Cecal perforation due to paralytic ileus following primary caesarean section

Stercoral perforation of the cecum: A case report

BACKGROUND

With less than 90 reported cases to date, stercoral perforation of the colon is a rare occurrence. Stercoral ulceration is thought to occur due to ischemic pressure necrosis of the bowel wall, which is caused by the presence of a stercoraceous mass. To underscore this urgent surgical situation concerning clinical presentation, surgical treatment, and results, we present the case of a 66-year-old man with a stercoral perforation.

CASE SUMMARY

A 66-year-old man with a history of hypertension, hyperlipidemia, and gout presented at the emergency department with lower abdominal pain and a low-grade fever lasting for a few hours. Abdominal computed tomography indicated a suspected bezoar (approximately 7.6 cm) in the dilated cecum, accompanied by pericolic fat stranding, mild proximal dilatation of the ileum, pneumoperitoneum, and minimal ascites. Intraoperatively, feculent peritonitis with isolated cecal perforation were observed. Consequently, a right hemicolectomy with peritoneal lavage was performed. A histopathological examination supported the intraoperative findings.

CONCLUSION

In stercoral perforations, a diagnosis should be diligently pursued, especially in older adults, and prompt surgical intervention should be implemented.

Post-cesarean ileus: An assessment of incidence, risk factors and outcomes

OBJECTIVE

To estimate the frequency of post cesarean paralytic ileus and to identify associated risk factors and outcomes.

STUDY DESIGN

A retrospective cohort study of woman who underwent cesarean delivery between 2005 and 2019. All parturients who had cesarean delivery were stratified and compared according to whether or not they were diagnosed with a paralytic ileus. Women were excluded if they had an intestinal injury or repair during the cesarean or if they suffered from a post cesarean mechanical bowel obstruction diagnosed during re-laparotomy. Basic demographics, obstetric history, current delivery characteristics, re-suturing indications and outcomes were obtained and analyzed. Univariate analyses were followed by a multivariate analysis (adjusted Odds Ratio (aORs) ; [95% Confidence Interval]).

RESULTS

A total of 23,486 women met the inclusion and exclusion criteria of which 135 (0.6%) were diagnosed with paralytic ileus whilst 23,347 (99.4%) did not and served as the control group. Multivariate analysis revealed that an estimated intra-operative blood loss ≥ 1000 ml was the most significant risk factor for post cesarean paralytic ileus (aOR 2.27 (1.18-4.36)), followed by multifetal gestation (aOR 2.08 (1.24-3.51)), corporeal uterine incision (aOR 1.97 (1.07-3.63)), use of topical hemostatic agents (aOR 1.78 (1.19-2.66)) and increasing maternal age (aOR 1.78 (1.19-2.66)). Regarding maternal outcomes, post cesarean paralytic ileus was associated with higher rates of postpartum hemorrhage (44.4% vs. 13.4%, p < 0.01), transfusion of blood products (23.7% vs. 3.9%, p < 0.01), post-cesarean exploratory laparotomy (4.4% vs. 0.1%, p < 0.01) and prolonged hospital stay (32.6% vs. 5.2%, p < 0.01).

CONCLUSION

In our population, whilst post cesarean paralytic ileus is infrequent, when it occurs it is associated with increased short-term maternal morbidity.

Iatrogenic caecal perforation two days after a caesarean section, a case report

INTRODUCTION

and importance: The caesarean section is a widely spread procedure and 29.7 million times performed every year inn 169 countries in the world. Overall, complications are seen in 6% for elective caesarean to 15% for emergency caesarean.

CASE PRESENTATION

We here report a case which was initially diagnosed as a postoperative paralytic ileus. After a complicated caesarean section caused by bleeding and problems with haemostasis, a healthy child was born with full mother recovery for the first 24 hours after surgery. Unfortunately, her condition deteriorated between 24 and 48 hours and she reported progressive nausea and painful bloating. Laboratory tests and CT imaging showed progressive signs of inflammation and distention of the caecum and colon. A second CT scan the next day revealed signs of perforation. An ileocecal resection was performed with a primary anastomosis. Full recovery occurred two weeks later.

CLINICAL DISCUSSION

With an estimated incidence of only 0,08%, bowel perforations due to caesarean section, are rare. Moreover, is the clinical presentation diverse and computed topography is essential during the diagnostic process. To avoid potential morbidity and mortality, the surgeon must consider performing a laparotomy in case of a deteriorating patient in non-invasive treatment fails.

CONCLUSION

Caecal perforation must be considered as complication after a caesarean section. An ileocecal resection is necessary in this situation. This case report shows that a primary anastomosis is a possible option in a healthy patient that is hemodynamically stable during the operation. In case of an unhealthy or hemodynamic unstable patient, the safest option is a temporary ileostomy.

Idiopathic spontaneous cecal perforation: A rare pathology with high mortality

Introduction

Spontaneous perforation of the colon (SPC) is a rare disease characterized by sudden perforation of a clinically healthy colon in the absence of underlying disease or trauma. The aim of reporting this case is to highlight this surgical emergency in terms of clinical presentations, surgical management and outcomes.

Presentation of case

A 68 year-old male with history of diabetes mellitus, hypertension and chronic constipation on daily laxatives presented to the emergency department with a diffuse abdominal pain and distention for 4 days associated with vomiting and absence of defecation where he was prescribed phosphate rectal enemas. Patient was in sepsis with generalized abdominal tenderness and distention. Intraoperative findings of feculent peritonitis with isolated cecal perforation was identified, for which a right hemicolectomy with end ileostomy was performed.

Discussion

The first case was described in a woman presented with spontaneous rectum rupture by Brodie in 1827, with a less than 100 cases being reported in literature. In 1984, spontaneous perforations were classified into either "stercoral" or "idiopathic" perforations. More than 60% of colonic perforations were reported in the sigmoid or at the recto-sigmoid junction, mainly at the anti-mesenteric border, making spontaneous cecal perforation a very uncommon condition. Cecal perforation is associated with high mortality in the range of 30%-72%.

Conclusion

The outcome of SPC depends on multiple factors like onset of perforation, peritoneal contamination, and time of intervention. Regardless the surgical technique, early detection and surgical management are the main strategies associated with improving the outcomes.

Spontaneous cecal perforation in a 40-year-old pregnant woman treated by primary repair and omental patch: a case report

Background

Spontaneous colonic perforations are scarce, and cecal perforations even more so. Preoperative diagnosis of the latter in a pregnant woman is particularly difficult because of physiologic changes and restrictions on some diagnostic imaging techniques, such as X-rays. Furthermore, management of these patients is a big challenge.

Case presentation

We present a case of a spontaneous cecal perforation in a 40-year-old pregnant black woman in the Regional Hospital of Bafoussam in Cameroon. The results of clinical examination and ultrasonography on admission were in line with acute generalized peritonitis in a woman at 20 weeks of a viable pregnancy, indicating an urgent laparotomy. Operative findings were a 1 × 1-cm perforation on a distended cecum with minimal fecal contamination. The treatment consisted of excision of the edges, primary suture of the perforation, and omentoplasty. The recovery of the patient was uneventful.

Conclusions

The management of spontaneous cecal perforation in a pregnant woman was a big challenge. The perforation was repaired by primary suture and omentoplasty. Further studies comparing this approach with right hemicolectomy are recommended.

Management of a Septic Open Abdomen Patient with Spontaneous Jejunal Perforation after Emergent C/S with Confounding Factor of Mild Acute Pancreatitis

Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.

Conservative Surgery for Right Colon Perforation Leads to Better Long-Term Outcomes in Children: A 21-year Experience

OBJECTIVE

There is no consensus on standard treatment for right colon perforation in pediatric patients. We reviewed our cases over the past 21 years, comparing the effects of different operations to the long-term growth of patients.

METHODS

From February 1990 to October 2011, 29 patients of right colon perforation were enrolled in our analysis after excluding tumors, diverticulum, volvulus, and tuberculosis. Clinical information was collected from medical records, and analysis was done over 26 cases younger than 10 years at the time of the treatment. Surgical options included primary repair (D group, 12 cases), segmental resection (S group, 5 cases) and right hemicolectomy (H group, 9 cases). The length of postoperative stay, complications, and body weight growth in body weight percentile curve chart at last follow-up visit in each group were compared by analysis of variance.

RESULTS

Of the 26 patients who underwent the right colon perforation treatment, cecum perforation was found in 16 (62%), ascending colon perforation in six (23%), transverse colon perforation in three (12%), and combined ascending and transverse colon in one (4%). No mortality or anastomotic leakage occurred. The mean length of postoperative stay was shorter in the D group than in the S and H groups but without statistical significance (mean 10.9 days vs. 11.6 days and 17.9 days, respectively). Long-term body weight growth was significantly better in the D group (+26.3 ± 22.2 percentile) than the H group (-4.8 ± 8.0 percentile; p = 0.02).

CONCLUSION

For right colon perforation in children, simple closure following debridement has long-term benefits over more extensive resections.

Adynamic ileus and acute colonic pseudo-obstruction occurring after cesarean section in patients with massive peripartum hemorrhage

The clinical histories (including radiographs) of 4 patients who suffered from significant adynamic ileus or acute colonic pseudo-obstruction after cesarean section are presented. The main manifestations were vomiting, severe colicky pain, and abdominal distension. These can occur immediately after or within 2 days of the operation. Based on our experience, the risk factors for the development of adynamic ileus are significant peripartum hemorrhage leading to unstable hemodynamic status, severe constipation, use of meperidine for pain relief, and overt bowel manipulation. Mild enema and metoclopramide seem to be helpful in facilitating its resolution. Here, we examine how to differentiate mechanical bowel obstruction from adynamic ileus and look at how to prevent the occurrence of adynamic ileus while minimizing its severity and shortening its clinical course.