Cecal Volvulus Resolved Spontaneously

Cecal volvulus is an uncommon cause of colonic obstruction. First-line treatment for cecal volvulus is surgery, as nonoperative management is rarely achievable. We herein report an extremely rare case of a patient with spontaneously resolved cecal volvulus; no recurrence occurred without elective surgery. A 47-year-old woman presented with acute lower abdominal pain. She was misdiagnosed with small bowel obstruction and treated conservatively. A few hours later, she was correctly diagnosed with cecal volvulus. Subsequently, her symptoms and computed tomography findings of cecal volvulus completely disappeared. She refused elective surgery, but no recurrence occurred during five months of follow-up.

Caecal volvulus: untwisting the mystery

Caecal volvulus is an infrequent cause of acute surgical abdomen, where an abnormally mobile cecum twists on its own axis. It can lead to the development of closed-loop obstruction, small bowel ischaemia and perforation. Early recognition and prompt treatment is key; however, due to the rarity of this pathology, it is seldom listed as a differential diagnosis. Here, we present a single-centre case series of two patients presenting with caecal volvulus to an Emergency Surgery Unit at a University Hospital.

Redundant mesocolonic mesentery in a Shire colt

An unusual condition in a 3-month-old Shire colt presented for colic unresponsive to medical therapy is documented in this report. A redundant mesocolonic mesentery resulting in intestinal displacement and volvulus was diagnosed during exploratory celiotomy. The finding was presumed to be congenital, resulting in a loose anatomic configuration that predisposed the intestine to displacement, torsion, volvulus, and entrapment. Key clinical message: This case demonstrates that congenial anatomical anomalies should be included in the differential of younger animals presented for recurrent conditions and highlights the use of exploratory celiotomy to reach a definitive diagnosis.

Transverse colonic volvulus due to mesenteric fibromatosis: a case report

BACKGROUND

Colonic volvulus, a condition in which a colonic segment partially twists around its base, is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. However, volvulus of the transverse colon is the rarest type of large intestinal volvulus. Moreover, the occurrence of transverse colonic volvulus secondary to a benign tumor originating from outside the intestine has never been reported. We hereby report a case of transverse colonic volvulus caused by mesenteric fibromatosis.

CASE PRESENTATION

A 53-year-old female with a history of rheumatoid arthritis and thyroid tumor presented with abdominal pain for 1 day. Abdominal computed tomography revealed intestinal torsion at the hepatic flexure. Twisted and obstructed mucosa of the transverse colon was observed during colonoscopy, but no tumor invasion of the mucosal surface was detected. A solid mass of a mesenteric origin with involvement of the transverse colon was observed during surgery. The mass was diagnosed surgically as transverse colonic volvulus induced by a mesenteric tumor. Hence, the patient underwent a right hemicolectomy. Histopathological results indicated mesenteric desmoid-type fibromatosis. The postoperative recovery was uneventful, and the patient was discharged 8 days after surgery.

CONCLUSIONS

Although mesenteric fibromatosis is rare, this disease should be considered when managing transverse colonic volvulus resulting from nonmucosal tumors.

Midgut volvulus in adult age associated with congenital malrotation - case report

INTRODUCTION

Malrotation is understood as a congenital anomaly of the intestinal position formed during embryonic development. Disorders of intestinal rotation and its manifestations in adulthood are less common; the symptoms of these disorders are characteristic of childhood. An asymptomatic bowel rotation disorder occurs in up to 1 of 200 newborns and symptomatic malrotation occurs in 1 of 6,000 live newborns. The incidence of intestinal rotation disorders in adulthood is estimated to be between 0.0001% and 0.19%. Acute complications in adulthood include volvulus with ischemia of the small bowel.

CASE REPORT

A 36-year-old man with a previously diagnosed bowel rotation disorder with intermittent abdominal pain was examined for sudden convulsive pain. The CT scan showed volvulus of small bowel. During surgery, a small bowel volvulus with venostasis and dilated mesenteric veins rotated 360 degrees clockwise, the mesenterium commune, and the presence of Ladds bands causing partial compression of the duodenum were found. The condition was managed surgically to derotate the loops into nonrotation with preserved viability of the intestinal loops, interrupt the Ladds bands and mobilize the duodenum, including fixation of the mesentery to the retroperitoneum and invagination appendectomy. The patient has been without problems and without any signs of complications based on his 2-year follow-up from the surgery.

CONCLUSION

Early surgical treatment of intestinal malrotation complications helps maintain intestinal viability and can prevent the development of the short bowel post-resection syndrome. Prophylactic surgery should be considered in symptomatic rotation disorders, although the determination of the indication for surgery and its timing remain uncertain.

[Secondary Small Bowel Volvulus after Laparoscopic Pancreaticoduodenectomy]

Laparoscopic pancreaticoduodenectomy(LPD)is less invasive and provides better cosmetic outcomes than open pancreaticoduodenectomy( OPD). LPD without vascular excision and lymph node dissection has been covered by insurance since 2016 in Japan. On the other hand, secondary small bowel volvulus is a rare condition caused after abdominal operation. A 77-year-old woman underwent a laparoscopic pancreaticoduodenectomy with pancreatic cancer of pT2N0M0, pStageⅠB. She suffered from epigastric pain after meal. The abdominal CT revealed counterclockwise rotation of the SMV on SMA about 540 degree. Gastrointestinal endoscopy showed no abnormal findings in May 2017. Her abdominal pain was disappeared in July 2017. But the pain was recurred in May 2019. The abdominal CT revealed mesenteric edema and counterclockwise rotation about 810 degree. Her abdominal pain was disappeared again in February 2020. The counterclockwise rotation was decreased about 540 degree. Between May 2012 and February 2020, 50 patients underwent LPD at Kansai Rosai Hospital. 111 patients who received OPD between 2010 and February 2015 were included for comparison. No significant differences were noted between the LPD and OPD groups with respect to patient age(67.9 vs 70.3), gender(M/F: 31/19 vs 70/41). The intraoperative blood loss was lower(106 g vs 1,064 g, p<0.0001)and the operation time was longer (624 vs 535 min, p<0.0001)in the LPD group than the OPD group. Small bowel volvulus over 270 degree was 7/43 vs 5/106(p=0.0338), and over 360 degree was 6/44 vs 1/110(p=0.0014), respectively. Small bowel volvulus after pancreaticoduodenectomy was frequently observed in the laparoscopic group.

Comparison of histomorphometric characteristics of dorsal colon and pelvic flexure biopsy specimens obtained from horses with large colon volvulus that underwent resection

OBJECTIVE

To determine the degree of histomorphometric damage in dorsal colon and pelvic flexure biopsy specimens (DCBSs and PFBSs, respectively) obtained from horses with large colon volvulus (LCV) and assess the accuracy of predicting short-term outcome for those horses on the basis of DCBS or PFBS characteristics.

ANIMALS

18 horses with ≥ 360° LCV that underwent large colon resection.

PROCEDURES

During surgery, biopsy specimens from the dorsal colon resection site and the pelvic flexure (when available) were collected from each horse. Interstitial-to-crypt (I:C) ratio (ratio of the lamina propria space occupied by the interstitium to that occupied by crypts), hemorrhage within the lamina propria (mucosal hemorrhage score [MHS] from 0 to 4), and percentage losses of glandular and luminal epithelium were determined in paired biopsy specimens and compared to determine optimal cutoff values for calculating the accuracy of DCBS and PFBS characteristics to predict short-term outcome (survival or nonsurvival after recovery from surgery).

RESULTS

Paired biopsy specimens were obtained from 17 of the 18 horses. The I:C ratio and percentage glandular epithelial loss differed between DCBSs and PFBSs. For DCBSs, an I:C ratio ≥ 0.9 and MHS ≥ 3 each predicted patient nonsurvival with 77.8% accuracy. For PFBSs, an I:C ratio ≥ I and MHS ≥ 3 predicted patient nonsurvival with 70.6% and 82.4% accuracy, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Although different, histomorphometric measurements for either DCBSs or PFBSs could be used to accurately predict short-term outcome for horses with LCV that underwent large colon resection, and arguably PFBSs are easier to collect.

Evaluation of a novel technique involving ultrasound-guided, temporary, percutaneous gastropexy and gastrostomy catheter placement for providing sustained gastric decompression in dogs with gastric dilatation-volvulus

OBJECTIVE

To evaluate the feasibility of ultrasound-guided, temporary, percutaneous T-fastener gastropexy (TG) and gastrostomy catheter (GC) placement for providing sustained gastric decompression in dogs with acute gastric dilatation-volvulus (GDV) and to compare findings with those of trocarization.

ANIMALS

16 dogs with GDV.

PROCEDURES

Dogs were randomly assigned to undergo gastric decompression by means of percutaneous trocarization (trocar group; n = 8) or temporary TG and GC placement (TTG+GC group; 8) with ultrasound guidance. The gastric volvulus was then surgically corrected, and the decompression sites were examined. Outcomes were compared between groups.

RESULTS

The proportion of dogs with successful decompression did not differ significantly between the TTG+GC (6/8) and trocar (7/8) groups; median procedure duration was 3.3 and 3.7 minutes, respectively. After the failed attempts in the TTG+GC group, the procedure was modified to include ultrasound guidance during T-fastener placement. The decrease in intragastric pressure by 5 minutes after trocar or GC insertion was similar between groups. For dogs in the TTG+GC group, no significant difference in intragastric pressure was identified between 5 and 60 minutes after GC insertion. Complications included inadvertent splenic or jejunal placement in 2 dogs (TTG+GC group) and malpositioned and ineffective trocar placement in 1 dog (trocar group). All dogs survived for at least 2 weeks.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided, temporary, percutaneous TG and GC placement was safe and effective at providing sustained gastric decompression in dogs with GDV, suggesting that this technique would be ideal for dogs in which surgical delays are anticipated or unavoidable.

Colonic volvulus after laparoscopic left colectomy

Volvulus of the mobilized colon after laparoscopic left colectomy is rare. Contributing factors seem to be excessive length of the mobilized colon, absence of peritonization and absence of adhesions due to laparoscopy. Onset of colonic volvulus after laparoscopic left colectomy should lead to routine computerized tomography (CT), searching for an image suggestive of small intestinal incarceration under the neo-mesocolon, which might be an additional risk factor. Treatment consists of disincarceration of the small intestines while closing the mesocolic defect remains a subject of controversy.

The need for Paediatric Emergency Laparotomy Audit (PELA) in the UK

INTRODUCTION

The National Emergency Laparotomy Audit (NELA) has raised serious concerns about the processes of care and outcomes in adult emergency laparotomies in the UK. To date, no comparable data have been published for children. The aim of this study was to investigate the need for a similar audit in children.

METHODS

Data were collected retrospectively following NELA guidelines. Results were analysed using QuickCalcs (GraphPad Software, La Jolla, CA, US).

RESULTS

The study period spanned 7.5 years. A total of 161 patients were identified for inclusion in the audit. The median patient age was 2.8 years. Half (49%) of the cohort were deemed ASA (American Society of Anesthesiologists) grade ≥2. A history of previous abdominal surgery was noted in 37% of the patients. The median time from admission to operation was 15 hours. Over a third (39%) of the operations were performed out of hours. The most common indications for surgery comprised adhesive bowel obstruction (37%), intussusception (27%) and volvulus (9%).The median length of hospital stay was 8 days with the median postoperative stay being 6 days (NELA data 10.6 days). Half (51%) of the cases required intensive care following surgery. The 30-day mortality rate was 3.1%. The overall mortality rate was 4.3% (NELA data 16%). Patient care was led by a consultant surgeon in 100% of cases (NELA data 89%).

CONCLUSIONS

This is the first study in children that provides baseline data about the standards of care and outcomes from a single centre paediatric emergency laparotomy audit. A larger study using data from multiple centres would be of great benefit.

Primary Segmental Intestinal Volvulus in a Neonate

Primary segmental intestinal volvulus is a rare disease with an aggressive clinical course. Early diagnosis and prompt management prevents life-threatening necrosis and perforation. A 1-day-old newborn girl with this disorder is reported to emphasize the presentation, imaging findings and management.

Laparoscopic Ladd's procedure for malrotation in infants and children is still a controversial approach

BACKGROUND

Open Ladd's procedure is the gold standard for the correction of intestinal malrotation and laparoscopic approach remains controversial. This study aimed to evaluate our experience in laparoscopic management of malrotation.

METHODS

Single center retrospective study including patients who underwent a laparoscopic assessment of intestinal malrotation with correction if appropriate between 2007 and 2017.

RESULTS

Sixty-five patients (median age 7 months) had a laparoscopic assessment with and without correction of malrotation. Forty-five (69%) were symptomatic, including 16 (25%) with a midgut volvulus. The procedure was completed laparoscopically in 55 (86%) patients in 110 min (30-190). Conversions happened more frequently at the beginning of the experience. With a follow-up of 12.5 months (8 days-5.3 years), morbidity rate was 15% and 4 (6%) patients underwent a redo surgery, all in the first 5 months after surgery, compared with 3/53 (6%) in a contemporaneous group undergoing open Ladd's.

CONCLUSION

This is the largest series reported so far of the laparoscopic management of malrotation. Laparoscopic Ladd's procedure is reliable but still exposes to open conversion which may be in part owing to a learning curve. A low conversion threshold is important in cases with volvulus. The redo rate is similar to that of the open procedure.

LEVEL OF EVIDENCE

Level III retrospective comparative treatment study.

Standardized Approach to Intervention for Intestinal Malrotation in Single Ventricle Patients with Heterotaxy Syndrome: Impact on Interstage Attrition and Time to Superior Cavopulmonary Connection

Heterotaxy syndrome (HS) is a significant determinant of outcome in single ventricle (SV) physiology. Attrition rate and time-related events associated with intestinal malrotation (IM) are, yet, to be determined. We sought to evaluate hospital and interstage outcomes in relation with operative intervention for IM (IMO). Twelve SV/HS patients, who underwent IMO, from January 2004 to December 2016, were studied. Early shunt failure, time to superior cavopulmonary connection (SCPC) and interstage attrition were assessed. Since September 2014, based on a comprehensive standardized protocol, IMO was performed at the time of hospitalization for stage-I palliation (S1P) irrespective of clinical manifestations. Patients were assigned to Group A (n = 8): expectant /symptoms-driven versus Group B (n = 4): protocol-driven. At S1P 7 had systemic-to-pulmonary shunt (SPS), 1 SPS with anomalous pulmonary venous return (APVR) repair (Group A) compared to 2 SPS, 1 SPS with APVR repair and 1 Norwood operation (Group B). Median duration from S1P to IMO was 82 days (range 57-336; Group A) compared to 14 days (range 11-31; Group B); p < 0.05. Median age at IMO was 87 days (range 8-345) [Group A: 99 days (range 68-345) vs Group B: 25 days (range 8-39)] (p < 0.05). Early SPS failure occurred in 25% (2 of 8) for Group A compared to none in Group B (p < 0.05). Hospital mortality following IMO was 25% [Group A: 37.5% (3 of 8) vs Group B: 0; p < 0.05]. Interstage survival was 67% [Group A: 50% (4 of 8) vs Group B: 100%; p < 0.05]. Time to SCPC following S1P was 186 days (range 169-218) for Group A compared to 118 days (range 97-161) (Group B); p < 0.05. Operative intervention for IM in SV/HS is associated with significant interstage attrition and might impact the time to SCPC. SPS is at risk for early failure after IMO. A comprehensive standardized concept can mitigate detrimental implications.

Gastrointestinal motility should be emphasized after laparotomy treatment for complete small intestinal volvulus in older adults: A case report

RATIONALE

Complete small intestinal volvulus is a rare entity in adults, unlike partial intestinal volvulus. Although prompt surgical intervention is the mainstay of treatment, attention should also be paid to recovery of intestinal function postoperatively. Ignoring this issue during the postoperative recovery process can have serious consequences. We report the case of an 82-year-old woman with complete small intestinal volvulus at the root of the superior mesenteric vessel.

PATIENTS CONCERNS

The patient was admitted for acute onset (22 hours) of abdominal pain and distention. Nausea and vomiting also developed during this period.

DIAGNOSES

Abdominal physical examination was suspicious for peritoneal irritation. Computed tomography scan showed anticlockwise swirl of the mesenteric vessels at the lower margin of the pancreas with distension of the entire small intestine. A complete small intestinal volvulus was diagnosed.

INTERVENTIONS

Laparotomy and detorsion of the volvulus were performed after early diagnosis.

OUTCOMES

The patient developed intestinal wall edema because of ischemic-reperfusion damage. She exhibited severe abdominal distention and absent intestinal motility. Two days later, she went into septic shock; she died 19 days after surgical intervention.

LESSONS

Because complete small intestinal volvulus involves the entire intestine, ischemic-reperfusion intestinal damage after detorsion may be severe and can predict prognosis.

Management of acute sigmoid volvulus in a provincial centre-a 20-year experience

AIM

At our institution there has been a long-standing early operative approach to large bowel volvulus as well as initial decompression with rigid sigmoidoscopy. The primary aim of this study was to investigate the safety and efficacy of this approach on reducing readmissions and complications. Secondary aims were to investigate the safety and efficacy of bedside rigid sigmoidoscopy in decompression of sigmoid volvulus and investigate the sensitivity of abdominal x-ray in the diagnosis of acute large bowel volvulus.

METHOD

A retrospective study was conducted on all patients presenting with acute obstruction due to large bowel volvulus between 1 January 1998-1 January 2018.

RESULTS

Thirty-four patients with acute sigmoid volvulus were identified that met the inclusion criteria with a median age of 81 years. The majority of patients 27/34 (79%) were booked for surgery on the first admission. Readmissions were reduced in the index operative group 1/20 (5%) vs the non-operative decompression group 3/4 (75%) RR 0.07 (CI 0.01-0.49 P=0.01).

CONCLUSION

Early sigmoid colectomy was associated with low morbidity and found to be safe in the elderly, and the results suggest that early surgery is associated with reduced readmissions and a low complication rate, with index surgery preferable to urgent elective surgery. Rigid sigmoidoscopy is a safe method of decompression as a bridge to index surgery and was not associated with any complications in this series.

Transverse colon volvulus in a patient with sickle cell disease

Although colonic volvulus is a relatively rare cause of large bowel obstruction, accounting for up to 5% of all cases of intestinal obstruction, transverse colon volvulus is extremely uncommon compared with volvulus of the sigmoid colon or caecum and is responsible for only 3% of all reported cases. We report an unusual case of spontaneous volvulus of the transverse colon in a young man with sickle cell disease who underwent resection with primary anastamosis. Having a high index of suspicion and early operative intervention allowed for this patient to have an uneventful postoperative course.

Reoperation after Ladd's procedure in the neonatal period

AIM OF THE STUDY

To investigate (1) the indications for reoperation after neonatal Ladd's procedure, (2) the type of reoperation and (3) its outcome.

METHODS

We reviewed all neonatal Ladd's procedures in our hospital from 2003 to 2017 and the outcomes of reoperation in these patients.

MAIN RESULTS

252 neonates had Ladd's procedure: 59 were laparoscopic (23.4%) and 193 open (76.6%). 15 (6.0%) required reoperation with no difference between laparoscopic and open (p = 0.12). Overall, the indications for reoperation were: adhesive intestinal obstruction (n = 10, 4.0%), recurrent midgut volvulus (n = 4, 1.6%), and missed diagnosis of associated anomaly (n = 1, 0.4%). The incidence of recurrent midgut volvulus was higher after laparoscopic Ladd's procedure (3/59; 5.1%) compared to open Ladd's procedure (1/193; 0.5%) (p = 0.04). Adhesive intestinal obstruction developed after both open (8/193, 4.1%) or laparoscopic Ladd's procedure (2/59, 3.3%). The duration of reoperation and the length of post-operative hospital stay were 63.4 ± 27.1 min and 10.1 ± 5.2 days, respectively. After reoperation, there were no post-operative complications. All children were well at follow-up (6 months-14 years).

CONCLUSIONS

In neonates, laparoscopic Ladd's procedure compared to the open Ladd's procedure is associated with a significantly higher risk of recurrent volvulus. The risk of developing this potentially dangerous complication after laparoscopic Ladd's procedure raises doubts about the effectiveness and safety of the laparoscopic approach in neonates.