be a rare cause of intestinal obstruction or strangulation with significant morbidity and mortality.
Case Report:
We present a case of intraabdominal retained artery forceps in a 70-years-old lady who underwent laparotomy with splenectomy for a large spleen in a peripheral hospital. Upon discharge she continued to complain of intermittent abdominal pain of increasing severity. 12 months later she presented to us with an acute (surgical) abdomen requiring another laparotomy. At laparotomy she had strangulated/gangrenous lower jejunual and upper ileal bowel loops, the small bowel mesentery of this area being tightly trapped between the jaws of the retained artery forceps. She had gut resection and enteroanastomosis. Unfortunately she died from continuing sepsis on the second post-operative day.
Retained instruments in intra-abdominal surgery can cause serious complication and should be treated surgically. High index of suspicion and appropriate investigations like plain abdominal X-ray, abdominal ultrasound and CT and MRI scans should be instituted in patients who develop chronic abdominal symptoms following laparotomy. Preventive measures against retained instruments must follow strict laid down protocols for surgical instruments handling in theatre.
PMCID: PMC3336885  PMID: 22540110
Retained intra-abdominal artery forceps; chronic abdominal pain; intestinal strangulation; gossypiboma; significant morbidity and mortality
20.  Perforation of small bowel caused by Schistosoma japonicum: A case report 
A 67-year-old man from Jingzhou was admitted to the First Hospital Affiliated to Yangtze University in July 2013 with sudden onset of abdominal pain with dizziness for 12 h. The patient had sign of peritoneal irritation. Ultrasonography of the abdomen and pelvis showed hepatic fibrosis due to schistosomiasis. Computed tomography showed free gas in the peritoneal cavity. Plain abdominal radiography showed bilateral subdiaphragmatic accumulation of gas, perforation of the viscus, and radio-opacity in the left renal area. The patient underwent emergency exploratory laparotomy. At laparotomy, a moderate amount of muddy yellow pus was found in the intra-abdominal cavity. At the junction of the jejunum and ileum, about 250 cm from Treitz’s ligament, there was an about 10-cm length of inflamed small bowel with perforation (3 mm in diameter) along the mesenteric border at the middle of the lesion. The patient underwent resection of the affected intestinal segment, along with end-to-end intestinal anastomosis. Histopathological examination revealed mucosal necrosis and hemorrhage with a large number of infiltrating eosinophils and neutrophils, and acute submucosal inflammation with a large number of infiltrating eosinophils and neutrophils associated with Schistosoma japonicum (S. japonicum) eggs. No intravascular adult parasite was found. Postoperatively, the patient was treated with praziquantel (30 mg/kg daily) for 4 d. The patient progressed well. To the best of our knowledge, this is the first case of small bowel perforation associated with eggs of S. japonicum.
PMCID: PMC4351245  PMID: 25759563
Schistosoma japonicum; Intestinal perforation; Small bowel
21.  Urgent Abdominal Re-Explorations 
Treatment of a number of complications that occur after abdominal surgeries may require that Urgent Abdominal Re-explorations (UARs), the life-saving and obligatory operations, are performed. The objectives of this study were to evaluate the reasons for performing UARs, outcomes of relaparotomies (RLs) and factors that affect mortality.
Demographic characteristics; initial diagnoses; information from and complications of the first surgery received; durations and outcomes of UAR(s) performed in patients who received early RLs because of complicated abdominal surgeries in our clinic between 01.01.2000 and 31.12.2004 were investigated retrospectively. Statistical analyses were done using the chi-square and Fisher exact tests.
Early UAR was performed in 81 out of 4410 cases (1.8%). Average patient age was 50.46 (13–81) years with a male-to-female ratio of 60/21. Fifty one (62.96%) patients had infection, 41 (50.61%) of them had an accompanying serious disease, 24 (29.62%) of them had various tumors and 57 (70.37%) patients were operated under emergency conditions during first operation. Causes of urgent abdominal re-explorations were as follows: leakage from intestinal repair site or from anostomosis (n:34; 41.97%); hemorrhage (n:15; 18.51%); intestinal perforation (n:8; 9.87%); intraabdominal infection or abscess (n:8; 9.87%); progressive intestinal necrosis (n:7; 8.64%); stomal complications (n:5; 6.17%); and postoperative ileus (n:4; 4.93%). Two or more UARs were performed in 18 (22.22%) cases, and overall mortality was 34.97% (n:30). Interval between the first laparotomy and UAR averaged as 6.95 (1–20) days, and average hospitalization period was 27.1 (3–78) days.
Mortality rate was found to be higher among the patients who received multiple UARs. The most common (55.5%) cause of mortality was sepsis/multiple organ failure (MOF). The rates for common mortality and sepsis/MOF-dependent mortality that occured following UAR were significantly higher in patients who received GIS surgery than in those who received other types of surgeries (p:0.000 and 0.010, respectively).
UARs that are performed following complicated abdominal surgeries have high mortality rates. In particular, UARs have higher mortality rates following GIS surgeries or when infectious complications occur. The possibility of efficiently lowering these high rates depends on the success of the first operations that the patient had received.
PMCID: PMC1475563  PMID: 16759414
22.  Small intestine bleeding due to multifocal angiosarcoma 
We report a case of an 84-year-old male patient with primary small intestinal angiosarcoma. The patient initially presented with anemia and melena. Consecutive endoscopy revealed no signs of upper or lower active gastrointestinal bleeding. The patient had been diagnosed 3 years previously with an aortic dilation, which was treated with a stent. Computed tomography suggested an aorto-intestinal fistula as the cause of the intestinal bleeding, leading to operative stent explantation and aortic replacement. However, an aorto-intestinal fistula was not found, and the intestinal bleeding did not arrest postoperatively. The constant need for blood transfusions made an exploratory laparotomy imperative, which showed multiple bleeding sites, predominately in the jejunal wall. A distal loop jejunostomy was conducted to contain the small intestinal bleeding and a segmental resection for histological evaluation was performed. The histological analysis revealed a less-differentiated tumor with characteristic CD31, cytokeratin, and vimentin expression, which led to the diagnosis of small intestinal angiosarcoma. Consequently, the infiltrated part of the jejunum was successfully resected in a subsequent operation, and adjuvant chemotherapy with paclitaxel was planned. Angiosarcoma of the small intestine is an extremely rare malignant neoplasm that presents with bleeding and high mortality. Early diagnosis and treatment are essential to improve outcome. A small intestinal angiosarcoma is a challenging diagnosis to make because of its rarity, nonspecific symptoms of altered intestinal function, nonspecific abdominal pain, severe melena, and acute abdominal signs. Therefore, a quick clinical and histological diagnosis and decisive measures including surgery and adjuvant chemotherapy should be the aim.
PMCID: PMC3508646  PMID: 23197897
Gastrointestinal bleeding; Small intestine; Angiosarcoma; Small intestinal neoplasm
23.  Appendectomy and Resection of the Terminal Ileum with Secondary Severe Necrotic Changes in Acute Perforated Appendicitis 
Patient: Female, 19
Final Diagnosis: Acute perforated appendicitis • appendiceal abscess • secondary necrosis of the ileal wall
Symptoms: Right lower quadrant abdominal pain • fever
Medication: —
Clinical Procedure: Diagnostic laparoscopy • open drainage of an appendiceal abscess • appendectomy • ileal resection
Specialty: Surgery
Management of emergency care
Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.
Case Report:
A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney’s incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.
In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.
PMCID: PMC4307687  PMID: 25618525
Abdominal Abscess; Appendicitis; Intestine, Small
24.  Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases 
Posttraumatic diaphragmatic rupture (PTDR) is a rare complication of thoracoabdominal injuries. In the emergency phase, it is generally treated via wide laparotomy. The laparoscopic approach is controversial and it is reserved for the chronic type of PTDR. Herein we present three cases of laparoscopic treatment of PTDR, one of which was conducted early after the injury.
The patients’ age was 42, 66 and 53 years and the time from the injury until the operation 1 week, 2 months and 4 years, respectively. Hernia involved the left hemidiaphragm in two patients and the right hemidiaphragm in the second patient. Prolapsing viscera were the omentum/stomach/spleen, the small intestine and the omentum/large bowel, respectively. The PTDR was diagnosed right after the injury of the first patient but its treatment was postponed until the fourth day of hospitalization because of severe respiratory distress due to bilateral pneumothorax, flail chest and extended bilateral lung contusions. All patients underwent laparoscopic operation and correction of the hernia with the use of non-absorbable sutures or endoclips in two patients. There were no serious intra- or postoperative complications and the patients were discharged 30, 5, 6 days after the operation. After a period of 1, 8 and 9 years, respectively the patients remain without clinical evidence of recurrence.
Trauma is the major cause of acquired diaphragmatic hernias.
Laparoscopy is an attractive approach for the management of chronic PTDR. Moreover, it may offer the benefits of minimally invasive surgery during the acute phase of injury in highly selected patients.
PMCID: PMC4201025  PMID: 25113661
DH, diaphragmatic hernia; PTDR, posttraumatic diaphragmatic rupture; ICU, intensive care unit; CT, computed tomography; FAST, Focused Abdominal Sonography for Trauma; Posttraumatic diaphragmatic rupture; Laparoscopy; Thoracoabdominal injuries
25.  Abdominal negative-pressure therapy: a new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature 
Annals of Intensive Care  2012;2(Suppl 1):S23.
Application of abdominal negative-pressure therapy (NPT) is lifesaving when conservative measures fail to reduce sustained increase of the intra-abdominal pressure and it is impossible to achieve source control in a single operation due to severe peritonitis. The aim of this study is to share the initial experience with abdominal NPT in Latvia and provide a review of the relevant literature.
In total, 22 patients were included. All patients were treated with KCI® ABThera™ NPT systems. Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission, daily sequential organ failure assessment score and Mannheim peritonitis index (MPI) were calculated for severity definition. The frequency of NPT system changes, daily amount of aspirated fluid effluent and the time of abdominal closure were assessed. The overall hospital and ICU stay, as well as the outcomes and the complication rate, were analysed.
A complicated intra-abdominal infection was treated in 18 patients. Abdominal compartment syndrome due to severe acute pancreatitis (SAP), secondary ileus and damage control in polytrauma were indications for NPT in four patients. The median age of the patients was 59 years (range, 28 to 81), median APACHE II score was 15 points (range, 9 to 32) and median MPI was 28 points (range, 21 to 40), indicating a prognostic mortality risk of 60%. Sepsis developed in all patients, and in 20 of them, it was severe. NPT systems were changed on a median of every 4 days, and abdominal closure was feasible on the seventh postoperative day without needing a repeated laparotomy. Two NPT systems were removed due to bleeding from the retroperitoneal space in patients with SAP. Intestinal fistulae developed in three patients that were successfully treated conservatively. Incisional hernia occurred in three patients. The overall ICU and hospital stay were 14 (range, 5 to 56) and 25 days (range, 10 to 87), respectively. Only one patient died, contributing to the overall mortality of 4.5%.
Application of abdominal NPT could be a very promising technique for the control of sustained intra-abdominal hypertension and management of severe sepsis due to purulent peritonitis. Further trials are justified for a detailed evaluation of abdominal NPT indications.
PMCID: PMC3527158  PMID: 23281649

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