Incomplete bowel obstruction caused by sigmoid colon cancer in an inguinal hernia: a case report

BACKGROUND

Most colon cancers that develop in the intestinal tract within the inguinal hernia sac are identified by incarceration. However, treatment methods for these cases vary depending on the pathology. Cases showing perforation or abscess formation require emergency surgery for infection control, while cases with no infection generally involve oncological resection, with laparoscopic surgery also being an option. We encountered a case of Incomplete bowel obstruction secondary to sigmoid colon cancer within the hernial sac. We report the process leading to the selection of the treatment method and the surgical technique, along with a review of the literature.

CASE PRESENTATION

A 79-year-old man presented to our hospital complaining of a left inguinal bulge (hernia) and pain in the same area. The patient had the hernia for more than 20 years. Using computed tomography, we diagnosed an incomplete bowel obstruction caused by a tumor of the intestinal tract within the hernial sac. Since imaging examination showed no signs of strangulation or perforation, we decided to perform elective surgery after a definitive diagnosis. After colonoscopy, we diagnosed sigmoid colon cancer with extra-serosal invasion; however, we could not insert a colorectal tube. Although we proposed sigmoid resection and temporary ileostomy, we chose the open Hartmann procedure because the patient wanted a single surgery. For the hernia, we simultaneously used the Iliopubic Tract Repair method, which does not require a mesh. Eight months after the surgery, no recurrence of cancer or hernia was observed.

CONCLUSIONS

We report a case of advanced sigmoid colon cancer with a long-standing inguinal hernia that later became incomplete bowel obstruction. Although previous studies have used various approaches among the available surgical methods for cancer within the hernial sac, such as inguinal incision, laparotomy, and laparoscopic surgery, most hernias are repaired during the initial surgery using a non-mesh method. For patients with inguinal hernias that have become difficult to treat, the complications of malignancy should be taken into consideration and the treatment option should be chosen according to the pathophysiology.

Determining a multidisciplinary intraoperative strategy in emergency surgery for bowel obstruction and its impact on outcomes

PURPOSE

Bowel obstruction accounts for around 50% of all emergency laparotomies. A multidisciplinary (MDT) standardized intraoperative model was applied (definitive, palliative, or damage control surgery) to identify patients suitable for a one-step, definitive surgical procedure favoring anastomosis over stoma, when undergoing surgery for bowel obstruction. The objective was to present mortality according to the strategy applied and to compare the rate of laparoscopic interventions and stoma creations to a historic cohort in surgery for bowel obstruction.

METHODS

In a retrospective cohort study, we included patients undergoing emergency surgery for bowel obstruction during a 1-year period at two Copenhagen University Hospitals (2019 and 2021). The MDT model consisted of a 30- and 60-min time-out with variables such as functional and hemodynamic status, presence of malignancy, and surgical capabilities (lap/open). Pre-, intra-, and postoperative data were collected to investigate associations to postoperative complications and mortality. Stoma creation rates and laparoscopies were compared to a historic cohort (2009-2013).

RESULTS

Three hundred sixty-nine patients underwent surgery for bowel obstruction. Intraoperative surgical strategy was definitive in 77.0%, palliative in 22.5%, and damage control surgery in 0.5%. Thirty-day mortality was significantly lower in the definitive patient population (4.6%) compared to the palliative population (21.7%) (p < 0.000). Compared to the historic cohort, laparoscopic surgery for bowel obstruction increased from 5.0 to 26.4% during the 10-year time span, the rate of stoma placements was reduced from 12.0 to 6.1%, p 0.014, and the 30-day mortality decreased from 12.9 to 4.6%, p < 0.000.

CONCLUSION

An intraoperative improvement strategy can address the specific surgical interventions in patients undergoing surgery for bowel obstruction, favoring anastomosis over stoma whenever resection was needed, and help adjust specific postoperative interventions and care pathways in cases of palliative need.

An authentic radiological triad of Rigler allowing the diagnosis of gallstone ileus: A case report

The Rigler's Triad consists by three radiological signs, including intestinal obstruction, pneumobilia, and an aberrant gallstone in the bowel. It is an inconstant triad considered being pathognomonic of gallstone ileus. Gallstone ileus is an exceptional complication of cholelithiasis due to the passage of one or more gallstones from the bile ducts into the lumen of the bowel through a biliodigestive fistula. We report the case of an 83-year-old female patient with a history of ischemic heart disease and an asymptomatic large gallstone. The patient was admitted to the emergency department for bowel obstruction, abdominal pain, and bilious vomiting. A clinical examination found a patient with an alteration in general condition and a distended abdomen with tenderness. An abdominal CT scan revealed Rigler's triad, allowing the diagnosis of gallstone ileus. A midline exploratory laparotomy was performed to find a giant gallstone blocked in the last ileum loop. A simple enterolithotomy was performed, allowing the extraction of giant lithiasis from an 8-cm major axis. The postoperative evolution was uneventful, and the patient was discharged 4 days after surgical treatment.

Ascariasis: A common disease with uncommon presentation in a resource limited setting. A case report

Ascaris-induced intestinal obstruction is a rare complication primarily seen in children in areas with a high prevalence of worm infestations. It can occur through 2 mechanisms: immune-mediated reactions releasing neurotoxins that cause contractions and inflammation in the small intestine (aperistalsis), or mechanical obstruction by adult worms, commonly at the ileocecal valve. Partial obstructions are managed conservatively, while complete obstructions often require surgical intervention. In a recent case, a 19-year-old male presented with persistent abdominal pain, vomiting, and inability to pass stools, and gas. Imaging revealed partial obstruction, and conservative management with fluids, a nasogastric tube, and antibiotics led to the spontaneous passage of worms, relieving symptoms. The patient was discharged with anthelmintics and advised on follow-up and sanitary measures. This case is notable for the uncommon occurrence of Ascaris-induced intestinal obstruction in adults and the successful conservative management resulting in early worm expulsion.

Bezoar in Meckel's diverticulum: Case report and narrative review

INTRODUCTION

Bezoars are a known cause of complications in Meckel's diverticulum. We present a case in which a bezoar in a Meckel's diverticulum resulted in intestinal obstruction. In addition, we conducted a narrative review to explore the association between Meckel's diverticulum and bezoars.

CASE PRESENTATION

We present the case of a 22-year-old patient admitted for bowel obstruction persisting for three days and periumbilical tenderness. Abdominal CT tomography revealed a hyper dense circular structure with a diameter of 2 cm, small bowel distension of 41 mm, and free fluid. During surgical exploration, a Meckel diverticulum was found between the antimesenteric border of the small bowel and posterior wall of the umbilicus. The Meckel diverticulum was resected, and upon examination, it was found to contain a calcified phytobezoar. The postoperative course was uneventful.

DISCUSSION

The clinical and paraclinical presentation of bezoars in Meckel's diverticulum is nonspecific and diagnosis remains challenging despite improved diagnostic modalities. The association between Meckel's diverticulum and bezoars is often identified during surgery, as it is difficult to diagnose using CT scans. The choice between laparoscopic and open surgery depends on the patient's situation.

CONCLUSION

Diagnosing a bezoar in a Meckel's diverticulum remains challenging. Treatment involves surgery, and the choice of surgical approach depends on the context.

A large iliopsoas abscess due to colon cancer complicated by bowel obstruction: A case report

INTRODUCTION

Iliopsoas abscesses (IPAs) associated with bowel obstruction due to colon cancer are rare, and there is no consensus regarding treatment strategies.

PRESENTATION OF CASE

A 63-year-old man presented with swelling and pain in the right iliac region. Imaging studies revealed an IPA expanding from the psoas major muscle and retroperitoneal space subcutaneously around the right ilium. After percutaneous drainage, the patient developed bowel obstruction secondary to colon cancer. Hemicolectomy and preventive ileostomy were performed at the gastrointestinal surgery department, and chemotherapy was administered at the medical oncology department after ileostomy closure. Three months later, local recurrence was confirmed in the right iliac region, and the recurrent lesion, including the ilium, was widely resected. One and a half years after the reoperation, there was no recurrence.

DISCUSSION

An IPA due to colorectal cancer without obvious perforation can also occur, and the treatment of IPAs depends on their size, location, shape, and presence of gas. Minimally invasive and staged treatment is preferable for IPAs due to colorectal cancer because the surgical mortality rate for colorectal cancer with local abscesses is high.

CONCLUSION

Colorectal cancer should be considered as a cause of IPAs. Treatment of IPAs caused by colon cancer should be performed in a less invasive manner after considering their size, location, shape, and the presence of gas. Cooperation between gastrointestinal surgeons and oncologists is essential for managing patients with an IPA due to colon cancer complicated by bowel obstruction.

A rare case report of patent vitellointestinal duct presenting as a periumbilical pain in an adult

The vitellointestinal duct (VID) is an embryological remnant of the vitelline duct, a structure that connects the developing fetus to the yolk sac and is responsible for the nutritional support of the fetus during the early embryological days. The VID usually gets obliterated by the fifth to ninth week of gestational age after the establishment of placental nutrition. The patent VIDellointestinal duct is a relatively rare congenital condition that occurs in approximately 2% of the general population, with the most common presentation being Meckel's diverticulum. Complete patency is rarer, occurring in 0.1% of the general population. The complete persistence of the VID results in enterocutaneous fistula, and the presentation may vary, ranging from cutaneous manifestations like skin lesions, granulomas, abscesses, or umbilical discharge to abdominal symptoms including acute abdominal pain and hematochezia. Some patients are even asymptomatic and are detected incidentally. We present a rare case of complete patency of the VID in a 30-year-old adult male presenting with acute periumbilical pain. Imaging findings guided the diagnosis, and surgical resection with histopathological examination further confirmed the condition.

Diffuse abdominal lymphangiomatosis without tumoral masses: a case report

Diffuse abdominal lymphangiomatosis is a rare and complex disease. It typically presents with non-specific gastrointestinal symptoms and characteristic cystic lesions or tumoral masses on imaging based on the literature to date. This report presents the rare case of a young man with an atypical form of diffuse abdominal lymphangiomatosis in the complete absence of cystic lesions or lymphangioma tumoral masses, thus presenting a unique diagnostic challenge. It was successively treated by surgery, gastric electrical stimulator, sirolimus, and imatinib.

Outcomes of elective and emergency surgical repair of incisional hernia: a comparative observational study

PURPOSE

Incisional hernia (IH) is a common complication following abdominal surgery. Surgical repair of IH is associated with the alleviation of symptoms and improvement of quality of life. Operative intervention can pose a significant burden to the patient and healthcare facilities. This study aims to describe and compare outcomes of elective and emergency surgical repair of IH.

METHODS

This study is a single-centre comparative retrospective study including patients who had repair of IH. Patients were divided into Group I (Emergency) and Group II (Elective), and a comparison was conducted between them.

RESULTS

Two hundred sixty-two patients were identified with a mean age of 61.8 ± 14.2 years, of which 152 (58%) were females. The mean BMI was 31.6 ± 7.2 kg/m2. More than 58% had at least one comorbidity. 169 (64.5%) patients had an elective repair, and 93 (35.5%) had an emergency repair. Patients undergoing emergency repair were significantly older and had higher BMI, p = 0.031 and p = 0.002, respectively. The significant complication rate (Clavien-Dindo III and IV) was 9.54%. 30 and 90-day mortality rates were 2.3% (n = 6) and 2.68% (n = 7), respectively. In the emergency group, the overall complications, 30-day and 90-day mortality rates were significantly higher than in the elective group, p ≤ 0.001, 0.002 and 0.001, respectively. Overall, 42 (16.1%) developed wound complications, 25 (9.6%) experienced a recurrence, and 41 (15.71%) were readmitted within 90 days, without significant differences between the two groups.

CONCLUSION

Patients who underwent emergency repair were significantly older and had a higher BMI than the elective cases. Emergency IH repair is associated with higher complication rates and mortality than elective repair.

Bowel obstruction complicating an encapsulating peritoneal sclerosis: A case report

Encapsulating peritoneal sclerosis (EPS) is a rare pathological entity that can be classified into an idiopathic or secondary affection. Bowel obstruction is a frequent complication that has a characteristic radiological finding, with a cocoon appearance. We present the case of a 40-year-old man who suffered an absolute constipation. He underwent a CT scan that was suggestive of encapsulating peritoneal sclerosis or abdominal cocoon responsible for small bowel obstruction.

Jejunal adenocarcinoma; a case report and literature review

INTRODUCTION AND IMPORTANCE

Small bowel carcinoma (SBC) is a rare malignancy comprising mainly of adenocarcinoma and carcinoid tumors. Among SBCs, small bowel adenocarcinoma (SBA) accounts for 30-40 % and is predominantly found in the duodenum, while jejunal and ileal presence considered rare.

CASE PRESENTATION

We have presented a case of jejunal adenocarcinoma in a patient with obstruction symptoms. Prior to the obstruction, the patient mainly suffered from weakness and weight loss, in addition to iron deficiency anemia. During the investigation of underlying causes, we observed evidence of mass. However, before any additional evaluation could take place, the obstruction necessitated surgical intervention.

CLINICAL DISCUSSION

Small bowel adenocarcinomas, particularly in the jejunum and ileum, are exceedingly rare and often present with complications such as obstruction, gastrointestinal bleeding, or perforation. Due to the non-specific symptoms, SBAs are challenging to diagnose before complications occur. SBAs are frequently diagnosed at advanced stages, so early diagnosis is crucial, as it can significantly impact patient survival. Thus, efforts should be made to expedite the diagnosis process to avoid complications and improve survival rates.

CONCLUSION

SBAs are a rare condition, often diagnosed by related complications. Recognizing the importance of early diagnosis and its positive influence on patient survival, physicians and surgeons should consider SBA in patients presenting with relevant symptoms or cases of obstruction.

The omphalomesenteric duct fibrous band as a rare cause of bowel obstruction: A case report and literature review

INTRODUCTION AND IMPORTANCE

The omphalomesenteric duct (OMD) is an embryonic structure that normally undergoes obliteration during embryonic development, typically not persisting after birth. Failure of complete or partial obliteration can result in a type of malformation known as OMD remnant.

CASE PRESENTATION

We report a case of a 24-year-old male patient diagnosed with bowel obstruction. Abdominal computed tomography (CT) scan revealed the presence of an adhesion band. During surgery, a fibrous band connecting from the umbilicus to the mesentery of terminal ileum was found and resected. Pathological investigation confirmed the presence of an OMD remnant fibrous band.

CLINICAL DISCUSSION

OMD remnant can manifest in different forms such as Meckel's diverticulum, umbilical polyp, OMD cyst, OMD fistula, and fibrous band, occurring in approximately 2 % of infants and often presenting symptoms in early childhood. These conditions rarely cause complications in adults. Complications may include obstruction, gastrointestinal bleeding, bowel perforation, and omphalitis which can present with symptoms such as abdominal pain, vomiting, melena, lack of defecation, umbilical discharge, and dermal manifestations. Diagnostic approaches vary depending on the type of OMD remnant and associated complications, but ultrasonography and CT scan can be useful. While asymptomatic OMD remnants generally do not require further intervention, surgical treatment is the main option for complicated and symptomatic cases.

CONCLUSION

OMD remnant is a rare condition in adults that can lead to complications. Given that obstruction is a common complication of OMD remnant, OMD remnant should be considered in the differential diagnosis of patients presenting with bowel obstruction.

Ultrasound imaging of bowel obstruction in neonates

Bowel obstruction (BO) in children has a wide differential diagnosis, ranging from non-urgent conditions to surgical emergencies. Abdominal radiographs are most often used as the first imaging modality for the evaluation of obstruction. However, for some indications, ultrasound can be the primary imaging modality. Therefore, it is incumbent on radiologists to recognize the types of bowel obstruction that can be recognized with US. Key sonographic features of BO include differential dilation of bowel loops, bowel wall thickening, and free fluid. "Do Not Miss" findings that indicate need for emergent treatment include volvulus, pneumoperitoneum, and/or signs of ischemia (bowel wall thinning and/or absent perfusion). The aim of this pictorial essay is to provide guidance on the sonographic technique and findings that enable identification of BO on US. Examples of neonatal BO on US, including common and less frequently encountered etiologies, are illustrated in this pictorial essay.

Towards an EKG for SBO: A Neural Network for Detection and Characterization of Bowel Obstruction on CT

A neural network was developed to detect and characterize bowel obstruction, a common cause of acute abdominal pain. In this retrospective study, 202 CT scans of 165 patients with bowel obstruction from March to June 2022 were included and partitioned into training and test data sets. A multi-channel neural network was trained to segment the gastrointestinal tract, and to predict the diameter and the longitudinal position ("longitude") along the gastrointestinal tract using a novel embedding. Its performance was compared to manual segmentations using the Dice score, and to manual measurements of the diameter and longitude using intraclass correlation coefficients (ICC). ROC curves as well as sensitivity and specificity were calculated for diameters above a clinical threshold for obstruction, and for longitudes corresponding to small bowel. In the test data set, Dice score for segmentation of the gastrointestinal tract was 78 ± 8%. ICC between measured and predicted diameters was 0.72, indicating moderate agreement. ICC between measured and predicted longitude was 0.85, indicating good agreement. AUROC was 0.90 for detection of dilated bowel, and was 0.95 and 0.90 for differentiation of the proximal and distal gastrointestinal tract respectively. Overall sensitivity and specificity for dilated small bowel were 0.83 and 0.90. Since obstruction is diagnosed based on the diameter and longitude of the bowel, this neural network and embedding may enable detection and characterization of this important disease on CT.

Small bowel obstruction due to congenital band in an adult: Radio-surgical correlation

Congenital band is a rare cause of bowel obstruction, most commonly occurring in childhood. We report a case of a young adult with no medical and surgical previous history who had symptoms of bowel obstruction evolving for 2 days. Computed tomography (CT) found an adhesive band causing a small bowel obstruction. An open laparotomy was performed, and the intraoperative findings were consistent with a congenital band compressing the ileum. Through this clinical case, we illustrate an uncommon cause of bowel obstruction and the interest of the CT for the management.

The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction

INTRODUCTION

Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS).

METHODS

This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction.

RESULTS

20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications.

CONCLUSIONS

Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.

Small bowel obstruction with bowel ischemia due to ingestion of water-absorbing bead

Foreign body aspiration accounts for 7% of accidental deaths in children under age 4 (4). Children between the ages of 6 months and 3 years of age, adolescent boys and children with mental health issues are at the highest risk of foreign body ingestion. Coins are the most commonly swallowed foreign body in the United States (US) and in other countries those related food such as fish bones are most common (10). Most cases are accidental and pass harmlessly through the gastrointestinal tract with low mortality (10). The most common complication is esophageal obstruction particularly at the thoracic inlet. However, the object can become lodged anywhere in the gastrointestinal tract. We present an unusual case of small bowel obstruction and bowel ischemia secondary to superabsorbent polymer water bead ingestion in a pediatric patient.

Partial annular pancreas as an incidental finding in a patient with intermittent bowel obstruction: A case report

Complete annular pancreas (AP) is a congenital anomaly, in which the duodenum is either completely or partially encircled by the ring of pancreatic tissue, which eventually becomes continuous with the head of the pancreas. The incidence of AP is estimated to be around 0.02%. Reports from endoscopic retrograde cholangiopancreatography show an incidence of 0.4%. Partial AP (PAP) is a rarer entity, in which a band of pancreatic tissue in continuity with the head of the pancreas, incompletely encircles the duodenum. It may be asymptomatic or may present later in life with complications. We report a case of a 72-years old male with features of intermittent bowel obstruct which was later found to be having PAP on contrast-enhanced computed tomography imaging at the level of renal hilum characterized by "crocodile-jaw appearance." The possibility of PAP should also be considered at the back of mind of the treating physician, if a patient presents with a long-term history of postprandial abdominal discomfort.

Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management.

METHODS

This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death.

RESULTS

At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35).

CONCLUSIONS

A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.

Nomogram for predicting adhesive small bowel obstruction following emergency gastrointestinal surgery

BACKGROUND

Postoperative adhesions are frequent and significant complications that typically arise following abdominal surgery. Currently, the existing evidence for predicting the risk of adhesive small bowel obstruction (ASBO) after emergency gastrointestinal surgery (EGS) remains inadequate. A reliable perioperative model that quantifies the risk of ASBO after EGS serves as a practical tool for guiding individually tailored surveillance.

METHODS

A consecutive series of 1296 patients who underwent EGS for radiologically confirmed bowel/visceral inflammation or perforation between 2012 and 2022 at a tertiary academic medical center were included in this study to establish a best-fit nomogram. The nomogram was externally validated by assessing discrimination and calibration using an independent cohort from a separate medical center.

RESULTS

A total of 116 patients (8.9%) developed at least one episode of ASBO after EGS during a median follow-up duration of 26 months. The results of multivariable logistic analysis indicated that male sex (P = 0.043), preoperative albumin level (P = 0.002), history of pelvic radiotherapy (P = 0.038), laparotomy (P = 0.044), and intensive care unit stay ≥ 72 h (P = 0.047) were identified as independent risk factors for developing ASBO. By incorporating these predictors, the developed nomogram exhibited good accuracy in risk estimation, as evidenced by a guide-corrected C-index score of 0.852 (95% CI 0.667-0.920) in the external validation cohort. Decision curve analysis and clinical impact curve demonstrated a clinically effective predictive model.

CONCLUSION

By incorporating the nomogram as a supplemental tool in perioperative management, it becomes possible to accurately assess the individual's likelihood of developing ASBOs. This quantification enables surgeons to implement appropriate preventive measures, ultimately leading to improved outcomes.

Simultaneous cecal and transverse colon volvulus: An exceedingly rare case of intestinal obstruction from Ethiopia: A case report and review of literatures

INTRODUCTION AND IMPORTANCE

Bowel obstruction is a mechanical or functional blockade of intestinal contents from evacuation to the adjacent distal bowel or external environment. Cecal volvulus is the twisting of distal ileum, cecum and ascending colon on their mesentery. Transverse colon volvulus is another rare cause of large bowel obstruction even less prevalent than cecal volvulus. Colectomy with decompression stoma is the widely practice of intervention in cecal or transverse colon volvulus.

CASE PRESENTATION

A 45 years-old male patient presented to our center with failure to pass feces and flatus of 5 days duration. He also had crampy abdominal pain, abdominal distention and vomiting of ingested matter. Vital signs were normal except mild tachycardia. He had distended non-tender abdomen, hyperactive bowel sound and hyper-tympanic percussion. However, there was no sign of fluid collection of abdominal or rectal mass. Plain abdominal X-ray showed distended large bowel loops with multiple air fluid levels. Exploratory laparotomy revealed simultaneous cecal and transverse colon clockwise volvulus 270 degrees on their mesentery.

DISCUSSION

Mechanical bowel obstruction is major cause of surgical admission in both developed and developing countries. Anatomic and congenital factors play significant role in both transverse colon and cecal volvulus. Endoscopic decompression in the case of cecal and transverse colon volvulus is less probable and not recommended.

CONCLUSION

Simultaneous cecal and transverse colon volvulus is an extremely rare occasion where there is no report in the history of literatures to date. Management involves extended right hemicolectomy with proximal diversion and distal mucus fistula.

Idiopathic Sclerosing Encapsulating Peritonitis - Preoperative diagnostic challenges: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Idiopathic Sclerosing Encapsulating Peritonitis (ISEP) is an uncommon condition of intestinal bowel obstruction due to encapsulation of the abdominal organs in a thick fibro-collagenous membrane. The case presented here describes the emergency acute presentation of septic peritonitis discovered intraoperatively upon laparotomy.

CASE PRESENTATION

A middle-aged woman was admitted to the emergency department and presented with generalized colicky abdominal pain associated with repetitive vomiting, abdominal distention, and absolute constipation. A digital rectal examination revealed an empty rectum and a bilious output was observed in the nasogastric tube. Abdominal X-Ray demonstrated multiple air-fluid levels with no air under the diaphragm. The patient was treated with fluid therapy and antibiotics intravenously (IV).

CLINICAL DISCUSSION

The clinical impression of acute-on-chronic intestinal obstruction with peritonitis and the possibility of bowel strangulation was made. Emergency exploratory laparotomy revealed viable bowel loops encased in thickened fibrous capsules covering the entire abdominal viscera establishing the existence of ISEP. The fibrous capsule layer was excised out in small pieces from all the abdominal organs excluding stomach through extensive adhesiolysis without loop resection.

CONCLUSION

The emergency presentation of acute peritonitis observed in this study could only be identified through diagnostic laparoscopy and differential radiological imaging techniques. Further, better reporting of such rare cases may help clinicians understand the different clinical features that could indicate the occurrence of ISEP.

Laparoscopic management of large bowel obstruction caused by late post-traumatic diaphragmatic hernia: A case report

INTRODUCTION

Post-Traumatic Diaphragmatic Hernia (PTDH) is a relatively uncommon condition, often a consequence of blunt or penetrative trauma to the thoracic or abdominal cavity. Its onset can be either immediate or delayed following the injury, typically presenting with the herniation of abdominal organs into the thoracic cavity. Large Bowel Obstruction (LBO) is an infrequent manifestation of PTDH. Here, we report a case of late PTDH presenting with LBO that was successfully managed through a laparoscopic approach.

CASE PRESENTATION

A 49-year-old male patient presented with symptoms indicative of LBO seven years after sustaining a penetrative thoracoabdominal injury. Computed Tomography (CT) of his abdomen and pelvis revealed an incarcerated colon within a left diaphragmatic hernia, further corroborated by a significant history of a past thoracoabdominal stab wound. Diagnostic laparoscopy confirmed the diagnosis, which facilitated the relief of obstruction and repair of the diaphragmatic hernia. The patient exhibited a smooth recovery post-surgery without complications.

CLINICAL DISCUSSION

An LBO presenting as a consequence of a post-traumatic diaphragmatic hernia is indeed rare. Given the mechanical nature of the obstruction, surgical intervention is the primary treatment strategy.

CONCLUSION

Our case demonstrates that a laparoscopic approach is a safe and viable method for managing this condition.

Visual Image Annotation for Bowel Obstruction: Repeatability and Agreement with Manual Annotation and Neural Networks

Bowel obstruction is a common cause of acute abdominal pain. The development of algorithms for automated detection and characterization of bowel obstruction on CT has been limited by the effort required for manual annotation. Visual image annotation with an eye tracking device may mitigate that limitation. The purpose of this study is to assess the agreement between visual and manual annotations for bowel segmentation and diameter measurement, and to assess agreement with convolutional neural networks (CNNs) trained using that data. Sixty CT scans of 50 patients with bowel obstruction from March to June 2022 were retrospectively included and partitioned into training and test data sets. An eye tracking device was used to record 3-dimensional coordinates within the scans, while a radiologist cast their gaze at the centerline of the bowel, and adjusted the size of a superimposed ROI to approximate the diameter of the bowel. For each scan, 59.4 ± 15.1 segments, 847.9 ± 228.1 gaze locations, and 5.8 ± 1.2 m of bowel were recorded. 2d and 3d CNNs were trained using this data to predict bowel segmentation and diameter maps from the CT scans. For comparisons between two repetitions of visual annotation, CNN predictions, and manual annotations, Dice scores for bowel segmentation ranged from 0.69 ± 0.17 to 0.81 ± 0.04 and intraclass correlations [95% CI] for diameter measurement ranged from 0.672 [0.490-0.782] to 0.940 [0.933-0.947]. Thus, visual image annotation is a promising technique for training CNNs to perform bowel segmentation and diameter measurement in CT scans of patients with bowel obstruction.

Self-expanding metal stents versus decompression tubes as a bridge to surgery for patients with obstruction caused by colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Using self-expanding metal stents (SEMS) and decompression tubes (DT) as a bridge-to-surgery (BTS) treatment may avoid emergency operations for patients with colorectal cancer-caused obstructions. This study aimed to evaluate the efficacy and safety of the two approaches.

METHODS

We systematically retrieved literature from January 1, 2000, to May 30, 2023, from the PubMed, Embase, Web of Science, SinoMed, Wanfang Data, Chinese National Knowledge Infrastructure, and Cochrane Central Register of Clinical Trials databases. Randomized controlled trials (RCTs) or cohort studies of SEMS versus DT as BTS in colorectal cancer obstruction were selected. Risks of bias were assessed for RCTs and cohort studies using the Cochrane Risk of Bias tool version 2 and Risk of Bias in Nonrandomized Studies of Interventions. Certainty of evidence was determined using the Graded Recommendation Assessment. Odds ratio (OR), mean difference (MD), and 95% confidence interval (95% CI) were used to analyze measurement data.

RESULTS

We included eight RCTs and eighteen cohort studies involving 2,061 patients (SEMS, 1,044; DT, 1,017). Pooled RCT and cohort data indicated the SEMS group had a significantly higher clinical success rate than the DT group (OR = 1.99, 95% CI 1.04, 3.81, P = 0.04), but no significant difference regarding technical success (OR = 1.29, 95% CI 0.56, 2.96, P = 0.55). SEMS had a shorter postoperative length of hospital stays (MD = - 4.47, 95% CI - 6.26, - 2.69, P < 0.00001), a lower rates of operation-related abdominal pain (OR = 0.16, 95% CI 0.05, 0.50, P = 0.002), intraoperative bleeding (MD = - 37.67, 95% CI - 62.73, - 12.60, P = 0.003), stoma creation (OR = 0.41, 95% CI 0.23, 0.73, P = 0.002) and long-term tumor recurrence rate than DT (OR = 0.47, 95% CI 0.22, 0.99, P = 0.05).

CONCLUSION

SEMS and DT are both safe as BTS to avoid emergency surgery for patients with colorectal cancer obstruction. SEMS is preferable because of higher clinical success rates, lower rates of operation-related abdominal pain, intraoperative bleeding, stoma creation, and long-term tumor recurrence, as well as a shorter postoperative length of hospital stays. Trial registration CRD42022365951 .

A case report of colonic Ameboma mimicking colon cancer in an immunocompromised patient

INTRODUCTION AND IMPORTANCE

Entamoeba histolytica is an anaerobic protozoan. It infects humans causing Amoebiasis. Most infections are asymptomatic; however, clinical manifestations include intestinal or extraintestinal. In rare instances, patients can present with Ameboma: a mass of granulation tissue consisting of a core of inflammation with peripheral fibrosis related to chronic amoebic infection usually found in the cecum/ascending colon.

PRESENTATION OF CASE

A 50-year-old patient presented with signs and symptoms of bowel obstruction. He had raised inflammatory markers and was HIV positive on treatment and virally suppressed. At laparotomy a hepatic flexure stricture with desmoid reaction, and wall thickening with induration at the mesenteric border of mid-transverse colon was found, with disseminated nodular disease. Histology confirmed entamoeba histolytica infection.

DISCUSSION

The parasite exists in two forms: a cyst stage and a trophozoite stage: the form causing invasive disease. The presentation of intestinal amoebiasis ranges from an asymptomatic carrier state, colitis, to abscess formation and bowel perforation The management principles: to eliminate the invading trophozoites and eradicate the organism's intestinal carriage and manage complications such as obstruction, fulminant colitis, or toxic megacolon with surgery.

CONCLUSION

This case identifies a rare cause of bowel obstruction in a patient without a travel history. Even with the lack of significant risk factors other than HIV, clinicians should be aware of the infective causes of colonic mass/stricture outside of malignant causes. Entamoeba histolytica is an infection of impoverished communities in developing countries, it should remain high on our differential for tumour-like granulation tissue in the colon.

Benefits of laparoscopy-assisted ileostomy in colorectal cancer patients with bowel obstruction

BACKGROUND

Ileostomies are commonly performed after colon and rectal surgeries. Laparoscopy-assisted ileostomy with adhesion lysis may have potential benefits over conventional open surgery.

AIM

To compare the outcomes of laparoscopy-assisted and conventional ileostomies.

METHODS

Data from 48 consecutive patients who underwent ileostomy at our institution between May 2021 and May 2022 were retrospectively analyzed. The groups comprised 26 and 22 patients who underwent laparoscopic ileostomy (laparoscopic group) and conventional ileostomy (conventional group), respectively, performed by a single surgeon. Patient demographics, operative characteristics, postoperative outcomes, and 30-d morbidities and mortality rates were analyzed.

RESULTS

The two groups had comparable mean ages, sex distributions, American Society of Anesthesiologists scores, and body mass indices. However, the laparoscopic group showed similar operative time, better visualization for adhesion lysis, and lower visual analog scale scores than the conventional group.

CONCLUSION

Laparoscopy-assisted ileostomy is a safe and efficient method that produces lower visual analog scale scores, better intraoperative visualization for effective adhesion lysis, and similar operative time compared with conventional ileostomy.

Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication

INTRODUCTION

Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions.

METHODS

In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall.

RESULTS

Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function.

CONCLUSION

Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.

Bowel obstruction in body-packing: A case report and literature review

INTRODUCTION AND IMPORTANCE

The body packer swallows or embeds drugs in body cavities in a purposeful way. Packets usually contain of opium, cocaine, cannabis and amphetamines. The significant complications of body packing usually are symptoms of drug toxicity due to leaking or ruptured packets or symptoms of ingesting relatively large foreign bodies. Herein, we present a case of heroin body-packing that resulted in subsequent bowel obstruction.

CASE PRESENTATION

A 30-year-old male, who was brought from the prison to the emergency department, complained of abdominal pain. After the absence of intoxication symptoms and insignificant plain abdominal radiograph results, abdominal computed tomography (CT) scan revealed the presence of ingested packets in the stomach as well as in the patient's small intestine. Therefore, the decision of surgery was immediately made for the patient, and during the surgery, the drug packets were entirely removed. The patient was discharged in good general condition three days after his surgery.

CLINICAL DISCUSSION

Body packers are in considerable risk as rupture of packet inside the body and risk of obstruction that both of them may be fatal. Patients should be monitored for complications, possible early treatment, and removal or assistance in expulsion drug packets from the body. Initially on plain abdominal radiographs, classic findings suggest the presence of drug packets.

CONCLUSION

In case of an inconclusive plain abdominal radiograph, further investigation with CT is indicated, with an almost 100 % sensitivity. For symptomatic patients, bowel obstruction and acute drug toxicity are the two most common indications for surgical intervention.

Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction

INTRODUCTION

Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management.

MATERIALS AND METHODS

A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO.

RESULTS

Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission.

CONCLUSIONS

Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Percutaneous Image-Guided Transesophageal Long Intestinal Tube Placement for Palliative Decompression in Advanced Cancer Patients with Unresectable Malignant Small Bowel Obstruction

PURPOSE

To assess the safety and efficacy of long intestinal tube placement following percutaneous image-guided esophagostomy for palliative decompression of incurable malignant small bowel obstruction.

MATERIALS AND METHODS

Between January 2013 and June 2022, a single-institution retrospective study was conducted to examine patients undergoing percutaneous transesophageal intestinal intubation for an occluded intestinal segment. Patients' baseline characteristics, procedural details, and clinical courses were reviewed. Severe complications were defined as those with ≥ 4 grade according to the CIRSE classification.

RESULTS

This study included 73 patients (mean age, 57.7 years) who underwent 75 procedures. All bowel obstructions were caused by peritoneal carcinomatosis or similar disease, which precluded transgastric access in almost 50% of the patients due to massive cancerous ascites (n = 28), diffuse gastric involvement (n = 5), or omental dissemination in front of the stomach (n = 3). Technical success (appropriate tube positioning) was achieved in 98.7% (74/75) of procedures. The cumulative 1-month overall survival and sustained clinical success (adequate bowel decompression) rates were estimated at 86.8% and 88%, respectively, using Kaplan-Meier analysis. At the median survival of 70 days, the disease progression required other gastrointestinal interventions, including additional tube insertion, repositioning, or venting enterostomy in 16 patients (21.9%). The severe complication rate was 4% (3/75); one patient aspirated to death due to tube clogging and two encountered fatal perforation of isolated intestinal loops developing far beyond the tip of the indwelling tube.

CONCLUSION

Percutaneous image-guided transesophageal intestinal intubation achieves feasible bowel decompression as palliative care in advanced cancer patients.

LEVEL OF EVIDENCE

Level 4, Case Series.

Understanding the spectrum of malignant bowel obstructions in gynecologic cancers and the application of the Henry score

OBJECTIVE

Malignancy-associated bowel obstruction (MBO) is a potential sequela of advanced gynecologic cancers, adversely impacting both quality of life and prognosis. The Henry score (HS) was developed in a gastrointestinal cancer-predominant population to predict 30-day mortality. We aim to characterize MBO in gynecologic cancers and assess the utility of the HS in this population.

METHODS

This is a retrospective review of patients with gynecologic cancer and MBO admitted to a single academic institution from 2016 to 2021. The primary outcome is to characterize malignant small and large bowel obstructions in primary and recurrent gynecologic cancer using readmission and mortality rates. Secondary outcomes are to assess the Henry score and inpatient MBO management.

RESULTS

179 patients totaling 269 were admissions identified, most commonly affecting patients with ovarian cancer. The majority (89.4%) were managed non-operatively while 10.6% were managed surgically. No significant differences were observed in survival for medical versus surgical management. Thirty-day mortality increased with increasing HS (0%, 0-1; 14.3%, 2-3; 40.9%, 4-5). Over 1/3 (34.1%) of patients were readmitted for recurrent or persistent MBO. Goals of care conversations were documented for 56.8% of patients with HS 4-5. Mortality rates across the entire cohort were high-20.1% and 60.9% had died by 1 and 6 months, respectively.

CONCLUSIONS

Survival rates following an initial MBO admission are poor. The HS has utility in gynecologic cancers for assessing 30-day mortality and may be a useful tool to aid in the management and counseling of patients with gynecologic cancer and MBO.

Transverse colon volvulus presenting as bowel obstruction, atelectasis, and displacement of the right lobe of the liver into the left upper abdominal quadrant: a case report

BACKGROUND

Transverse colon volvulus is an uncommon cause of intestinal obstruction. It is a surgical emergency that can lead to bowel infarction, peritonitis, and death.

CASE PRESENTATION

We report a case of transverse colon volvulus in a 35-year-old Congolese immigrant man who had a rare presentation with features of intestinal obstruction associated with right lung collapse and left mediastinal shift.

CONCLUSION

This case is unusual because it presented with respiratory features that mimicked a pneumothorax in addition to features of intestinal obstruction. The use of point-of-care lung ultrasound was helpful in ruling out a pneumothorax, and this could help avoid situations such as unintentional chest drain insertions by other professionals who may encounter a similar case. Because transverse colon volvulus is rare, a high level of suspicion and awareness is required to make an accurate diagnosis.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database.

METHODS

We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation.

RESULTS

In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis.

CONCLUSION

SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Retrospective Comparative Study.

Outcomes and survival in patients with advanced intestinal neuroendocrine tumours on home parenteral nutrition, an international multicentre retrospective cohort study

BACKGROUND AND AIMS

Only limited information is available on the use of home parenteral nutrition (HPN) in patients with advanced neuroendocrine tumours (NETs) causing intestinal failure (IF). This study aims to report the outcomes of the explore the use of HPN in this patient cohort, in the largest case series to date.

METHODS

A retrospective study in the United Kingdom and the Netherlands was performed, using the UK National British Artificial Nutrition Survey (BANS) and local databases in the Netherlands. Data regarding age, sex, NET grading, staging, treatment, HPN characteristics and survival outcomes were collected.

RESULTS

Data were collected on 41 patients (n = 18 males, 44%) with a median age of 65. Most primary tumours were in the small bowel (n = 35, 85%). The NETs were Grade 1 (n = 16, 39%), Grade 2 (n = 7, 17%), Grade 3 (n = 1, 2%). In 28 patients (n = 68%) there was stage IV disease with metastases located in the peritoneum, mesentery and or liver. There were two indications for HPN; short bowel syndrome (n = 27, 66%) and inoperable malignant bowel obstruction (n = 14, 34%). The median period on HPN was 11 months (interquartile range 4-25 months). 11 patients were still alive and receiving HPN treatment after 2 years, and 6 patients after 3 years. Six patients (22%) with short bowel syndrome (SBS) could be weaned from HPN. There was a statistically significant improved survival for patients with short bowel syndrome (median 24 months) compared to inoperable malignant bowel obstruction (median 7 months). The catheter-related bloodstream infection rate was comparable to other HPN patient cohorts at 1.0 per 1000 catheter days.

CONCLUSION

This study shows that HPN can be used safely in patients with NET and IF to increase survival beyond that reasonably expected in the context of either short bowel syndrome or inoperable malignant bowel obstruction. Patients with short bowel syndrome are most likely to benefit. Further prospective studies are necessary to validate survival benefits and to demonstrate the effect of HPN on quality of life.

The Rapunzel syndrome: a hairy tale

BACKGROUND

Trichobezoars are a rare medical condition, often requiring a surgical approach and commonly associated with an underlying psychiatric disorder. The Rapunzel syndrome is a rare variant of trichobezoar in the stomach extending from the stomach into the small intestine causing a bowel obstruction.

CASE PRESENTATION

In this case report, the clinical presentation, diagnostic approach, and surgical removal of a large-size bezoar (Rapunzel syndrome) in a young and otherwise healthy female is described. Different surgical strategies are discussed. Psychiatric exploration gives an insight on development of trichophagia ultimately leading to the forming of the trichobezoar.

CONCLUSIONS

This brief report sheds light on the importance of the collective mind of a multidisciplinary team preventing a potentially fatal outcome.

Ileostomy volvulus as an underreported problem causing small bowel obstruction in patients living with ostomy: a case report and literature review

Purpose

Ileostomy volvulus is a rare cause of small bowel obstruction. We present an unusual case of ileostomy volvulus without the presence of adhesions. Additionally, a systematic literature review was performed to collate the current literature on the causes, diagnosis, treatment, and preventative measures of ileostomy-related small bowel obstruction.

Methods

PubMed (Medline), Embase, Google Scholar, Scopus, and Cochrane CENTRAL were searched from their inception up to August 2022. This study adhered to the PRISMA guidelines and was registered on PROSPERO. The primary outcomes included patients' demographics, imaging modality, indication for initial surgery, type and configuration of stoma, surgical treatment, and recurrence of volvulus. The quality of included studies was assessed using the Murad tool. Written informed consent was obtained from the patient.

Results

Seven studies were included, comprising 967 patients. Stoma outlet obstruction (SOO) was reported in all 159 patients, and 12 had ileostomy volvulus as the cause. A majority of patients had loop ostomies for ileostomy volvulus. No complications or mortality were reported in the included studies, and half of the included studies were deemed to be of good quality.

Conclusion

This case demonstrates the need for high clinical suspicion of SOO in patients with loop ileostomy, and rapid management should be undertaken. Whilst loop ileostomies, increased rectus abdominal muscle thickness, and lower preoperative total glucocorticoid dosage are associated with SOO, large-scale retrospective studies are needed to validate our findings.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

Early Onset Outlet Obstruction of a Temporary Diverting Loop Ileostomy Secondary to Urinary Retention

A mechanical obstruction is not a physiological entity, and when it occurs within the 30-day postoperative period, it is called an early postoperative small bowel obstruction. Kinking of small bowel segments at the ileostomy outlet secondary to a distended bladder is an unusual source of early postoperative small bowel obstruction. A 36-year-old female underwent a redo J-Pouch surgery and creation of loop ileostomy after pouch failure related to recurrent small bowel obstruction and perianal fistulae. Her foley catheter was removed on postoperative day 3 and she passed a trial of void test. On postoperative day 6, the abdomen became progressively more distended. Computerized tomography (CT) imaging with IV contrast showed small bowel distension extending to the midline anterior to the urinary bladder where it demonstrated a narrowed lumen. These findings were thought to be the cause of small bowel obstruction at this level before the ileostomy. Immediately after CT, a foley catheter was applied with which 2 L of urine was removed, and consequently, gas and stool were observed in the ostomy soon thereafter. Although rare, urinary retention may cause intestinal obstruction, especially in the presence of a loop ileostomy in close proximity.

Intraductal papillary mucinous neoplasm mimicking a duodenal tumor

Intraductal papillary mucinous neoplasms of the pancreas are characterized by ductal dilatation, mucus secretion, and intraductal papillary growth. Intraductal papillary mucinous neoplasms can cause fistulation and extend to adjacent organs. However, they rarely present as large mass in the small bowel that causes bowel obstruction. Herein, we describe a case of intraductal papillary mucinous neoplasm that protruded into the duodenal lumen through the ampulla of Vater, presented as a large duodenal tumor, and developed duodenal obstruction. A 78-year-old woman was admitted to the emergency department with a 2-day history of vomiting and epigastric pain and 2 kg weight-loss in 2 months. Esophagogastroduodenoscopy showed a duodenal mass; however, the endoscope could not pass further, and visualization of the entire tumor was impossible. Computed tomography and magnetic resonance imaging revealed a heterogeneous enhancing mass measuring 8 cm in the second portion of the duodenum, which continued further as an intraductal mass of the pancreas. The main pancreatic duct was dilated, and the parenchyma was atrophied. The biopsy showed a well-differentiated adenocarcinoma and an intact overlying duodenal mucosa. Surgical option of treatment was offered to the patient; however, she refused it due to her advanced age and personal religious beliefs. Thus, we conclude that the experience and knowledge gathered through this patient regarding intraductal papillary mucinous neoplasms could provide further understanding of this disease and evolve subsequent patient care.

Rapunzel syndrome: An infrequent cause of paediatric mechanical occlusion

Despite numerous cases of trichobezoars reported in the literature, few Rapunzel syndromes have been described. Rapunzel syndrome is a rare case of bowel obstruction resulting from hair ingestion (trichobezoar). The obstruction can occur in any level of the intestinal tract. This syndrome is usually reported in patients affected by trichotillomania and trichophagia. We reported a case of Rapunzel syndrome in a 5-year-old girl diagnosed on an abdominal computed tomography scan and confirmed during surgery.

A Patient with Crohn's Disease Who Gave Birth Despite Sigmoid Volvulus, Venous Thrombosis, Nontraumatic Fracture of the Rib, and Sepsis during Pregnancy

The patient was a woman in her 40s who was diagnosed with Crohn's disease (CD) of the large and small intestines in 1996. In 2005, she was referred to our hospital for treatment. We treated her for 17 years with corticosteroids, biologics, immunosuppressive agents, 5-aminosalicylic acid, and nutrition care. However, her Crohn's Disease Activity Index remained between 200 and 250, indicating refractory CD. During her medical treatment, the patient also underwent 3 operations. One year ago, the patient became pregnant through in vitro fertilization. Even after pregnancy was confirmed, the patient continued her treatment for refractory CD with ustekinumab, granulocyte apheresis, and budesonide. Nonetheless, her CD was highly active during pregnancy, and she experienced various complications: sigmoid volvulus at gestational week 15, venous thrombosis at gestational week 17, nontraumatic rib fracture due to fetal movement at gestational week 32, and sepsis from central venous catheter infection at gestational week 37. At gestational week 38, the patient gave birth by emergency cesarian delivery. This paper reports details of the case in which delivery was achieved after various complications were overcome and discusses previous relevant reports.

Understanding the Presentation of Terminal Ileitis

Our patient is a 47-year-old African American female with a past medical history of recurrent episodes of small bowel obstruction. She presented to the emergency department with symptoms of nausea, vomiting, and abdominal pain. Upon further evaluation, imaging showed obstruction at the terminal ileum. Based on the holistic clinical presentation, we initially thought that this patient was experiencing symptoms of early onset Crohn's disease. Gastroenterology evaluated the patient and was uncertain of the formal diagnosis. Colonoscopy and biopsy were not pathognomonic for Crohn's disease, suggesting that there may be a component of terminal ileitis or another inflammatory bowel disease process. This case exemplifies the degree to which these inflammatory bowel disease processes frequently overlap.

Outcome of Tapering Enteroplasty in Managing Jejunoileal Atresia

Background

Jejunoileal atresia (JIA) represents a common cause of neonatal bowel obstruction. There is a discrepancy between the diameters of the proximal and the distal bowel loops and this is managed with excision or tapering of the dilated proximal bowel loop. We aim primarily to evaluate the outcome of tapering enteroplasty (TE) in managing JIA and secondarily to compare the outcome of TE to non-TE.

Materials and Methods

A retrospective analysis of records of all neonatal admissions with JIA from January 2017 to December 2018 at a tertiary university children's hospital. Type and location of atresia, time to full enteral feeds, length of stay (LOS), complications, and outcome were assessed in TE and non-TE groups.

Results

Forty-one patients were included in the study; 29 (70.7%) cases had jejunal atresia and 12 (29.3%) had ileal atresia. Seventeen (41.4%) patients had TE. The median days to full feeds was 19; 28 in the TE group versus 16 in the non-TE group (P = 0.022). Four (9.7%) cases needed a re-exploration because of failure to start feeds; all in the non-TE group. The median LOS was 33 days for TE versus 22 days for non-TE (P = 0.101). Twenty-one cases (51.2%) developed a wound infection and showed a significantly longer median LOS of 29.5 versus 19 days (P = 0.019). Mortality was 7 (17.1%).

Conclusions

TE did not show a superior outcome when compared to resection of the dilated bowel. It was associated with longer time to reach full enteral nutrition and longer LOS.

Intussusception of the cecum due to the acute appendicitis: A case report

Introduction and importance

Intussusception of the cecum due to acute appendicitis is rare condition.

Presentation of case

A 17-year-old male patient presented to our hospital with a chief complaint of right lower abdominal pain, which had lasted for two days. Computed tomography (CT) revealed a “target sign” from the cecum to the ascending colon, leading to a diagnosis of cecocolic intussusception. Colonoscopy revealed an erythematous, edematous, and internally distorted cecum in the ascending colon, which was difficult to repair with air insufflation. Laparoscopic surgery was performed to remove the bowel obstruction. Repositioning of the invaginated cecum was difficult due to the presence of a hard and edematous colic wall. Therefore, laparoscopic ileocecal resection was performed to release the obstruction. The pathological diagnosis was appendicitis and abscess within the cecum wall, with no malignant findings.

Discussion

In our case, intussusception was considered to have caused thickening of the intestinal wall of the cecum due to inflammation of the appendix, and the thickened area became the leading point.

Conclusion

Considering that malignancy is a frequent leading point in adult patients with intussusception, a preoperative endoscopic examination is important for minimizing bowel resection.

•

Most cases of intussusception outside of childhood are caused by tumors, but inflammation of the appendix or cecum can be a cause.

•

If malignancy is not the cause of intussusception, bowel resection can be minimized.

•

In order to determine the appropriate extent of resection, an accurate preoperative diagnosis is necessary, keeping in mind the possibility that appendicitis or inflammatory changes in the cecum may be the leading point.

Predictors of Small Bowel Obstruction Post-Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal malignancies carries considerable morbidity; however, the significance of postoperative small bowel obstruction (SBO) is not well defined. We aim to identify predictors for post-CRS/HIPEC SBO and their oncologic associations.

METHODS

A retrospective review was conducted of all CRS/HIPEC cases performed at a surgical oncology center (2013-2018). Patient demographics, tumor characteristics, perioperative factors, and province-wide hospital readmissions were analyzed. Descriptive statistics were used for baseline characteristics, multivariate logistic regression for predictors of SBO at 1 year, and Kaplan-Meier method with log-rank test for survival analysis.

RESULTS

A total of n = 97 CRS/HIPEC procedures were performed for diagnoses of low-grade appendiceal mucinous neoplasm (44%), high-grade appendiceal adenocarcinoma (8%), colorectal adenocarcinoma (34%), and mesothelioma (9%). The median peritoneal carcinomatosis index (PCI) score was 16. Cumulative incidence of post-CRS/HIPEC SBO readmission was 24% at 1 year and 38% at 2 and 3 years. Of 29 patients readmitted with SBO, 14 (48%) had more than one readmission for SBO, and nine surgeries were performed for obstruction. Multivariate regression identified significant independent predictors of SBO within 1-year post-CRS/HIPEC as high-grade appendiceal or colorectal primaries (odds ratio [OR] 4.58, p = 0.02) and PCI ≥ 20 (OR 3.27, p = 0.05). Overall survival (OS) was worse in patients readmitted with SBO within 1 year compared to those without (3-year OS 58% vs. 75%, p = 0.017).

CONCLUSION

SBO is the most common readmission diagnosis post-CRS/HIPEC and is associated with worse survival. High-grade appendiceal and colorectal primary tumors and PCI ≥ 20 are predictors for SBO.