Closed-bowel Loop Obstruction-An Unusual and Forgotten Complication of Feeding Jejunostomy: Case Report

Feeding jejunostomy (FJ) is done as a part of significant upper gastrointestinal surgical procedures for patients who cannot tolerate enteral feeds. This procedure is related to different mechanical, infective, and metabolic inconveniences. However, closed-bowel loop obstruction following FJ is rare. We report an unusual complication of closed-bowel loop obstruction in the postoperative period of FJ done for a locally advanced carcinoma of gastroesophageal (GE) junction for enteral access in a 67-year-old male patient. This patient required an emergency laparotomy, to forestall exacerbating of abdomen distension which could have led to gastric ischemia and perforation following obstruction. A redo FJ was done, and the patient had an uneventful postoperative recovery. Therefore, surgeons should have high clinical suspicion for a rarer complication like a closed-loop obstruction in a patient with upper abdominal pain and distension without vomiting following FJ.

How to cite this article

Balamurugan S, Aslam MM, Kadambari D, et al. Closed-bowel Loop Obstruction-An Unusual and Forgotten Complication of Feeding Jejunostomy: Case Report. Euroasian J Hepato-Gastroenterol 2022;12(2):92-94.

Quality of life in lower limb amputees: a cross-sectional study from a tertiary care center of South India

BACKGROUND

Various literature have dealt with the physical aspect of amputation and the functional outcome after amputation. There are a few studies that give focused attention to the quality of life (QOL) of amputees. These studies are mostly from the developed countries. This study analyzed amputation as a whole and how it affects an individual physically, psychologically, emotionally, and socially, which would enable the health care providers to help the amputees to attain a better QOL.

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

This cross-sectional study was conducted on lower limb amputees. Data were collected using a proforma for demographic details and two pretested questionnaires-the World Health Organization QOL-Bref and prostheses-specific Trinity Amputation and Prosthesis Experience Scales-Revised questionnaires. The data were analyzed using SPSS software, version 20.

RESULTS

Amputation significantly affects all domains of the QOL. Age was a significant determinant of QOL of amputees, and it was found that the QOL decreased with an increase in age. 48.1% of the amputees were using a prosthetic device, and they were found to have a significantly better QOL. The prevalence of residual limb pain and phantom limb pain was 52.9% and 37%, respectively.

CONCLUSION

Nearly half of the population perceived that their QOL was neither poor nor good. The QOL of the physical domain was better than the other domains. The most important factors that were found to be associated with QOL of amputees were age, duration since amputation, and use of prosthesis.

Abstract P3-07-13: Neoadjuvant composite score as a prognostic marker in early and locally advanced triple negative breast cancer

Aim Triple negative subtype (TNBC) is an aggressive breast cancer with inferior survival. Pathological CR (pCR) is a good surrogate endpoint for survival among patients receiving neoadjuvant chemotherapy (NACT). We attempted to validate the composite score(CPS) (Jaccqueline et al, J Clin Oncol 26:246-252) combining clinical and pathological variables among TNBC patients receiving NACT at our center. Methodology Data of patients with TNBC who underwent NACT between January 2014 to July 2017 was retrospectively analysed. The composite CPS score included cTN stage and y pTN stage, and ranged from 0 to 4. This was calculated using an online software (http://www3.mdanderson.org/app/medcalc/index.cfm?pagename=bcnt). The scores obtained from the calculator was used to develop a risk grouping into low risk (0,1) and High risk (2,3,4). Overall survival (OS)and disease free survival (DFS) were calculated using the Kaplan-Meier method and differences was examined using the log rank test. Results Seventy-eight patients with TNBC [median age: 45 (24-75)] had received NACT (anthracyclines and taxanes). Early and locally advanced breast cancer constituted 17 (21.8 %) and 61 (78.2%) respectively and 22 (28.2 %) achieved pCR. After a median follow up of 28 months (5-62), 3-yr DFS and OS were 59% and 82% respectively for the entire population. The 3-yr DFS in low (n=18) and high risk (n=60) patients was 85.7% and 51.4% respectively (p=0.032). The 3-yr OS in the low and high risk was 93% and 79% respectively(p=0.28, NS). Conclusion Our study supports the use of the composite clinical pathological score (CPS) as a prognostic marker in patients with non-metastatic triple negative breast cancer. The risk stratification developed may help identify patients who may require additional adjuvant therapy.

Citation Format: Biswajit Dubashi, Smita Kayal, Kirankumar Matta, Divya bala Thumaty, Nisha Yadav, D Kadambari, Pampa ch Toi, K Gunaseelan, Prasanth Ganesan. Neoadjuvant composite score as a prognostic marker in early and locally advanced triple negative breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-07-13.

Delayed Presentation of Complete Ileal Transection Following Blunt Trauma Abdomen: A Condition to Cognize

Isolated small bowel perforation is a rare presentation of blunt abdominal trauma, and most cases present immediately following the trauma. Delayed presentation of such cases beyond one week of trauma is extremely rare, and various pathophysiological mechanisms were described for the same. We present a 20-year-old male patient who sustained blunt abdominal and pelvic trauma, underwent open reduction and internal fixation for right acetabular fracture, and later developed features of acute peritonitis after one month. On laparotomy, complete terminal ileal transection was found and an ileostomy was done. Delayed perforation of the intestine following trauma occurs due to ischemic necrosis, either through direct trauma to the intestinal wall or indirectly by injury to the mesenteric vessels. Direct trauma to the bowel can result in large hematomas on the bowel wall, which can later perforate due to ischemia. Surgeons should be aware of this rare presentation as the management is challenging and it poses significant medico-legal sequel. Close monitoring of the patient’s vitals and examination for the development of abdominal signs along with repeat imaging at the onset of abdominal signs are cornerstones for successful management of these patients.

Pregnancy in women with Klippel-Trenaunay syndrome: Report of three pregnancies in a single patient and review of literature

Klippel-Trenaunay syndrome is characterised by vascular abnormality which increases the risk of thromboembolism and haemorrhage. Physiological changes in pregnancy pose an increased risk to these complications. Being an uncommon disorder, there is limited literature about the management of women with pregnancy and Klippel-Trenaunay syndrome. We report in detail two of three pregnancies in a woman with Klippel-Trenaunay syndrome who had repeated episodes of haematochezia leading to anaemia, managed with Argon laser Photo-Coagulation in pregnancy and also reviewed the complications and the management of pregnant women with Klippel-Trenaunay syndrome.

Early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery-a randomized controlled trial

OBJECTIVE

This prospective randomized controlled trial was conducted to compare the safety, tolerability and outcome of early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery.

METHODS

A total of 120 consecutive patients who underwent elective open bowel surgeries were randomized into either early feeding (n = 60) or traditional feeding group (n = 60). Patients in the early feeding group were started on oral fluids on post-operative day 1, while those in the traditional feeding group were started orals after the resolution of ileus. Patient characteristics, surgical procedures, co-morbidity, first flatus, first defecation, time of starting solid diet, complications and length of hospitalization were assessed between the two groups.

RESULTS

The two groups were similar in demographic and baseline data. The number of days to first flatus (p < 0.0001), first defecation (p < 0.0001), length of post-operative stay (p = 0.011) and time of starting solid diet (p < 0.0001) were significantly earlier in the early feeding group. Anastomotic leak, wound infection, fever, vomiting, abdominal distention and other complications were similar. Multivariate analysis showed that patients in the early oral feeding group were discharged 3.4 days earlier (p = 0.037).

CONCLUSION

In patients undergoing elective open bowel surgeries, early post-operative feeding is safe, is well tolerated and reduces the length of hospitalization.

Non-healing ulcer on the great toe due to cellular schwannoma

Cellular schwannoma (CS) occurring in the foot is uncommon, and when it does occur, it usually presents as a slowly growing tumour. Ulceration of CS on the foot is rare. We report a 20-year-old woman who presented with a painful and non-healing ulcer on the lateral area of the right great toe, which failed to heal despite treatment. Six months after onset of the ulcer, a small swelling appeared below it. Histological examination of a biopsy taken from the edge of the ulcer established the diagnosis of CS. Preoperative magnetic resonance imaging delineated the mass on the lateral area of the right great toe. The mass was surgically excised, which led to resolution of the symptoms. This case highlights the fact that chronic ulcers in the foot can be due to CS. Correct diagnosis and management depend on a histopathological diagnosis.

Effect of early enteral feeding after upper gastrointestinal surgery

BACKGROUND AND AIMS

The impact of early enteral nutrition in elective upper gastrointestinal surgery was the focus of this study, with particular reference to its feasibility and benefits.

METHOD

This prospective study was carried out over 2 years. The study group included 30 patients and the control group had 31patients. Twenty-two patients in each group underwent truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer and gastric outlet obstruction. Eight patients in the study group and nine in the control group underwent gastrectomy for carcinoma stomach. A standard milk-based diet was initiated 12 hours after surgery through a nasojejunal tube. The patients were monitored for side effects of enteral feeding and postoperative infective complications. Nitrogen balance and nutritional parameters like the body weight, serum albumin, and serum transferrin were measured pre and postoperatively.

RESULTS

The groups were comparable with respect to age, sex, and preoperative nutritional factors like body weight, serum albumin, and serum transferrin. The return of bowel sounds and passage of flatus took place significantly earlier in the study group (1.43 vs. 2.81 days). Diarrhoea and abdominal cramps were the significant complications noted in the study group in relation to early enteral feeding. No patient required withdrawal of enteral feeds. They showed a positive nitrogen balance on the fourth postoperative day. The patients in the study group showed significant increase in the serum transferrin level compared with the preoperative level but the serum albumin level was not significantly altered.

CONCLUSION

Early enteral feeding through the nasojejunal tube following elective upper gastrointestinal surgery is feasible, safe and improves the nutritional status.

Feasibility of breast conservation surgery in locally advanced breast cancer downstaged by neoadjuvant chemotherapy: a study in mastectomy specimens using simulation lumpectomy

BACKGROUND

The response of locally advanced breast cancer (LABC) to neoadjuvant chemotherapy (NACT) offers these patients previously treated by mastectomy, the chance for breast conservation.

AIM

This study aims to assess the feasibility of lumpectomy in patients with LABC treated by NACT, with residual tumor < or =5 cm. SETTINGS, DESIGN: Single group prospective study from August 2001 to June 2003 in a teaching hospital.

MATERIALS AND METHODS

Thirty patients with LABC whose tumors reduced with NACT to 5 cm were included. Simulation lumpectomy was performed on the mastectomy specimens to achieve 1 to 2 cm clearance from tumor and hence margin negativity. Multiple sections of the inked margin were studied.

STATISTICAL ANALYSIS

Margin positivity was correlated with patient factors. Chi square test and Fisher's exact test used as appropriate. P value 0.05 was considered significant.

RESULTS AND CONCLUSIONS

After three cycles of NACT, 4 patients (13%) had complete clinical response including 2 with complete pathological response. Twenty-two (73%) showed partial response and 4, no response. Fourteen out of thirty (47%) had tumor involvement of margins. Tumors with post-chemotherapy size> 4 cm were margin positive in 10/13 (77%). Tumors with post-chemotherapy size>3 cm were margin positive in 13/24 (54%). Tumors with post-chemotherapy size 3 cm were margin negative in 5/6 (83%). Pre-chemotherapy tumor size and post-chemotherapy tumor size were significantly associated with margin positivity (P=0.003). Tumors in the subareolar location had significantly higher incidence of residual tumor in the nipple areola complex. (P=0.04). Margin positivity of lumpectomy on downstaged tumors can be reduced by removing the nipple areola complex in subareolar tumors and by limiting breast conservation to tumors with post-chemotherapy size < or =3 cm.

Complete axillary conversion after neoadjuvant chemotherapy in locally advanced breast cancer: a step towards conserving axilla?

OBJECTIVES

This study was designed to assess the clinical, sonographic and histopathological response of axillary lymph node metastasis to neoadjuvant chemotherapy in patients with locally advanced breast cancer.

MATERIAL AND METHODS

Forty patients with locally advanced breast cancer (LABC) with clinically palpable or sonographically detectable axillary nodes were studied. FNAC of the primary tumor and axillary nodes was done and patients were started on neoadjuvant chemotherapy. Axillary nodes were assessed clinically and sonographically for response after 3 cycles of chemotherapy. All patients underwent total mastectomy with axillary clearance and the lymph nodes in the specimen were examined for metastasis.

RESULTS

47% patients had complete clinical nodal response, while 19% showed complete sonographic response. Complete pathological nodal response was documented in 22% of patients. Ultrasonography was found to be more sensitive than clinical examination in assessing complete nodal response. 10% of the patients had complete pathological response of both primary tumor and axillary nodes. There was significant correlation between pathological response of primary tumor and lymph nodes (P=0.004). Patients with complete sonographic or clinical response were found to have no or minimal residual disease in axilla and hence axillary dissection may be avoided in them.

Postoperative intussusception in the adult: a case report

We report the case of a 40-year-old man who presented with a history of sudden onset abdominal pain and obstipation of 1 day's duration. During laparatomy, a 5mm perforation was seen in the anterior wall of the first part of the duodenum, which was closed by a Graham patch and the abdomen was closed after peritoneal lavage. Postoperatively, the patient's condition worsened and he was posted for a laparatomy with a diagnosis of postoperative obstruction. During the laparatomy, an ileocolic was seen which could be easily reduced. After the second surgery, the patient made an uneventful recover.

Primary pyogenic psoas abscess in children

Primary pyogenic psoas abscess, although quite a common condition, particularly in the tropics, is often overlooked as a clinical entity, probably because a psoas abscess has been traditionally associated with tuberculous spondylitis. The abscess is easily diagnosed by ultrasonography (US). Treatment by open drainage and antibiotics effective against Staphylococcus aureus results in complete reversal of symptoms and signs. In our series of 55 cases in the pediatric age group (0-12 years), pain and flexion at the hip were the most frequent clinical features at presentation. US was diagnostic in all cases in which it was performed. All except 1 patient showed complete resolution with extraperitoneal drainage, antibiotics, and skin traction. Although 4% of the cases were associated with suppurative external-iliac lymphadenitis, the remaining ones arose de novo in the psoas sheath, suggesting a primary pyomyositis of the psoas muscle.