Ischemia-modified albumin as a predictor of the severity of acute appendicitis

BACKGROUND

The early prediction of gangrenous/perforated appendicitis is of great importance for the surgical planning, further treatments, and predicting the course of disease. Ischemia-modified albumin (IMA) was previously reported as a biomarker of various ischemia-based diseases. Our aim is to determine the predictive value of serum IMA in the severity of acute appendicitis.

METHODS

Sixty-two patients who underwent urgent appendectomy were included in the study. Plasma level of IMA was measured after diagnosis and before treatment. All patients were classified as noncomplicated (acute) appendicitis and complicated (gangrenous/perforated) appendicitis according to histopathological findings, and comparisons were made between the groups.

RESULTS

The data of 62 patients with a mean age of 30.1 years were statistically evaluated. The pathological diagnoses were acute appendicitis in 33 (53.2%), and gangrenous/perforated appendicitis in 29 (46.8%) patients. There were significant differences in computed tomography (CT) findings (P = .031) and IMA (P = .012) levels between the groups. A strong positive correlation between IMA levels and CT findings was also found (Spearman ρ = +0.688, P = .003).

CONCLUSIONS

The IMA can be considered as a novel and useful marker to distinguish gangrenous/perforated appendicitis from noncomplicated appendicitis. The correlation of IMA with CT findings also enhances the predictive value of IMA.

Malrotation syndrome resulting in fatal ileus in children

BACKGROUND

This report deals with two deaths of children involving intestinal volvulus, i. e. a pathological knotting and twisting of the mesenterial root on the basis of congenital malrotation followed by obstruction and extensive ischaenia.

CASE REPORTS

(1) A 10-year-old girl (premature, 25th week) with severe disability, amaurosis and epilepsy was admitted to hospital due to general agitation and a bloated abdomen without peristaltic sounds, but died some hours later. Autopsy revealed a volvulus of 2/3 of the small intestine based on congenital malrotation with additional clamping of the intestine underneath adhesions (previous appendectomy). The abdominal cavity showed beginning peritonitis as the cause of death. (2) A 2-month-old premature male baby (surviving twin, 29th week) with a persisting ductus arteriosus was hospitalised for four weeks after failed vascular surgery due to acute general deterioration. Radiological diagnostics using a contrast medium revealed a vascular anomaly (right-sided aortic arch). Around 10 hours later, the infant developed an acute abdomen with ileus symptoms. Emergency surgery showed infarction of the entire small intestine due to an anti-clockwise 180⁰-volvulus, with death occurring 24h later. Further examination showed a malrotation as anomaly. Apparently, the volvulus had been caused by extensive use of contrast medium resulting in increased intestinal mobility.

Terminal ileum gangrene secondary to a type IV paraesophageal hernia

Type IV paraesophageal hernia (PEH) is very rare, and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a 78-year-old woman who presented at our emergency department because of epigastric pain that she had experienced over the past 24 h. On the day after admission, her pain became severe and was accompanied by right chest pain and dyspnea. Chest radiography revealed an intrathoracic intestinal gas bubble occupying the right lower lung field. Emergency explorative laparotomy identified a type IV PEH with herniation of only the terminal ileum through a hiatal defect into the right thoracic cavity. In this report, we also present a review of similar cases in the literature published between 1980 and 2015 in PubMed. There were four published cases of small bowel herniation into the thoracic cavity during this period. Our patient represents a rare case of an individual diagnosed with type IV PEH with incarceration of only the terminal ileum.

Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.

An unusual outcome of a giant ventral hernia

Hernias are routine general surgical problems that may present in any age group, regardless of the patient’s socioeconomic status. We present a rare case of a complicated ventral hernia leading to short bowel. This is an unusual case and is very rarely reported in the literature. This current case report describes a 54-year-old gentleman who presented to the hospital with a giant strangulated ventral hernia causing massive bowel ischemia and resulting in a short bowel. The literature on large abdominal wall hernias leading to short bowel is reviewed, and a discussion on short bowel syndrome is also presented.

A rare case of Amyand's hernia in a 67-year-old male. A case report and review of the literature

AIM

The aim of the study is to indicate the Amyand's hernia as a possible complication during surgery for hernia repair performed in emergency

CASE REPORT

A case Amyand's hernia complicated by the presence of acute gangrenous appendicitis perforated at the base is reported.

DISCUSSION

Amyand's hernia is an hernia which is the vermiform appendix inside. This condition may remain asymptomatic and behave like a normal inguinal hernia or can simulate strangulated hernia when the hernia contains inflamed appendix.

CONCLUSION

Acute appendicitis in an incarcerated inguinal hernia is a rare event. The preoperative diagnosis is very difficult because it simulates the behavior of a strangulated inguinal hernia. The treatment depends on the severity of appendicitis. The appendicitis status influences the type of surgery and the type of access.

The calcium invasion: Calciphylaxis in Lupus

Calciphylaxis is a poorly understood and highly morbid syndrome of vascular calcification and skin necrosis. We describe the case of a 52-year old woman with systemic lupus erythematosus (SLE), inappropriately treated with oral steroids for 18-years who developed renal impairment followed by skin necrosis and gangrene of right hand. She had subcutaneous calcium deposition with bilateral renal stones and widespread vascular calcifications. She was diagnosed with calciphylaxis and in spite of treatment died of a myocardial infarction.

Portomesenteric venous thrombosis: An early postoperative complication after laparoscopic biliopancreatic diversion

The number of bariatric operations, as well as the incidence of perioperative complications, has risen sharply in the past ten years. Perioperative acute portal vein thrombosis is an infrequent and potentially severe postoperative complication that has not yet been reported after biliopancreatic diversion (BPD). Three cases are presented of portal vein thrombosis that occurred following BPD treatment for morbid obesity and type 2 diabetes. The thromboses were detected by abdominal ultrasound and computed tomography with intravenous contrast. The portomesenteric venous thromboses in all three cases presented as unexpected abdominal pain several days after discharge from the hospital. The complications occurred despite adequate perioperative prophylaxis and progressed to bowel gangrene in the diabetic patients only. These cases demonstrate the occurrence of this rare type of complication, which may be observed by physicians that do not routinely treat bariatric patients. Awareness of this surgical complication will allow for early diagnosis and prompt initiation of adequate therapy.

PATENT VITELLINE DUCT WITH GANGRENOUS SMALL BOWEL PROLAPSE: CASE REPORT AND REVIEW OF LITERATURE

Vitelline duct anomalies (VDA) are rare complications of persistent omphalomesentric duct or vitelline duct connecting the developing embryo with the yolk sac. VDA can be asymptomatic (detected incidentally) or symptomatic, most common of which is Meckel's diverticulum. A patent vitelline duct is the. most common symptomatic presentation in African children and we present here a four day old neonate with patent vitelline duct with ileal prolapse. The neonate was operated with the patent vitelline duct and gangrenous ileum resected and end to end ileal anastomosis done.

Adult necrotising enterocolitis: a rare entity

A case of Adult Necrotising Enterocolitis in an adult female whom diagnosed with intestinal obstruction was reported. On exploratory laparotomy, the mechanical caused was not found although major part of small bowel, caecum and proximal ascending colon were gangrenous along with intervening normal parts. Resection of affected bowel was performed followed by jejunostomy and transverse colostomy. Unfortunately, the patient not survive in the postoperative periods. Adult Necrotising Enterocolitis may mimic intestinal obstruction clinically or radiologically and prompt medical and surgical intervention is indicated in doubtful cases although it carries a poor prognosis.

Bilateral torsion of testes with purpura fulminans

BACKGROUND

Purpura fulminans and bilateral perinatal testicular torsion are rare and may co-exist.

CASE CHARACTERISTICS

A 3-day-old neonate with bilateral swelling of scrotum; torsion and gangrenous changes were observed on exploration.

INTERVENTIONS

Left orchidectomy with preservation of right testis was done.

OUTCOME

At 2-month follow-up, right testis showed signs of atrophy. Child developed full thickness skin lesions and died of sepsis.

MESSAGE

Perinatal testicular torsion can be bilateral, and requires urgent surgical exploration.

Lucio Leprosy with Lucio's phenomenon, digital gangrene and anticardiolipin antibodies

Lucio's phenomenon (LPh) is considered a necrotizing panvasculitis and a variant of leprosy Type 2 reaction, clinically characterised by necrotic-haemorrhagic lesions on the extremities and trunk. LPh is observed in diffuse lepromatous leprosy (DLL or Lucio-Latapí leprosy). This is a distinct form of lepromatous leprosy (LL) reported mainly in Mexico. Anti-phospholipid antibody syndrome (APS) has been rarely described in LPh. We report a case of Lucio-Latapí leprosy with LPh observed in a patient from the province of El Oro in Ecuador, who presented clinical manifestations of long standing DLL (non-nodular infiltration of the skin, collapse of the nasal pyramid, madarosis, atrophy of the earlobes), of LPh (necrotic-haemorrhagic macules with irregular shapes) and of APS (necrosis of the right big and second toe). Histopathology showed perineural and periadnexal foamy macrophages with numerous bacilli (diagnostic of LL) in the subcutis, a mild lobular panniculitis with a large subcutaneous vessel infiltrated by macrophages in the wall (typical of LPh) and vessels of the superficial and mid dermis occluded by thrombi but without signs of vasculitis (typical of occlusive vasculopathy as in APS). Our observations suggest that some cases of LPh may be associated with APS. Anti-cardiolipin antibodies (aCL) and lupus anticoagulant (LA) should be tested in patients with LPh because this may have therapeutic implications.

[Amyand's hernia: a report of two cases and review of the bibliography]

BACKGROUND

Presence of the vermiform appendix in an inguinal hernia sac is an uncommon finding (1%), exceptionally rare if it's inflamed (0.13%). Clinically simulating incarcerated inguinal hernia and proper preoperative diagnosis is exceptional. We present two unusual cases of Amyand's hernia, and review of the bibliography.

CLINICAL CASES

1. Male patient 78 year old with an incarcerated right inguinal hernia which was performed preoperatively the diagnosis of Amyand's hernia by abdominal Computed Tomography. Clinical case 2. Female patient 82 year old with symptoms of an incarcerated right femoral hernia that finally showed an Amyand's hernia through a right inguinal hernia.

CONCLUSIONS

Amyand's hernia is a rare entity whose preoperative diagnosis is uncommon, that it should always be considered in the differential diagnosis in cases with clinical signs of incarcerated right inguinal hernia.

Surgical venous thrombectomy for phlegmasia cerulea dolens and venous gangrene of the lower extremities

OBJECTIVE

Phlegmasia cerulea dolens (PCD) and venous gangrene are limb and life-threatening conditions of iliofemoral acute deep vein thrombosis (DVT).

MATERIAL AND METHOD

The authors retrospectively evaluated surgical management of 15 patients from 125 patients with acute iliofemoral DVT (6 PCD and 9 venous gangrene) between January 1991 and August 2002 with long-term follow-up.

RESULTS

All of our 15 patients underwent surgery within 10 days of the onset of symptoms. Six patient with impending gangrene and failure for initial management with bed rest, extremity elevation, fluid resuscitation, and systemic anticoagulation for six to 12 hours underwent iliofemoral venous thrombectomy and distal arteriovenous fistula (AVF) can preserve limbs. In nine patients with venous gangrene that underwent iliofemoral thrombectomy below knee had transmetatarsal amputation done after decreasing leg edema. All patients underwent caval filter insertion before venous thrombectomy. There was no pulmonary embolism (PE) or immediate mortality. Anticoagulation treatment was given for at least six months. The distal arteriovenous fistula was closed as a secondary operation six weeks after initial operation. On the follow-up, 10-year period, seven patients died from the advanced carcinomas 7, 9, 9, 12, 14, 18, and 20 months after an operation. The remaining eight patients have regularly followed-up over 120 months. Three patients (37.5%) had recurrence of DVT; the rate of recanalization in common iliac veins on duplex scan was 100%. Three patients (37.5%) developed reflux in at least one deep venous segment without signs and symptoms of postphlebitic syndrome.

CONCLUSION

Surgical venous thrombectomy with distal AVF are safe method and should be reserved to treat PCD and venous gangrene patients with contraindications to thrombolysis or in condition that thrombolytic therapy is not available. There is no postphlebitic syndrome on the long-term follow-up (> 120 months) of all surviving patients.

Unusual complication of vaginal delivery: is misoprostal the cause?

A 20-year-old primiparous woman who delivered vaginally in a private hospital 5 h ago was referred to our institute as a case of ruptured uterus. She was very pale and tachycardic with well-contracted uterus of 18-week size but had a cervical tear extending up to the left fornix. Examination under anaesthesia showed colporrhexis of posterior vaginal wall with intestines at the site of colporrhexis. Emergency laparotomy confirmed the above findings and also revealed intestinal gangrene involving more than 10 cm. Repair of colporrhexis, cervical tear and resection and anastomosis of small intestines was carried out. She gave a history of administration of five doses of vaginal misoprostal during labour and fundal pressure at the time of delivery. Literature review revealed that vaginal misoprostal can cause overgrowth of clostridial organisms by decreasing the macrophage function and thus can lead to developmental gangrene of reproductive tract and gastrointestinal tract.

Timing of gangrene tissue debridement after autologous bone marrow cell implantation in patients with superficial femoral arterial occlusion: preliminary experiences

AIM

Although implantation of bone marrow mononuclear cells (BMI) was shown to improve outcomes in patients with severe peripheral arterial occlusive disease (PAOD), little experience has been reported in patients with an arterial occlusion level above the knee, ischemic gangrene, and high cardiovascular risk. This study sought to investigate the timing of gangrene tissue debridement and the safety of BMI in these patients.

METHODS

Six "no-option" PAOD patients were enrolled with an arterial occlusion level above the knee, ischemic gangrene, and 3 systemic diseases related to a high cardiovascular risk. The ischemic status was evaluated by measuring the ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), and wound healing after BMI.

RESULTS

All patients safely underwent the procedures with intravenous general anesthesia by titrating propofol. Major lower extremity amputation, minor debridement amputation, and debridement surgery were performed in 2 (33.3%), 1 (16.7%), and 2 (33.3%) patients, respectively, 3.1 2.8 months after BMI. Compared to the amputation group (N=3), the salvage group (N=3) had a significantly higher baseline ABI (P=0.02) and a shorter distance between the gangrene site and arterial occlusion site (P=0.01). In the 3 patients who underwent debridement, ABI and TcPO2 significantly improved 1 month after BMI, and gangrenous tissues were debrided 3.8 ± 3.6 (range, 1~8) months after BMI with complete healing within 1 month.

CONCLUSION

Autologous BMI therapy is safe in patients at high cardiovascular risk with an arterial occlusion level above the knee and ischemic gangrene. Effective predictors of BMI include the baseline ABI and distance to the ischemia. Gangrene tissue should be debrided at least 1 month after BMI.

Digital ischemia as a paraneoplastic consequence of squamous cell lung carcinoma

We report the case of a 40-year-old man who presented with digital ischemia and squamous cell lung carcinoma. Based on review of the literature, to our knowledge this case represents the youngest patient with lung carcinoma associated with digital ischemia and the only one with this type of tumor. The patient's digital ischemia symptoms improved rapidly with systemic chemotherapy; however, he did eventually lose the distal portion of 1 finger to dry gangrene and mummification.

[Effectiveness of Reamberin in correction of oxidative stress syndrome in patients with phlegmonous and gangrenous erysipelas against the background of the 2 type diabetes mellitus]

The influence of modern detoxic preparation Reamberin on indicators of oxidative stress syndrome (OSS)--the content of lipoperoxidation products was investigated. It was established that inclusion of Reamberin in the complex of surgical treatment of destructive forms of erysipelas on the background of type 2 DM accelerates the liquidation of OSS.

[Diabetic foot infections: microbiological aspects]

The diagnosis of wound infection is based on clinical signs and local and/or systemic inflammation. Therefore, the examination has a major role in the diagnosis of infected lesions of the foot. Once the clinical diagnosis of infection is made, the next step is to determine the etiology with the aim to undertake a rational and appropriate treatment. The most reliable method for assessing microbiological etiology is the specimen of material from infected lesion to perform a bacterioscopic examination and culture. The microorganisms involved in the etiology of diabetic foot depends on the type of injury and on specific patient features (antibiotic therapy, previous hospitalization). The most frequently detected pathogen is Staphylococcus aureus. Mild infections are mostly caused by Gram positive cocci, with a prevalence of S. aureus. Moderate infections are mostly supported by pyogenic Gram positive cocci, but also Gram-negative bacteria can be involved. In severe infections the etiology is polymicrobial. As regards the involvement of fungi in diabetic foot infections data are few and mostly conflicting.

[Infected lesions of diabetic foot]

The diabetic foot lesions are the result of a complex set of factors including peripheral neuropathy, trauma, joint deformities and perfusion abnormalities. The foot becomes vulnerable and insensitive to minor injuries caused by excessive pressure, mechanically or minimum thermal insults that can determine the primum movens of a foot ulcer. Due to the trauma, the subcutaneous tissues are exposed to bacterial colonization. Therefore, the wound can develop an infection. So, the first step in the treatment of the lesion is the evaluation of tissue damage, in order to guide therapy and prognosis. Wagner's classification, used by over 25 years, is still one of the best known systems of lesion classification; however, it is giving way to the most recent Texas's classification. However, in both systems infection have a minority role. Therefore, the Infectious Diseases Society of America has developed a classification system that divides infections in mild, moderate and severe. The purpose of this classification is to recognize the severe patients because they require immediate hospitalization, parenteral antibiotic therapy and specific instrumental examinations.

Gangrene of the auricle as the first sign of antiphospholipid antibody syndrome

Antiphospholipid syndrome (APS), more common in females, manifests clinically as thrombosis and/or recurrent fetal loss. Hemolytic autoimmune anemia and neurological, cardiac and cutaneous manifestations are common. This is the case report of a male patient whose first manifestation of the disease was gangrene of the auricle. The diagnosis of APS was established by biopsy of the lower limb skin, which showed thrombotic vasculopathy with no evidence of vasculitis. This is one of the two major criteria, which, along with a minor criterion, establishes the diagnosis of APS. Possible differential diagnoses are discussed. The importance of the biopsy in the APS diagnosis of this male patient is emphasized.

Right paraduodenal hernia leading to bowel strangulation

Up to half of all internal hernias are caused by paraduodenal hernia, a rare congenital midgut malrotation that accounts for less than 1% of all intestinal obstructions. The diagnosis may arise from an incidental finding on abdominal imaging or the patient may present with abdominal pain, vomiting, and obstipation. Early recognition and management of this disease entity are keys because serious complications such as bowel ischemia and infarction may result from a delay in diagnosis. We present a case involving a 14-year-old boy with gangrenous small bowel secondary to right paraduodenal hernia.

Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis

BACKGROUND

Gangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies.

METHODS

Patients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC.

RESULTS

A total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38 °C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 10⁹/l vs. 10.7 × 10⁹/l; P < 0.001), C-reactive protein (CRP) (94 mg/l vs. 17 mg/l; P= 0.001), bilirubin (19 µmol/l vs. 17 µmol/l; P= 0.029), urea (5.3 mmol/l vs. 4.7 mmol/l; P= 0.016) and creatinine (82 µmol/l vs. 74 µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0-14 days vs. median = 1 day, range: 0-10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis.

CONCLUSIONS

Gangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.

Early laparoscopic cholecystectomy is the appropriate management for acute gangrenous cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications. We determined whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. The medical records of 116 patients with acute gangrenous cholecystitis admitted to the Korea University Guro Hospital between January 2005 and December 2009 were reviewed. The early operation group, those patients who had cholecystectomies within 4 days of the diagnosis, was compared with the delayed operation group, who had cholecystectomies 4 days after the diagnosis. Of the 116 patients, 57 were in the early operation group and 59 were in the delayed operation group. There were no statistical differences between the groups with respect to gender, age, body mass index, operative methods, major complications, duration of symptoms, mean operative time (98 vs 107 minutes), or postoperative hospital stay. However, the total hospital stay was significantly longer in the delayed operation group. More patients underwent preoperative percutaneous cholecystostomy in the delayed operation group (3.5 vs 15.3%). Early laparoscopic cholecystectomy for acute gangrenous cholecystitis is safe and feasible. There is no advantage to postponing an urgent operation in patients with acute gangrenous cholecystitis.

Gangrenous herpes zoster with multidermatomal involvement in a patient after kidney transplantation

We present the case of a 66-year-old female after renal transplant with severe course of herpes zoster (HZ). Although HZ represents a common infectious complication of transplant patients, its variable manifestation and ability to disseminate warrants serious consideration. Prompt diagnosis and treatment are essential in preventing further spread and disastrous complications.

Report of one case]

We report a 46-year-old woman, subjected to a laparoscopic sleeve gastrectomy, that had to be converted to open surgery due to the presence of adherences. She required an immediate new intervention due to a hemoperitoneum caused by a liver tear and venous bleeding from the splenic hilus. Both lesions were successfully repaired. In the postoperative period the patient had fever, leukocytosis and sialorrhea. A CAT scan showed a splenic infarction and a huge intra abdominal collection that communicated with the stomach. Streptococcus anginosus was isolated from the collection. The patient was managed with antimicrobials and percutaneous drainage with a favourable evolution and closure of the communication with the stomach.