An unusual cause of intussusception due to small bowel obstruction secondary to dried apricot consumption was encountered. Phytobezoar small bowel obstruction is a rare, but interesting pathology that accounts for 2–4% of small bowel obstructions (18). Even rarer, is an intussusception caused by dried fruit ingestion. We present the case of a 56-year-old female that presented with an intussusception after she ingested a large amount of dried apricots.
PRESENTATION OF CASE
The patient is a 56-year-old female with a small bowel obstruction secondary to intussusception in the distal ileum. She was taken to the operating room for a celiotomy where an intussusception of the distal small bowel was found. An enterotomy was performed which revealed dried apricots as the lead point. The intussusception was successfully reduced and the apricots removed.
Small bowel obstruction due to intussusception can be caused secondary to malignancy, Meckel's Diverticulum, benign neoplasm, and strictures. A less common cause for small bowel obstruction due to intussusception in adults is secondary to mechanical obstruction by bezoars. Risk factors for bezoar formation include previous gastric surgery, diabetes, and mastication problems.
Bezoars are an extremely rare cause of intussusception in adults. A high level of suspicion needs to exist in the presence of a history of eating dried fruit, history of gastric surgery, diabetes mellitus, and problems with mastication. Various treatment modalities exist to treat obstructions secondary to bezoars, including open reduction and removal of bezoar via enterotomy.
Phytobezoar; Small bowel obstruction; Intussusception; Bezoar; Dried apricot
Phytobezoar impacted in a Meckel’s diverticulum causing small bowel obstruction can be managed laparoscopically.
Background and Objectives:
Meckel's diverticulum is a common anomaly of the gastrointestinal tract that may result in gastrointestinal bleeding, diverticulitis, and small bowel obstruction. This report describes the use of laparoscopy to treat a rare complication of Meckel's diverticulum–small bowel obstruction due to phytobezoar impaction. More generally, it provides an example of the feasibility and utility of a laparoscopic approach to small bowel obstructions of unknown causes.
A 34-year-old male presented to the emergency department complaining of episodic abdominal pain and vomiting. He had no history of abdominal surgery. His vital signs were stable, and his abdomen was distended, but only mildly tender. He had no abdominal wall hernias on examination. Imaging was consistent with small bowel obstruction. He was brought to the operating room where laparoscopy revealed a Meckel's diverticulum with an impacted phytobezoar as the source of obstruction. The diverticulum was resected and the phytobezoar removed laparoscopically.
The patient recovered well and was discharged home on the third postoperative day, tolerating a regular diet.
Phytobezoar impaction in a Meckel's diverticulum causing small bowel obstruction is a rare event. It can be effectively treated laparoscopically. This case provides an example of the potential utility of laparoscopy in treating small bowel obstructions of unclear etiology.
Laparoscopy; Bowel obstruction; Meckel's diverticulum; Bezoar
Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy.
Presentation of case
A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH.
The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient.
A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.
Hernia; Laparoscopic; TEP; Extraperitoneal; Obturator hernia
Background and Objectives:
Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.
A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.
Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.
Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.
Meckel's diverticulum; Bowel obstruction; Bowel resection; Laparoscopy
Phytobezoars are a rare cause of small-bowel obstruction and an accurate preoperative diagnosis is very difficult. After diagnosis, the majority of patients in this study underwent surgery. The conventional management of small-bowel obstruction is done by laparotomy. Many studies have demonstrated that laparoscopy can be an alternative to laparotomy for the treatment of small-bowel obstruction in select patients, and it also brings the benefits of minimally invasive surgery. This report demonstrates the case of a patient with intestinal obstruction caused by phytobezoar (mango seed) who was treated laparoscopically. During the laparoscopy, a hard mass 5 cm proximal to the ileocaecal junction was palpable with graspers. An ileotomy was then performed. The bezoar was extracted and inserted into a bag. In this case, the intestinal obstruction management by laparoscopy was safe and feasible.
Laparoscopy; Minimally invasive; Intestinal obstruction; Bezoar; Mango
Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity.
We performed a review without any language restrictions considering international literature indexed from 1980 to 2007 in Medline, Embase and Cochrane Library. We analyzed the reference lists of the key manuscripts. We also added a review based on international non-indexed sources.
The feasibility of diagnostic laparoscopy is high (60–100%), while that of therapeutic laparoscopy is low (40–88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies ≤ 2, non-median previous laparotomy, appendectomy as previous surgical treatment causing adherences, unique band adhesion as phatogenetic mechanism of small bowel obstruction, early laparoscopic management within 24 hours from the onset of symptoms, no signs of peritonitis on physical examination, experience of the surgeon.
Laparoscopic adhesiolysis in small bowel obstruction is feasible but can be convenient only if performed by skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay and a lower postoperative morbidity. Although a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients.
This study is based on the laparoscopic treatment of 1,225 patients with ovarian cysts and 165 patients with ovarian malignancy by outstanding pioneers in laparoscopic gynecology. It crystallizes their extensive experience with adnexal masses and provides reasoned conclusions for the management of these diseases. The principles set forth merit attention by all practitioners of minimally invasive surgery.
The laparoscopic management of suspicious adnexal masses and early ovarian malignancies is discussed with the aim of maintaining accepted oncologic treatment principles. Comparative survival data of patients with gynecological malignancies managed by laparoscopy or laparotomy are still very scarce and the survival of cancer patients must not be compromised by new techniques. It is time to closely analyze laparoscopy and determine if it has a positive impact on the diagnosis and treatment of ovarian malignancies. In this paper we will address the following points:
1) Which ovarian cysts can be surgically treated by laparoscopy (pelviscopy)?2) Is staging laparoscopy an accepted technique?3) Is laparoscopy, as a second-look procedure, of benefit?4) Is laparoscopic staging, together with histologic tissue sampling, adequate surgical technique in inoperable ovarian cancer with ascites and peritoneal carcinomatosis?5) Does endoscopic biopsy of ovarian cancer stage Ia change the destiny of a patient into ovarian cancer Ic?
The above questions are analyzed based on our experience with the laparoscopic treatment of 1,225 patients with ovarian cysts and 165 ovarian cancer patients stage I to IV treated immediately by laparotomy during the years 1992-1995.
Ovarian cystic tumors with no signs of malignancy can be dealt with by laparoscopic means with the option of immediate conversion to laparotomy or within one week if an ovarian malignancy is diagnosed. Today sampling laparoscopic lymphadenectomy of both pelvic and para-aortic is feasible and adequate. On a curative level, the number of lymph nodes to be resected has yet to be determined. The adnexa can be extracted from the abdominal cavity with bag extraction without the danger of spillage. The uterus can be removed transvaginally with laparoscopic assisted vaginal hysterectomy (LAVH). We must be cautious to advocate laparoscopy for ovarian cancer. However, it is an excellent tool when used as a staging procedure. A careful preoperative screening of the patient and an exact definition of existing cysts with imaging techniques allows us to frequently apply laparoscopic surgery for ovarian cysts, leaving only readily detectable cancer cases for laparotomy. Many gynecological oncologists employing staging and second-look procedures for ovarian cancer agree that initiating a case with laparoscopy may preclude laparotomy for many patients. Tumor propagation by performing a biopsy in FIGO stage Ia ovarian cancer patients does not occur if the patient receives adequate radical surgical treatment within one week. According to the reports of Sevelda et al. and Dembo et al., the degree of differentiation and the existence of ascites are more relevant to decreasing the five-year survival rate of patients with ovarian cancer stage I than the rupture of capsule or penetration of the tumor.16,17A dependency on the first two parameters was found in these two large statistical studies.
As the question of endoscopic operations for adnexal mass is predominantly put for the sanitation of small ovarian tumors (ovarian tumors with solid particles in the cysts can be put into the section of primary laparotomies) there remains a wide field of indications for the laparoscopic treatment of adnexal mass and ovarian cysts with benign indications. For many young patients with non-malignant ovarian lesions such as endometriosis, benign cysts, benign cystic proliferations and fibromas, a laparotomy can be avoided and these lesions treated by laparoscopy.
Laparoscopy; Adnexal mass; Ovarian malignancy; Second-look laparoscopy
Small bowel obstruction associated with abdominal cocoon (AC) is a rarely encountered surgical emergency. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. It is usually difficult to be able to make a definitive diagnosis in the presence of obscure clinical and radiological findings. Diagnosis is usually made at laparotomy when the encasement of the small bowel within a cocoon-like sac is visualised. Here, we report on a 29-year-old male patient who presented with acute small bowel obstruction and was eventually diagnosed with AC at laparoscopy. In this case, laparoscopic excision of the fibrous sac and extensive adhesiolysis resulted in complete recovery. Although rare, the diagnosis of AC should be kept in cases of patients with intestinal obstruction combined with relevant imaging findings. Laparoscopy should also be considered for the management of this condition in suitable patients.
Abdominal cocoon; laparoscopy; management; small bowel obstruction
Small bowel obstruction caused by biliary stent migration may be managed without enterotomy by using a combination of laparoscopy, endoscopy, and fluoroscopy.
Distal stent migration is a well-known complication following insertion of biliary stents. Most such cases can be managed expectantly, because the stents pass through the gastrointestinal tract. However, small bowel obstruction as a result of the stent mandates surgical intervention.
We report the case of a patient who had distal stent migration causing a small bowel obstruction. We successfully retrieved the stent without an enterotomy, by using a combination of laparoscopy, endoscopy, and fluoroscopy. Our unique technique greatly decreased the risk of bacterial peritonitis in this patient with decompensated cirrhosis and associated ascites, which in this patient population results in a high mortality.
Management of small bowel obstruction secondary to biliary stent migration necessitates operative intervention. Retrieval of a dislodged stent can be performed safely without subjecting the patient to an enterotomy or a small bowel resection. Postoperative morbidity should be significantly reduced by this approach.
Retrieval of biliary stents in cases of small bowel obstruction without perforation may be successfully performed without enterotomy or bowel resection. A similar approach may be applied to other foreign bodies dislodged in the small bowel.
Biliary stent migration; Surgical management of small bowel obstruction from biliary stent migration
Background and Objective:
Although laparoscopic surgery for removal of adnexal masses is common, controversy exists about the safety and efficacy of this procedure for patients with malignancies. The aim of this study was to evaluate the effectiveness and safety of laparoscopic surgical treatment for patients with adnexal masses.
This was a retrospective chart review of one surgeon's experience in managing patients diagnosed with adnexal masses at 2 urban referral teaching hospitals in New York City. We reviewed the charts for 100 consecutive patients who underwent operative laparoscopy for management of adnexal masses between March 4, 1996 and November 9, 1998. Conversion to laparotomy, malignancy rate, complications, length of stay, and blood loss were recorded for each patient.
Laparoscopic management was successfully completed for 81 of the 100 patients in this study; however, 19 required conversion to laparotomy. All 81 patients managed laparoscopically had a benign diagnosis, whereas 7 of the 19 patients who underwent laparotomy were diagnosed with malignancy. The median length of stay, estimated blood loss, and operating room time were significantly lower for those treated by laparoscopy alone compared with those converted to laparotomy (2 vs. 7 days; 100 vs. 500 ccs; 130 vs. 235 minutes, respectively; P < 0.05). Though few patients were in the laparotomy group, that data are presented for completeness. A total of 10 complications occurred, 4 in the group of patients managed laparoscopically (2 enterotomies, 1 pneumothorax, and 1 vaginal cuff cellulitis). Six complications occurred in those managed with laparotomy (2 enterotomies, 2 wound infections, 1 pneumonia, and 1 postoperative fever). The indications for conversion to laparotomy were: 7 malignancies (5 ovarian cancers and 2 uterine cancers), 7 dense adhesions, 2 small bowel enterotomies, 1 intraoperative bleeding, 1 secondary to a large uterus (880 grams), and 1 secondary to a large myoma (13 cm x 14.5 cm x 6 cm).
The laparoscopic approach is effective and safe for managing patients with adnexal masses of unknown pathology. Malignancies can be diagnosed accurately, converted to laparotomy, and staged appropriately. Adequate surgical skills along with timely use of frozen sections are required for successful operative management.
Adnexal diseases-diagnosis-surgery; Laparoscopy; Adnexal mass; Ovarian carcinoma
A laparoscopic approach to gastrointestinal stromal tumors (GISTs) of the small bowel seems to be a safe method even in the face of emergent surgery when open oncologic principles of bowel and tumor handling are followed.
Gastrointestinal stromal (GIST) tumors make < 1% of all gastrointestinal neoplasms and 20% of small bowel neoplasms. The most common acute presenting symptom of these tumors is gastrointestinal hemorrhage with obstruction being rare. We discuss our laparoscopic approach to 2 patients with small bowel GIST tumors that presented to our institution with obstruction of the small bowel.
Two patients presented to the emergency department with signs and symptoms of small bowel obstruction. On workup, each was found to have a solid lesion either within or adjacent to the small bowel at the point of obstruction and both were emergently taken to the operating room. The pathologic diagnosis of small bowel GIST tumor was the same in both cases, but the pathophysiologies of the obstructing tumors were different.
Both patients underwent laparoscopic surgery with successful resection of the lesions. The details and crucial points of the laparoscopic approach to these tumors are described with specific attention to its appropriateness and safety in treating GIST tumors. Attention to particular details of the manipulation and management of the bowel in the face of obstruction and removal of the lesions is described.
The laparoscopic approach to GIST tumors of the small bowel, even in the face of emergent surgery, is a safe method.
Laparoscopy; GIST tumor; Small bowel obstruction
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.
Meckel’s diverticulum; Axial torsion; Gangrene; Bowel obstruction; Emergency surgery
This article discusses various indications for reoperation and how employing laparoscopy at primary operation might affect the incidence, presentation, and treatment of common complications. The abdomen is likely to be far less hostile after laparoscopic surgery than after laparotomy. Adhesions to the anterior abdominal wall are minimal or absent. As a result, relaparoscopy is a reasonable diagnostic and often successful treatment modality in patients suspected of having intra-abdominal complications following laparoscopic operation. Laparoscopic success in dealing with acute bowel obstruction after laparoscopic surgery is related to the paucity of adhesions and unique mechanisms of obstruction that are localized and amenable to minimal dissection. The same mechanisms are also responsible for the increased risk of bowel necrosis associated with bowel obstruction after laparoscopic surgery. Limited experience with successful laparoscopic management of bleeding and anastomotic leak has been reported with the caveat that if the bleeding or contamination is excessive, cannot be identified and controlled quickly, or is unresponsive to a reasonable and brief effort using laparoscopy, a prompt laparotomy is indicated. Based on the current literature, it is reasonable to conclude that laparoscopic approaches to primary Crohn's disease and relaparoscopy for recurrence are an appropriate (perhaps the most appropriate) management strategy. Also, laparoscopic restorative proctocolectomy and ileal pouch–anal anastomosis after laparoscopic subtotal colectomy is the preferred treatment for toxic ulcerative colitis. We conclude that laparoscopic reoperative surgery is feasible for the treatment of many complications following laparoscopic major abdominal surgery and bowel resection.
Laparoscopy; reoperative surgery; colon resection; complication; inflammatory bowel disease
The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction.
Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was “run” in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem.
Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days.
Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.
Acute small bowel obstruction; Adhesiolysis; Laparoscopy
Intersigmoid hernia is a rare internal hernia presenting with symptoms of bowel obstruction. Preoperative diagnosis is uncommon but computerised tomography (CT) may show signs to suggest internal hernia.
PRESENTATION OF CASE
A 63-year-old female presented with abdominal pain, vomiting and absolute constipation. Examination revealed a tense distended abdomen. A plain abdominal radiograph showed features of small bowel obstruction. Conservative management was initiated without success and a CT scan was performed which showed a dilated distal oesophagus, stomach and small bowel with a non-dilated length of distal ileum and large bowel. Internal hernia was suggested as a possible cause and the patient underwent a laparotomy where a loop of small bowel was found to be strangulated and gangrenous within the intersigmoid fossa. The gangrenous bowel was resected, an end-to-end anastamosis was performed and the fossa was closed. The patient made an uneventful recovery.
Hernias of the sigmoid mesocolon account for 6% of internal hernias with internal hernias themselves causing between 0.2 and 4.1% of intestinal obstruction. This report presents a case of intersigmoid hernia, a rare internal hernia which should be suspected in patients presenting with acute obstruction, no past surgical history and no external hernia. Patients with these symptoms should receive an urgent CT scan to facilitate early surgery and minimise strangulation and prevent bowel resection.
Intersigmoid hernia presents with acute obstruction, no past surgical history and no external hernia. Urgent CT scanning and early surgery may minimise strangulation, conserve bowel and reduce patient morbidity and mortality.
Intersigmoid hernia; Intersigmoid fossa; Sigmoid mesocolon hernia; Internal hernia; Intestinal obstruction
The clinical manifestations of abdominal ‘cocoon’ are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.
PRESENTATION OF CASE
A 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal ‘cocoon’ which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.
Abdominal ‘cocoon’ is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.
Abdominal ‘cocoon’ should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.
Abdominal cocoon; Intestinal obstruction; Surgery; Adhesionlysis
Laparoscopy has rapidly emerged as the preferred surgical approach to a number of different diseases because it allows for a correct diagnosis and proper treatment. In abdominal emergencies, both components of treatment—exploration and surgery—can be accomplished via laparoscopy. The aim of the present work is to illustrate retrospectively the results of a case-control experience with laparoscopic versus open surgery for abdominal emergencies performed at our institution.
From January 1992 to January 2002, 935 patients (mean age, 42.3±17.2 years) underwent emergent or urgent surgery, or both. Of these, 602 (64.3%) were operated on laparoscopically (small bowel obstruction, 28; gastroduodenal ulcer disease, 25; biliary disease, 165; pelvic disease, 370 cases; colonic perforations, 14) based on the availability of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than 2 previous major abdominal surgeries, or massive bowel distension were not treated laparoscopically. Peritonitis was not deemed a contraindication to laparoscopy.
The conversion rate was 5.8% and was mainly due to the presence of dense intraabdominal adhesions. Major complications ranged as high as 2.1% with a postoperative mortality of 0.6%. A definitive diagnosis was accomplished in 96.3% of cases, and 94.1% of these patients were treated successfully with laparoscopy.
Even if limited by its retrospective nature, the present experience shows that the laparoscopic approach to abdominal emergencies is as safe and effective as conventional surgery, has a higher diagnostic yield, and results in less trauma and a more rapid postoperative recovery. Such features make laparoscopy an attractive alternative to open surgery in the management algorithm for abdominal emergencies.
Laparoscopy; Abdominal emergencies; Appendicitis; Diagnosis; Surgery
Peutz-Jeghers is a rare autosomal dominant disorder characterized by hamartomatous polyps and discoloration of mucosal membranes. The polyps can occur anywhere in the gastrointestinal tract and can grow large enough to cause bowel obstructions.
A 16-year-old male presented to the emergency department with signs and symptoms of an acute bowel obstruction. He had 2 days of abdominal pain, obstipation, and vomiting. He had a previous history of a colonoscopy with polypectomy at age 4, and hyperpigmentation of his mucous membranes.
Computed tomographic (CT) scan revealed an intussusception of the small intestine. An exploratory laparoscopy found an intussusception of the mid jejunum. A laparoscopic-assisted small bowel resection was performed. Pathology showed a 5-cm polyp that acted as a lead point for the intussusception. Colonoscopy and upper endoscopy revealed 5 more polyps in the stomach and colon that were removed.
Small bowel obstructions can be managed successfully with minimally invasive approaches. The treatment of obstruction in these patients is to remove the offending hamartomatous polyp(s). The rest of the intestine needs to be examined and those polyps found should be removed. This can be done intraoperatively with laparoscopic-assisted enteroscopy and colonoscopy.
Peutz-Jeghers; Intussusception; Laparoscopic; Hamartomatous; Polyp
Small bowel obstruction is rarely caused by bezoars concretions formed from undigested foreign material in the gastrointestinal tract. An important cause of bezoars is phytobezoars, formed from vegetables or fruits. A four-year-old boy presented to our emergency department with symptoms of acute intestinal obstruction. Upright plain abdominal radiography revealed multiple air fluid levels. Ultrasound showed no abnormalities, and because of worsening symptoms computed tomography of abdomen was performed. It showed intraluminal obstruction of the terminal ileum. Exploratory laparotomy revealed a phytobezoar consisting of undigested rhubarb. The mass was milked through the large bowel and out the anus. Although rare in humans, bezoars are a well-documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction may require surgical treatment.
Obturator hernia is a rare type of hernia which accounts for only 0.07–1.4% of all intra-abdominal hernias and 0.2–5.8% of small-intestinal obstructions. Because the symptoms are non-specific, the diagnosis is often delayed until laparotomy is performed to treat bowel obstruction. The need for awareness of the condition is stressed, and the diagnosis of obturator hernia should be strongly suspected in a thin, elderly woman who has small bowel obstruction and no previous abdominal surgery. Here is a case report of obturator hernia in which the diagnosis was difficult because of the slow development of symptoms; on laparotomy it was found to be a Richter hernia. Computed tomography scanning can be helpful and will typically show an incarcerated small bowel behind the pectineus muscle. Laparoscopy may be necessary for diagnosis, and the hernia can be repaired laparoscopically.
Richter obturator hernia; Strangulated
AIM: To determine the value of bowel sounds analysis using an electronic stethoscope to support a clinical diagnosis of intestinal obstruction.
METHODS: Subjects were patients who presented with a diagnosis of possible intestinal obstruction based on symptoms, signs, and radiological findings. A 3M™ Littmann® Model 4100 electronic stethoscope was used in this study. With the patients lying supine, six 8-second recordings of bowel sounds were taken from each patient from the lower abdomen. The recordings were analysed for sound duration, sound-to-sound interval, dominant frequency, and peak frequency. Clinical and radiological data were reviewed and the patients were classified as having either acute, subacute, or no bowel obstruction. Comparison of bowel sound characteristics was made between these subgroups of patients. In the presence of an obstruction, the site of obstruction was identified and bowel calibre was also measured to correlate with bowel sounds.
RESULTS: A total of 71 patients were studied during the period July 2009 to January 2011. Forty patients had acute bowel obstruction (27 small bowel obstruction and 13 large bowel obstruction), 11 had subacute bowel obstruction (eight in the small bowel and three in large bowel) and 20 had no bowel obstruction (diagnoses of other conditions were made). Twenty-five patients received surgical intervention (35.2%) during the same admission for acute abdominal conditions. A total of 426 recordings were made and 420 recordings were used for analysis. There was no significant difference in sound-to-sound interval, dominant frequency, and peak frequency among patients with acute bowel obstruction, subacute bowel obstruction, and no bowel obstruction. In acute large bowel obstruction, the sound duration was significantly longer (median 0.81 s vs 0.55 s, P = 0.021) and the dominant frequency was significantly higher (median 440 Hz vs 288 Hz, P = 0.003) when compared to acute small bowel obstruction. No significant difference was seen between acute large bowel obstruction and large bowel pseudo-obstruction. For patients with small bowel obstruction, the sound-to-sound interval was significantly longer in those who subsequently underwent surgery compared with those treated non-operatively (median 1.29 s vs 0.63 s, P < 0.001). There was no correlation between bowel calibre and bowel sound characteristics in both acute small bowel obstruction and acute large bowel obstruction.
CONCLUSION: Auscultation of bowel sounds is non-specific for diagnosing bowel obstruction. Differences in sound characteristics between large bowel and small bowel obstruction may help determine the likely site of obstruction.
Bowel sounds; Intestinal obstruction; Spectral analysis; Electronic stethoscope
Carcinoid tumours are well-differentiated neuroendocrine tumours with secretory properties. Although fairly rare, they are the most common malignancy seen to affect the distal small bowel. Presentation is often non-specific with symptoms mimicking those of irritable bowel syndrome. Given this, the condition is often diagnosed late following disease progression, by which time the prognosis is poor.
A 74 year old Caucasian lady presented with a two week history of loose stools, nausea and one episode of vomiting. This sub-acute presentation occurred on a background of a four year history of intermittent abdominal pain and bloating, previously diagnosed as irritable bowel syndrome. CT scans identified dilated loops of small bowel proximal to a spiculated mass in the region of the terminal ileum. This ileal lesion was removed at laparotomy and identified as a carcinoid tumour.
This case highlights the issue of misdiagnosis of intestinal malignancy as the benign condition of irritable bowel syndrome. There have been several other references to this happenstance in the literature, and the problem is reflected in the percentage of patients with widespread disease at the time of diagnosis. Prognosis in this condition can be dramatically improved with early diagnosis, and surgical management at this stage is often curative. For this reason it is imperative to keep this differential diagnosis in the back of one's mind when assessing patients presenting with symptoms of intermittent partial bowel obstruction. The clinical presentation of this tumour, along with investigation and management of these cases, is discussed here.
Small-bowel myeloid sarcoma is rare. Acute bowel obstruction is its usual clinical presentation.
PRESENTATION OF CASE
We report a case of small-bowel myeloid sarcoma that occurred in a 64-year-old woman who presented chronic secretory diarrhoea, hypokalaemia, and weight loss. Immature white blood cells in a peripheral smear and small-bowel capsule endoscopic features were the main diagnostic clues. The patient experienced capsule retention and developed acute bowel obstruction. Urgent laparotomy showed a stricturing ileal mass and pathology of the resected bowel specimen unveiled a CD34+, CD117+, and myeloperoxidase-positive myeloid sarcoma. The diarrhoea promptly resolved after surgery, and the patient is now undergoing chemotherapy.
Secretory diarrhoea can be the first manifestation of small-bowel myeloid sarcoma. Capsule endoscopy may provide a diagnostic clue, but it can trigger an acute bowel obstruction. Differential diagnosis of the pathologic specimen may be difficult and a high suspicion index of is mandatory to perform immunophenotyping to determine the correct management.
Chronic diarrhoea with alarm features can be the first manifestation of small-bowel myeloid sarcoma.
AML, acute myeloid leukaemia; MS, myeloid sarcoma; SBCE, small bowel capsule endoscopy; Acute leukaemia; Capsule endoscopy; Chloroma; Granulocytic sarcoma; Myeloid sarcoma; Small-bowel
Stricture formation is recognized as one of the complications of chronic radiation enteritis. Here, we present a case of a 73-year-old woman who presented with small bowel obstruction 16 years after pelvic irradiation for uterine cancer. Computed tomographic (CT) scan of the abdomen demonstrated a 1-cm foreign body in the terminal ileum. Laparotomy revealed a stone of ume (Japanese apricot) stuck in an ileal stricture, leading to complete impaction and perforation. She was successfully treated with ileocecal resection and ileocolic anastomosis without any complication. Pathological study revealed that the low compliance caused by fibrosis of the bowel wall prevented the small ume stone from passing through the irradiated ileum. Our case implies the specific risk of food-induced small bowel obstruction in patients with a history of pelvic irradiation.
Radiation injury; Intestinal obstruction; Foreign bodies; Enteritis
The term "gossypiboma" denotes a mass of cotton that is retained in the body following surgery. Gossypiboma is a medico-legal problem especially for surgeons. To the best of our knowledge, the patient presented herein is the second reported patient in whom the exact site of migration of a retained surgical textile material into the intestinal lumen could be demonstrated by preoperative imaging studies.
A 74-year-old woman presented with symptoms of small bowel obstruction due to incomplete intraluminal migration of a laparotomy towel 3 years after open cholecystectomy and umbilical hernia repair. Plain abdominal radiography did not show any sign of a radio-opaque marker in the abdomen. However, contrast enhanced abdominal computerized tomography revealed a round, well-defined soft-tissue mass with a dense, enhanced wall, containing an internal high-density area with air-bubbles in the mid-abdomen. A fistula between the abscess cavity containing the suspicious mass and gastrointestinal tract was identified by upper gastrointestinal series. The presence of a foreign body was considered. It was surgically removed with a partial small bowel resection followed by anastomosis.
Although gossypiboma is rarely seen in daily clinical practice, it should be considered in the differential diagnosis of acute mechanical intestinal obstruction in patients who underwent laparotomy previously. The best approach in the prevention of this condition can be achieved by meticulous count of surgical materials in addition to thorough exploration of surgical site at the conclusion of operations and also by routine use of surgical textile materials impregnated with a radio-opaque marker.
gossypiboma; foreign bodies; retained surgical towel; intestinal obstruction; radiography; CT