Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

Unintentional Plastic Blister Ingestion Leading to Intestinal Perforation: A Report of Two Cases

BACKGROUND Unintentional medication-blister ingestion is rare but frequently leads to intestinal perforation. The diagnosis of intestinal perforation following blister ingestion is often delayed because of an unreliable history and nonspecific clinical presentation. The purpose of this case report is to raise awareness about a rare but difficult diagnosis and its importance in avoiding potentially fatal events. CASE REPORT Herein, we describe successful cases of surgical and endoscopic removal after blister ingestion. The first case was that of a polymorbid 75-year-old man who presented with acute onset of abdominal pain in the right upper quadrant and epigastric regions. No indication of the cause was observed on initial computed tomography (CT). The patient developed an acute abdomen, and emergency laparotomy was performed, during which 2 small perforations were observed in the terminal ileum, and an empty tablet blister was retrieved. The second patient was a 55-year-old man who presented with a considerable lack of awareness. On the initial CT, a subdural hematoma, aspiration, and an unidentified foreign body in the stomach were observed. Gastroscopy was performed after emergency craniotomy. In addition to the initial foreign body, a second object, which had gone unnoticed on the initial CT, was found and removed from the esophagus. CONCLUSIONS With an increased risk of perforation and difficult clinical and radiological diagnoses, prophylactic measures and special awareness of high-risk patients are particularly important.

Outcomes for pediatric acute lymphoblastic leukemia patients with intestinal perforation

OBJECTIVES

Intestinal perforation during acute lymphoblastic leukemia (ALL) treatment in children is rare, but represents a severe complication with possible long-term consequences. In this study, we aim to provide an overview of the epidemiology and clinical characteristics of these patients; analyze surgical pathology findings for possible causes; and determine its impact on patients' therapy, nutritional status, and outcome.

STUDY DESIGN

Historical chart review from January 2000 to October 2020 of children with ALL and intestinal perforation during therapy diagnosed at a single institution. Data collected included patient demographics, anthropometric measurements, ALL characteristics, diagnosis and surgery of intestinal perforation, pathology, adjustments to treatment plan, and outcome.

RESULTS

Of 1840 ALL patients, 13 (0.7%) presented with intestinal perforation during treatment. Perforation occurred during induction phase in 91% of cases. Most patients underwent laparotomy with ostomy creation, and no patient died from the intervention or developed malnutrition. Pathology mainly revealed inflammation at the perforation site. Two samples showed leukemic infiltration and presence of microorganisms. Patients were able to resume ALL therapy in all cases. A total of eight patients (73%) were in first remission at last follow-up, with a median follow-up time of 42 months (interquartile range = 42).

CONCLUSION

Early surgical intervention is a successful treatment approach for intestinal perforation in ALL patients. There is a clear predilection for induction phase in the occurrence of intestinal perforation in ALL patients. No specific cause was identified. Patients can receive bridging chemotherapy during surgical recovery and proceed with their treatment without apparent impact on outcome.

Comparison of preoperative and intraoperative surgeon diagnosis and pathologic findings in spontaneous intestinal perforation vs necrotizing enterocolitis

OBJECTIVE

To investigate the accuracy of preoperative and intraoperative diagnosis via comparison to pathologic diagnosis in spontaneous intestinal perforation (SIP) vs. necrotizing enterocolitis (NEC).

STUDY DESIGN

A retrospective review of neonates <1500 g treated for pneumoperitoneum between 07/2004-09/2022 was conducted. Patients treated for NEC medically prior to diagnosis and those treated with drain only were excluded. Fleiss' Kappa analysis assessed agreement between all three diagnoses: preoperative, intraoperative, and pathologic.

RESULT

Overall, 125 patients were included with mean birthweight 834.2 g (SD:259.2) and mean gestational age 25.8 weeks (SD:2.2). Preoperative and intraoperative diagnoses agreed in 90.3%, intraoperative and pathologic agreed in 71.1%, and preoperative and pathologic agreed in 75.2% of patients. Fleiss' Kappa was 0.55 (95% CI:0.43,0.68), indicating moderate agreement between the three diagnoses.

CONCLUSION

Our study shows moderate agreement between preoperative, intraoperative, and pathologic diagnoses. Further studies investigating the clinical characteristics of SIP and NEC are needed to improve diagnostic accuracy and management.

Gastrointestinal perforation associated with bevacizumab in metastatic colorectal cancer

OBJECTIVE

To investigate the risk factors for gastrointestinal perforation in metastatic colorectal cancer patients receiving bevacizumab.

METHODS

We retrospectively reviewed 217 patients with metastatic colorectal cancer receiving bevacizumab to investigate the risk factors for gastrointestinal perforation. Three patients occurred intestinal perforation after receiving bevacizumab. We analyzed the clinical characteristics of three patients with intestinal perforation.

RESULTS

All patients receiving bevacizumab. Three of 217 patients occurred intestinal perforation after receiving bevacizumab. Patient no. 1 was 70 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation and ultimately died after receiving bevacizumab. Patient no. 2 was 59 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation after receiving bevacizumab, and recovered smoothly after symptomatic treatment. Patient no. 3 was 60 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation and ultimately died after receiving bevacizumab.

CONCLUSIONS

Patients with advanced colorectal cancer receiving bevacizumab are at risk of gastrointestinal perforation. The patient's age, gender and history of bowel obstruction may be associated with gastrointestinal perforation.

Acute abdominal perforation as a clinical presentation of coeliac disease

Intestinal perforation is described in coeliac disease in the setting of refractoriness or Enteropathy-Associated T-cell Lymphoma (EATL). We report the case of a man with untreated coeliac disease who presented intestinal perforation and was diagnosed with EATL over one year later.

Jejunal perforation and septic abdomen resulting from a choristoma in a dog

A 4.6-year-old spayed female German shepherd dog was admitted to a specialty hospital emergency service upon referral for suspected gastrointestinal foreign body obstruction. Free abdominal fluid was collected, and results of cytologic evaluation were consistent with a septic abdomen. An abdominal barium study revealed free gas and intraperitoneal barium, along with an obstructive gas pattern within the small bowel. Ultrasonography revealed a full-thickness jejunal perforation. On exploratory laparotomy, the perforation was noted to be located mid-jejunum with no associated mass or foreign material. A resection and anastomosis were completed. Histopathologic evaluation of the affected jejunal tissue showed aberrant gastric glandular epithelium consistent with a gastric choristoma, or heterotopic gastric tissue. Key clinical message: Clinicians should consider gastric glandular choristoma as a differential diagnosis in cases of seemingly idiopathic small intestinal perforation with no known cause (i.e., foreign body penetration, neoplasia, NSAID use), and histopathologic evaluation should always be done to obtain a definitive diagnosis.

Metastatic melanoma causing small intestinal perforation at the jejunojejunostomy after Roux-en-Y gastric bypass: a case report

BACKGROUND

Metastatic melanoma of the small intestine is relatively common, and among affected patients, the proportion with involvement of the small intestine ranges from 35% to 70%. Small intestinal perforation as a primary manifestation of metastatic melanoma is rare. We present the exceptional case of a perforation at the jejunojejunostomy after Roux-en-Y gastric bypass caused by metastatic melanoma.

CASE PRESENTATION

A 59-year-old woman with a history of a laparoscopic Roux-en-Y gastric bypass and toe amputation due to malignant melanoma (stadium IIIC) presented with an acute abdomen. The abdominal computed tomography scan showed a covered perforation at the jejunojejunostomy of the gastric bypass. The patient underwent an urgent surgical exploration revealing massive tumoral invasion of the anastomosis. The tumoral mass and anastomosis were resected and a new jejunojejunostomy was created. Histopathological examination identified the tumor as a malignant melanoma, so the current abdominal lesions were presumed to be metastases. The postoperative course was uneventful and adjuvant immunotherapy was started a week later. One year after surgery she was doing well with maintenance immunotherapy and there was no evidence of recurrent metastatic disease.

CONCLUSION

We report the first case of a perforation at the jejunojejunostomy after Roux-en-Y gastric bypass caused by metastatic melanoma. This exceptional case illustrates that a history of malignant melanoma in case of an acute abdomen should raise suspicion of possible metastatic disease.

Postoperative Outcomes, and Growth and Brain Injury Outcomes in Spontaneous Intestinal Perforation vs Surgical Necrotizing Enterocolitis in Preterm Infants

OBJECTIVE

To compare the clinical outcomes in preterm infants following surgical necrotizing enterocolitis (sNEC) and spontaneous intestinal perforation (SIP).

METHODS

Retro-spective comparison of clinical information in preterm infants with sNEC and SIP admitted between January, 2013 and December 31, 2018. The clinical outcomes were compared in two groups, including postoperative and brain injury detected on brain magnetic resonance imaging (MRI) after clinical and histopathological confirmation of the SIP and the NEC diagnosis.

RESULTS

114 infants had sNEC, and 37 had SIP. Infants with SIP had lower median gestational age [25.1 weeks (23.5, 27.1) vs 26.6 (24.4, 31.0), P=0.03], an earlier mean (SD) age of disease onset [10.1 (11.3) days vs 19.6 (17.9); P<0.001] and lower maternal chorioamnionitis on placental pathology [4 (23.5%) vs 22 (68.8%); P=0.007), received more often Penrose drain therapy (54% vs 33%; P=0.03), had less median (IQR) bowel length loss [3.3 cm (1.72, 4.38) vs 21.4 (9.55, 35.3); P=<0.001] and had more often intact ileocecal valve (91.4% vs 65.7%; P=0.006] compared to those with sNEC. In addition, those with sNEC had lower median (IQR) weight z scores at the time of discharge [-1.88 (-2.80, -1.09) vs -1.14 (-2.22, -0.44); P=0.036] than SIP. There were no significant differences in postoperative ileus, duration of parenteral nutrition, surgical morbidity, length of stay, mortality, white matter, and grey matter injury on brain MRI at term equivalent age in preterm infants with SIP and sNEC.

CONCLUSION

In our cohort, preterm infants with SIP and sNEC did not show significant differences in postoperative morbidity and brain MRI abnormalities at term equivalent age. sNEC had lower discharge weight z scores. Larger prospective studies are needed for confirmation of these findings.

Spontaneous rectosigmoid perforation at the watershed area of the Sudeck point in an apparently healthy toddler boy: a case report

BACKGROUND

Spontaneous colon perforation can be classified into stercoral and idiopathic. Stercoral type is associated with chronic constipation, thus it is rare in infants and children. The idiopathic type is sporadic and could occur at any age. Delay in diagnosing or treating idiopathic colon perforation is associated with high mortality and morbidity rates. There are few studies on rectal perforation related to other etiologies or past the neonatal period, and their effect on disease onset and prognosis are unknown.

CASE PRESENTATION

We report on a case of 2-year-and-5-month-old Oromo boy who presented with fever, diarrhea, vomiting, and progressive abdominal pain of 5-day duration. The boy underwent an exploratory laparotomy for suspected peritonitis and there was a single perforation of approximately 2.0 cm size in the anterior part of the upper one-third of rectum. The perforated rectum was repaired primarily and sigmoid divided diversion colostomy was carried out.

CONCLUSION

It is important to be aware of idiopathic colon perforation in children, a rare but dangerous condition with high mortality and morbidity in cases of delayed diagnosis or management. Pediatricians and surgeons should consider colon perforation as a cause in children who present with abdominal distention and a history of diarrhea for more than 5 days.

Bowel perforation associated with Cushing's disease: a case report with literature review

Although rare, endogenous hypercortisolemia, including Cushing's disease (CD), is known to cause bowel perforation and to mask typical symptoms of bowel perforation, leading to delayed diagnosis. Additionally, elderly patients with CD are considered to be at a higher risk for bowel perforation because intestinal tissue fragility tends to increase in the elderly. Herein, we describe a rare case in which a young adult patient with CD was diagnosed with bowel perforation associated with CD following severe abdominal pain. A 24-year-old Japanese man was admitted to the hospital for the evaluation of ACTH-dependent Cushing's syndrome. He suddenly complained of severe abdominal pain on the 8th day of hospitalization. Computed tomography revealed free air around the sigmoid colon. The patient was diagnosed with bowel perforation, underwent emergency surgery, and was saved. He was subsequently diagnosed with CD, and the pituitary adenoma was resected transsphenoidally. To date, eight cases of bowel perforation due to CD had been reported, with a median age of 61 years at the time of bowel perforation. Hypokalemia was detected in half of the patients, and all had a history of diverticular disease. Nevertheless, not many patients complained of peritoneal irritation. In conclusion, this is the youngest reported case with bowel perforation due to CD and the first report of bowel perforation in a patient without a history of diverticular disease. Bowel perforation may occur in patients with CD, irrespective of age and the presence of hypokalemia, diverticular disease, or peritoneal irritation.

Case report: a case report and literature analysis on intestinal tuberculosis intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula

BACKGROUND

Intestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine. Due to the nonspecific clinical presentation, it is stressed that intestinal perforation complicates umbilical intestinal fistula and bladder ileal fistula is very rare and extremely difficult to be diagnosed. It is significant to identify the disease and take urgent intervene in the early stage.

CASE PRESENTATION

An 18-month-old boy patient presented with abdominal pain. Abdominal CT suggested abscess formation in the right lower abdomen and pelvis. The patient underwent resection of necrotic and stenotic intestinal segments with the creation of an ileostomy, cystostomy and vesicoureteral fistula repair for the presence of intestinal perforation complicated by vesicoureteral fistula and umbilical enterocutaneous fistula. Histopathology confirmed the intestinal tuberculosis. The patient was discharged successfully after 11 days post anti-tuberculosis treatment.

CONCLUSION

Our case report here is a rare case of umbilical intestinal fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. The purpose of this report is to make the surgical community aware of atypical presentations of intestinal tuberculosis. If our peers encounter the similar situation, they can be prepared for corresponding diagnosis and treatment.

Intestinal Behcet’s syndrome with an unusual complication bladder-intestines fistula and urinary tract infections—A case report

A 33-year-old male patient with a 17-year Behcet’s syndrome history showed abdominal pain and fever symptoms. The abdominal CT was suggestive of an acute ileocecal intestinal perforation. In addition, the symptoms disappeared after the conservative treatment. Some related examinations, including capsule endoscopy, were performed to explain the phenomenon of the food residue urine. These results indicated the intestine-urinary tract fistula formation, supposed to be the outcome of intestinal Behcet’s syndrome perforation. This is a rare case of intestinal Behcet’s syndrome with abdominal symptoms as the main manifestation. It was complicated by entero-urinary fistula formation and urinary tract infections. Now, we report this story to emphasize that capsule endoscopy is conducive to the diagnosis and assessment of the intestinal Behcet’s syndrome; moreover, anti-inflammatory treatment including biological agents is effective to relieve the disease at the acute stage in addition to surgical methods.

Development of an enterocutaneous fistula from an intestinal perforation in a patient with autosomal dominant polycystic kidney disease

We herein report a case of enterocutaneous fistula in a patient with autosomal dominant polycystic kidney disease (ADPKD). A 37-year-old Japanese man was admitted to our hospital. Three months prior to transfer to our hospital, he developed intense flank pain with gross hematuria. His serum creatinine had decreased to 7.8 mg/dL and hemodialysis was started, but gross hematuria persisted and he developed hypotension. Upon admission, plain chest radiography did not reveal any free air, but computed tomography (CT) showed generalized ventral subcutaneous air from the head to the lower extremities and enlarged kidneys. Enterography showed leakage of contrast medium from the descending colon into the subcutaneous area. C-reactive protein was 23.1 mg/dL. A colostomy was placed in the transverse colon proximal to the perforation, and systemic subcutaneous drainage was performed. The fever subsequently resolved, and the C-reactive protein test became negative. Three months later, renal artery embolization was performed, and 12 months thereafter, CT showed a marked decrease in kidney size. We assume that a markedly enlarged kidney leaded to intestinal perforation, which developed into an enterocutaneous fistula. Consequently, intestinal fluid leaked into the subcutaneous cavity of the abdominal wall and spread systemically, resulting in extensive subcutaneous abscesses.

[Surgical treatment of a patient with tubular colonic duplication complicated by perforation and peritonitis]

We present successful treatment of a patient with tubular colonic duplication complicated by fecal impaction, perforation and fecal peritonitis. This anomaly is usually detected in children younger 2 years old. In adulthood, this diagnosis is of a precedent-setting nature. If the diagnosis was not confirmed in early childhood, the absence of typical clinical picture, long-term course of disease and difficult interpretation of clinical data complicate subsequent verification of congenital anomaly. Only infectious complications and emergency surgery in adults can make a correct diagnosis.

Enterococcus gallinarum group meningitis after transanal migration of the ventriculoperitoneal shunt: a pediatric case report

In the literature, only 11 Enterococcus gallinarum group meningitis has been reported so far. The Enterococcus gallinarum group was shown for the first time in a pediatric patient presenting with meningitis after bowel perforation, a complication of a ventriculoperitoneal shunt. A 30-month-old male patient presented with vomiting and fever, with the ventriculoperitoneal shunt distal catheter protruding from the anal orifice. The patient was diagnosed with intestinal perforation and meningitis. Enterococcus gallinarum group bacterial yield in cerebrospinal fluid culture. A total of 6 weeks of intravenous antibiotic treatment was given in the hospital. After the treatment, the patient was re-ventriculoperitoneal shunt and was discharged. Among the shunt complications, meningitis with intestinal perforation is rare. It should be kept in mind that meningitis in such patients may be caused by very rare microbiological factors such as Enterococcus gallinarum group. Antibiotherapy should be given according to the culture result. Then planning should be made for a permanent shunt.

Coexistence of Colon Perforation and Congenital Lipodystrophy

Lipodystrophy (LD) is an acquired or congenital rare condition consisting of hyperlipidaemia, glucose intolerance/ insulin resistance, and almost complete absence and storage of adipose tissue. Colon perforations can be observed in type 4 congenital LD. Here, we aimed to present a case of sigmoid colon perforation which developed in a young woman with the diagnosis of LD. Extensive purulent peritonitis, significant wall thickening, and oedema in the sigmoid colon were detected during surgical exploration. Anterior resection with end colostomy procedure was then performed. Although bowel perforation has been theoretically reported to occur in LD, the presented case is the first adult patient in the literature. These individuals tend to develop colon perforation as a result of histological changes in their gastrointestinal tract. This situation should always be taken into consideration in order to avoid delay in diagnosis, especially in patients who present with abdominal pain and have a history of LD. Key Words: Intestinal perforation, Congenital lipodystrophy, Peritonitis, Sigmoid colon.

Chronic constipation that resulted in fecal impaction and colon perforation: A case report

RATIONALE

Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ.

PATIENT CONCERNS

A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids.

DIAGNOSIS

An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying.

INTERVENTIONS

Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed.

OUTCOMES

The patient had an uneventful postoperative course and was discharged in good condition.

LESSONS

Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

[Furtive small bowel perforation after blunt abdominal trauma]

A rare case of delayed jejunal perforation is reported, with a time window of approximately five hours. The diagnosis is challenging: there are no proper protocols, planned early physical examination checkups are advised. The forensic medical aspects of the occasional therapeutical delays are remarkable.

Small bowel perforation caused by thermal injury during colonic polypectomy: A case report and literature review

RATIONALE

Iatrogenic gastrointestinal perforation is a known uncommon complication of colonoscopy. The perforation usually occurs in the colon itself. Rarely, colonoscopic procedures can also cause the perforations of the small intestine.

PATIENT CONCERNS AND DIAGNOSES

We describe the case of a 70-year-old man who experienced abdominal pain several hours after electrical polypectomy in the transverse colon. Urgent abdominal computed tomography scans showed a few bubbles on the frontal surface around the liver and a little extraluminal free air in the upper abdomen. Urgent exploratory laparotomy revealed a round perforation with a diameter of approximately 5 mm in the ileum 80 cm proximal to the ileocecal valve, accompanied by the outflow of intestinal contents. A small bowel perforation by thermal injury was diagnosed during colonic polypectomy.

INTERVENTIONS AND OUTCOMES

The ileal perforation was repaired primarily after debridement of the perforation site and abdominal cavity. The patient recovered well after surgery. Histopathological examination of the perforation site demonstrated inflammatory necrosis and infiltration of inflammatory cells.

LESSONS

Small bowel perforation should be considered after colonoscopic procedures although the incidence is exceedingly rare. Urgent exploratory laparotomy is warranted when a visceral perforation is identified after colonoscopy.

Medullary carcinoma of jejunum presenting as perforation peritonitis: A case report

Small intestinal medullary carcinoma (MC) is a newly recognized subclass of small intestinal carcinomas and is an exceptional entity for this site. A search of the literature for similar cases arising in the small intestine revealed only six previously reported cases. Here we present a case of MC arising in the jejunum of a 65-year-old male. The patient presented to the emergency with features of perforation peritonitis with liver metastasis and no known predisposing factors like inflammatory bowel disease and celiac disease. Studies conducted on this tumor's colonic counterpart have shown microsatellite instability (MSI) and B-type Raf kinase (BRAF) mutations; however, few exceptions are known. Also, this subtype of carcinoma is known to have a better prognosis than its other histological subtypes.

A Patient with Acute Abdominal Pain Caused by an Unnoticed Swallowed Toothpick Misdiagnosed as Acute Appendicitis

The differential diagnosis of acute abdominal pain is a challenging task for medical doctors working in the department of gastroenterology. It is clear that acute abdominal pain may be associated with a number of pathologic conditions. We report an unusual case of an unnoticed swallowed wooden toothpick stuck in the ileocecal area of a young man with right lower abdominal pain who was misdiagnosed as acute appendicitis. However, an abdominal computed tomography scan showed an elongated foreign body stuck in the ileocecal area. The elongated foreign body was identified as a wooden toothpick, which was then grasped with a foreign body forceps and successfully removed through colonoscopy. The patient's abdominal pain was significantly relieved within 2 days following treatment. On the basis of the case report, we suggest the importance of abdominal computed tomography scans for the differential diagnosis of acute abdominal pain and highlight the need for extra vigilance in excluding the diagnosis of foreign bodies in the gastrointestinal tract of patients with acute abdominal pain.

Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department?

BACKGROUND

Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery.

OBJECTIVES

To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department.

METHODS

The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts.

RESULTS

Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR.

CONCLUSIONS

MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.

Colonic diverticular perforation by a migrated biliary stent: A case report with literature review

RATIONALE

Plastic endobiliary stents, after endoscopic retrograde cholangiopancreatography, can get spontaneously dislocated from the common bile duct and migrate intothe distal bowel. Most migrated biliary stents are removed with the passing of stool. However, migrated biliary stents can cause bowel perforation, albeit rarely, and surgical intervention may be required. Recently, we observed a colonic diverticular perforation caused by a migrated biliary stent, and we have reported this case with a review of the literature.

PATIENTS CONCERNS

A 74-year-old man presented with severe right lower quadrant pain after biliary stent insertion 1month ago.

DIAGNOSES

Abdominal computed tomography revealed perforation of the proximal ascending colon by the migrated biliary stent, combined with localized peritonitis.

INTERVENTIONS

Emergency diagnostic laparoscopic examination revealed penetration of the proximal ascending colon by the plastic biliary stent, and right hemicolectomy was performed.

OUTCOMES

On pathological examination, colonic diverticular perforation by the biliary stent was confirmed. The patient was discharged without any additional complications.

LESSONS

Endoscopic retrograde cholangiopancreatography endoscopists must always be cautious of the possibility of stent migration in patients with biliary stents in situ. In cases of biliary stent dislocation from the common bile duct in asymptomatic patients, follow-up with serial, plain abdominal radiographs, and physical examination is needed until confirmation of spontaneous passage through stool. In symptomatic cases suggesting peritonitis, abdominal computed tomography scan confirmation is needed, and early intervention should be considered.

Using machine learning analysis to assist in differentiating between necrotizing enterocolitis and spontaneous intestinal perforation: A novel predictive analytic tool

PURPOSE

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are devastating diseases in preterm neonates, often requiring surgical treatment. Previous studies evaluated outcomes in peritoneal drain placement versus laparotomy, but the accuracy of the presumptive diagnosis remains unknown without bowel visualization. Predictive analytics provide the opportunity to determine the etiology of perforation and guide surgical decision making. The purpose of this investigation was to build and evaluate machine learning models to differentiate NEC and SIP.

METHODS

Neonates who underwent drain placement or laparotomy NEC or SIP were identified and grouped definitively via bowel visualization. Patient characteristics were analyzed using machine learning methodologies, which were optimized through areas under the receiver operating characteristic curve (AUROC). The model was further evaluated using a validation cohort.

RESULTS

40 patients were identified. A random forest model achieved 98% AUROC while a ridge logistic regression model reached 92% AUROC in differentiating diseases. When applying the trained random forest model to the validation cohort, outcomes were correctly predicted.

CONCLUSIONS

This study supports the feasibility of using a novel machine learning model to differentiate between NEC and SIP prior to any intended surgical interventions.

LEVEL OF EVIDENCE

level II TYPE OF STUDY: Clinical Research Paper.

Colon Perforation in a 22-year-old Male with Bartter's Syndrome, Systemic Lupus Erythematosus and Leishmaniasis

Bartter's syndrome (BS) is an inherited renal tubular disorder characterized by hypochloremia, hypokalemia, metabolic alkalosis. Prognosis of Bartter's syndrome depends on the severity of the receptor dysfunction. In many cases the prognosis is good and patients are able to have fairly normal lives. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. The prognosis of SLE is quite variable, depending on the severity of the disease, the clinical course and organs involved. The last decades, there is a marked improvement in patient survival due to earlier diagnosis and treatment. Despite these improvements, patients with SLE still have higher mortality rates ranging from two to five times higher than that of the general population. Leishmaniasis is a disease caused by an intracellular protozoan parasite transmitted by the bite of a female phlebotomine sandfly. We report herein the case of a 22-year-old man with Bartter's syndrome (BS) and Systemic lupus erythematosus (SLE), who was hospitalized in the clinic of internal medicine because of Leishmaniasis. In the third day of his hospitalization the patient underwent Hartmann's operation for perforation located on descending colon. Management of patients with many severe diseases is very difficult for medical professionals.

A Validated Prognostic Model and Nomogram to Predict Early-Onset Complications Leading to Surgery in Patients With Crohn's Disease

BACKGROUND

Predicting aggressive Crohn's disease is crucial for determining therapeutic strategies.

OBJECTIVE

We aimed to develop a prognostic model to predict complications leading to surgery within 1 year after diagnosis of Crohn's disease and to create a nomogram to facilitate clinical decision making.

DESIGN

This is a retrospective study.

SETTING

This study was conducted from January 2012 to December 2016 in a single tertiary IBD center.

PATIENTS

Patients diagnosed with Crohn's disease showing B1 behavior according to the Montreal classification were included.

MAIN OUTCOME MEASURES

We measured the occurrence of complications that would ultimately lead to surgery, including severe GI bleeding (Glasgow-Blatchford score ≥6), stenosis, and perforations, confirmed by endoscopy, CT scan, and/or interventional radiology.

RESULTS

The mean follow-up period was 54 months (SD 13 months). Of the 614 eligible patients, 13.5% developed complications leading to surgery. Multivariable logistic regression revealed the independent predictors of early-onset complications to be age (adjusted odds ratio per 10-year increase in age = 0.4; 95% CI, 0.2-0.8; p = 0.004), disease duration (adjusted odds ratio = 2.7, 95% CI, 1.9-3.8; p < 0.001), perianal disease (adjusted odds ratio = 16.0; 95% CI, 4.3-59.9; p < 0.001), previous surgery (adjusted odds ratio = 3.7; 95% CI, 1.6-8.6; p = 0.003), and extraintestinal manifestations (adjusted odds ratio = 7.6; 95% CI, 2.3-24.9; p = 0.001). The specificity and sensitivity of the prognostic model were 88.3% (95% CI, 84.8%-91.2%) and 96.6% (95% CI, 88.1%-99.6%), and the area under the curve was 0.97 (95% CI, 0.95-0.98). This model was validated with good discrimination and excellent calibration using the Hosmer-Lemeshow goodness-of-fit test. A nomogram was created to facilitate clinical bedside practice.

LIMITATIONS

This was a retrospective design and included a small sample size from 1 center.

CONCLUSIONS

Our validated prognostic model effectively predicted early-onset complications leading to surgery and screened aggressive Crohn's disease, which will enable physicians to customize therapeutic strategies and monitor disease. See Video Abstract at http://links.lww.com/DCR/B442.Registered at Chinese Clinical Trial Registry (ChiCTR1900025751).

UN MODELO DE PRONSTICO VALIDADO Y UN NOMOGRAMA PARA PREDECIR COMPLICACIONES PRECOCES QUE REQUIRAN CIRUGA EN PACIENTES CON ENFERMEDAD DE CROHN

ANTECEDENTES:Predecir una enfermedad de Crohn muy agresiva es fundamental para determinar la estrategia terapéutica.OBJETIVO:Desarrollar un modelo de pronóstico para predecir las complicaciones que requieran cirugía dentro el primer año al diagnóstico de enfermedad de Crohn y crear un nomograma para facilitar la toma de decisiones clínicas.DISEÑO:El presente etudio es retrospectivo.AJUSTE:Estudio realizado entre Enero 2012 y Diciembre 2016, en un único centro terciario de tratamiento de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron todos aquellos pacientes diagnosticados de enfermedad de Crohn que mostraban manifestaciones tipo B1 según la clasificación de Montreal.PRINCIPALES MEDIDAS DE RESULTADO:Medimos la aparición de complicaciones que finalmente conducirían a una cirugía, incluida la hemorragia digestiva grave (puntuación de Glasgow-Blatchford ≥ 6), estenosis y perforaciones, confirmadas por endoscopía, tomografía computarizada y / o radiología intervencionista.RESULTADOS:El período medio de seguimiento fue de 54 meses (desviación estándar 13 meses). De los 614 pacientes elegibles, el 13,5% desarrolló complicaciones que llevaron a cirugía. La regresión logística multivariable reveló que los predictores independientes de complicaciones de inicio temprano eran la edad (razón de probabilidades ajustada [ORa] por aumento de 10 años en la edad = 0,4; intervalos de confianza del 95% [IC del 95%]: 0,2-0,8, p = 0,004), duración de la enfermedad (ORa = 2,7, IC del 95%: 1,9-3,8, p <0,001), enfermedad perianal (ORa = 16,0, IC del 95%: 4,3-59,9, p <0,001), cirugía previa (ORa = 3,7, 95% IC: 1,6-8,6, p = 0,003) y manifestaciones extraintestinales (ORa = 7,6, IC del 95%: 2,3-24,9, p = 0,001). La especificidad y sensibilidad del modelo pronóstico fueron 88,3% (IC 95%: 84,8% -91,2%) y 96,6% (IC 95%: 88,1% -99,6%), respectivamente, y el área bajo la curva fue 0,97 (95% % CI: 0,95-0,98). Este modelo fue validado con buena discriminación y excelente calibración utilizando la prueba de bondad de ajuste de Hosmer-Lemeshow. Se creó un nomograma para facilitar la práctica clínica al pié de la cama.LIMITACIONES:Diseño retrospectivo que incluyó un tamaño de muestra pequeña en un solo centro.CONCLUSIONES:Nuestro modelo de pronóstico validado predijo eficazmente las complicaciones precoces que conllevaron a cirugía y la detección de enfermedad de Crohn agresiva, lo que permitió a los médicos personalizar las estrategias terapéuticas y controlar la enfermedad. Consulte Video Resumen en http://links.lww.com/DCR/B442.Registrado en el Registro de Ensayos Clínicos de China (ChiCTR1900025751).

Delta neutrophil index and symptomatic time are effective factors for predicting perforated appendicitis

Appendicitis is a common intra-abdominal inflammatory disease, and morbidity increases with age when perforation occurs. Because, not all patients require emergency surgery, there have been numerous studies on factors for predicting perforated appendicitis. In this study, we aimed to confirm whether the delta neutrophil index (DNI) and the time from symptom onset to surgery are effective predictors for perforated appendicitis in different age groups.This was a retrospective study conducted on 542 appendicitis patients who underwent surgery at Kangdong Sacred Heart Hospital. The simple group consisted of 431 subjects, and the perforation group consisted of 111 subjects.Multiple logistic regression analyses demonstrated that age, neutrophil percentage, DNI, C-reactive protein (CRP), and symptomatic time were significant predictors of perforation. Analysis of the receiver-operating characteristic curve showed that the DNI was the most reliable predictive value. In the analyses according to age, the perforation rate was higher in the >65-year-age group; these patients also had a higher DNI, CRP, and symptomatic time. In the DNI analysis using receiver operating characteristic (ROC) analysis, the area under the curve was higher in the >65-year-age group than in other age groups. In addition, the cutoff values have been determined and perforation occurred significantly in the group with a DNI value of 2.1 or higher and a symptomatic time of 33 hours or longer.DNI is effective in predicting perforation in patients with appendicitis compared with other inflammatory factors. Furthermore, the simultaneous measurement of symptomatic time and DNI is helpful in predicting perforation and determining whether emergency surgery is necessary.

A Flat Inferior Vena Cava on Computed Tomography Is Associated With Worse Outcomes in Emergency General Surgery

BACKGROUND

Several trauma studies have shown that a "flat" inferior vena cava (IVC) is associated with poor clinical outcomes, including hypovolemic shock, major bleeding, transfusions and mortality. These studies utilize IVC measurements on computed tomography (CT) scans, and rarely include emergency general surgery patients. We examine the association between IVC flatness and clinical outcomes in a series of patients with perforated viscus.

MATERIALS AND METHODS

Medical records at an academic hospital were reviewed of adults with perforated viscus. Patients who underwent laparotomy or laparoscopy were included if they underwent CT within 12 h prior to incision time. Perforated appendicitis was excluded. A ratio was calculated of the transverse to anterior-posterior diameter of the IVC at 3 locations, then averaged. Clinical outcomes were analyzed by the average IVC ratio.

RESULTS

A total of 83 patients were included. Using binomial regression, the average IVC ratio significantly correlated with ICU admission (OR 3.6, 95% CI 1.2 to 11) and acute kidney injury (OR 2.3, 95% CI 1.0 to 5.3), but not postoperative shock (OR 1.2, 95% CI 0.56 to 2.6).

CONCLUSIONS

A flat IVC on CT prior to an operation for perforated viscus was associated with worse outcomes, including increased rate of ICU admission and acute kidney injury. More outcomes research is needed to assess the potential role of IVC assessment in preoperative resuscitation.

The "misfortune" of being a COVID-19 negative patient during the coronavirus pandemic

COVID-19 pandemic has obviously affected patients' behavior towards seeking medical help as well as physicians' decision in the management of emergencies. Our recent experience as surgeons at a COVID-19 referral hospital revealed cases which share an alerting characteristic: the delay in appropriate management. Unfortunately for COVID-19 negative patients a "coronacentric" health system has been adopted. In view of measures applied to avoid spread of the disease, a significant delay in patients' presentation as well as in their in-hospital management is observed. We present cases where delay in appropriate management affected the patients' outcome and underline the fact that balancing between COVID-19 safety measures and a patient who needs urgent treatment can be very challenging and stressful.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Polymicrobial Solitary Retroperitoneal Abscess Due to Sigmoid Colon Perforation

We treated an 85-year-old man with an abscess perforating into the retroperitoneal space from the sigmoid colon, with retroperitoneal drainage combined with antibiotics. CT showed no abscess formation in the intraperitoneal space. The patient consulted a doctor with a chief complaint of left-side low back pain and fever. He was first diagnosed with bacteremia due to Escherichia coli and close examination by CT revealed a retroperitoneal abscess. On referral to our hospital, we determined by CT that the cause of abscess formation was perforation of the intestine into the retroperitoneal space and spreading into the psoas muscle compartment. We then performed colostomy and abscess drainage through the retroperitoneal space to prevent the abscess disseminating into the intraperitoneal space. The abscess and necrotic tissue cultures were polymicrobial, including Enterobacteriaceae and Bacteroides spp. The abscess almost disappeared after drainage, and the patient's general condition gradually improved. The retroperitoneal abscess did not relapse by follow-up CT. In conclusion, this rare case presented with perforation of the intestine (Sigmoid colon) disseminated only to the retroperitoneal space without no intraperitoneal space abscess formation. We performed drainage only by a retroperitoneal approach without entering the intraperitoneal space.

[Ingestion of multiple magnets in pediatrics: endoscopic or surgical emergency?]

Ingestion of foreign bodies is common in the pediatric population. Most foreign bodies have a benign behavior and are usually eliminated without generating greater morbidity and mortality. In relation to the intake of magnets, its frequency has increased to the point that it currently represents a public health problem in the pediatric population. The ingestion of a single magnet does not generate any risk, but the ingestion of 2 or more of these, or even of magnets and metals in succession is considered an emergency since they can attract each other and can cause serious symptoms of intestinal obstruction, bleeding, fistulas, perforation and even intestinal necrosis. We present 2 pediatric patients, who ingested multiple magnets, in these cases we highlight the variety in the clinical presentation, as well as the complications presented in relation to a late diagnosis.

Colon perforation by foreign body insertion for sexual gratification: a case report

Occurrence of retained rectal foreign bodies with bowel perforation resulting from auto-eroticism is rare among males in Africa. Embarrassment attached to this condition may delay or derail acquisition of information and management. A 30-year-old male presented with abdominal pain and constipation for 3 days. Abdominal X-rays revealed free air-stripes under both hemidiaphragms and in the peripherals, a 25cm x 5.9cm lucent foreign body on the left side with proximal tapering. There was no evidence of intestinal obstruction. This was consistent with bowel perforation secondary to foreign body introduction. Exploratory laparotomy was performed, a plastic bottle of 250mls was removed from the colon. Transverse repair of a 10cm laceration extending from the rectum to the sigmoid was done and a colostomy placed. A high index of suspicion, a systematic approach and a lower threshold for imaging studies were key to successful management and favorable outcomes of this patient.

Colorectal surgery obesity-related morbidity during COVID-19

Tocilizumab, a monoclonal antiinterluekin-6 receptor antibody, has been empirically used in the treatment of cytokine release syndrome associated with severe coronavirus disease 2019 infections. The efficacy and safety of these medications for these patients is unknown. The purpose of this report was to present a case of acute large bowel perforation in a morbidly obese patient with coronavirus disease 2019 pneumonia who received empiric Tocilizumab. This case report analyzes the risks of acute large bowel perforation after using this medication empirically and discusses the appropriate management of this adverse event.

Spontaneous colonic perforation in adults: Evaluation of a pooled case series

Spontaneous colonic perforation in adults (SCPA) is rare but important. Its clinicopathological features and outcomes remain unclear. Therefore, the aim of the current study was to explore and investigate the clinicopathological characteristics, clinical outcomes and potential risk factors for patients with SCPA. Data of seven patients with SCPA treated in our hospitals from January 2008 to December 2017, and 221 cases from research databases before 2018 were retrospectively analyzed. The description of SCPA included stercoral perforation of the colon (SPC), idiopathic perforation of the colon (IPC) and spontaneous colonic perforation (SCP) in the study. All SCPA patients presented with unexplained abdominal pain and peritonitis. The median age was 62.5 years. The definite diagnosis preoperatively was 20.6%. The commonest lesion location was sigmoid colon and Hartmann's operation accounted for 59.3%. Histopathology of stercoral perforation (HSP) and histopathology of idiopathic perforation (HIP) were two histopathological findings. Postoperative complication was 67.7% and mortality was 31.1%. Univariate and multivariate analyses showed that chronic constipation was an independent risk factor for histopathological features (p ≤ 0.001, p = 0.005). Age of patients was associated with both postoperative complication (p = 0.012, p = 0.044) and mortality (p = 0.013, p = 0.034). Univariate analysis showed that HSP was associated with postoperative complication (p = 0.015). Our findings from the analysis pertaining to SCPA confirm those from previous studies, supporting the SCPA, as a uniform description, is an infrequent and life-threatening disease requiring early surgical intervention. We found that the elderly with chronic constipation was a high-risk category and those with HIP had a more favorable outcome than that of patients with HSP.

Neonatal and Infant Appendicitis

Neonatal appendicitis is a rare disease with a high mortality rate. Appendicitis is difficult to diagnose in neonatal and infant populations because it mimics other more common conditions in these age groups. Furthermore, signs and symptoms of appendicitis are often nonspecific in nonverbal patients and a high index of suspicion is necessary to initiate the appropriate diagnostic work-up. The keys to successful management of appendicitis in infants include keeping the diagnosis on the differential in the setting of unexplained intra-abdominal sepsis, following a diagnostic algorithm in the work-up of infant abdominal pathology, and performing appendectomy once the diagnosis is confirmed.

Colonic Perforation in a Term Newborn with Hereditary Protein C Deficiency

We describe a term infant who experienced recurrent apnea associated with intracranial hemorrhage and later, developed colonic perforation. Plasma protein C activity was below detectable limits and a heterozygous PROC mutation was identified. Neonatal colonic perforation is rare, and this case report highlights the importance of considering congenital Protein C deficiency.

Case report: successful endoscopic treatment of a large bowel perforation caused by chicken bone ingestion

RATIONALE

Large bowel perforations by a foreign body are rarely diagnosed pre-operatively due to non-specific clinical symptoms. The safety and efficacy of foreign body removal via upper endoscopy is well-established and strongly recommended. There is far less experience of endoscopic treatment of sharp foreign bodies impacted in lower parts of gastrointestinal tract.

PATIENT CONCERNS

The patient was 78-year-old female with abdominal pain and nausea. Symptoms had begun 48 hours prior to hospital admission. She had lost over 10 kg of body weight in the previous couple of months DIAGNOSIS:: A multidetector-row computed tomography (MDCT) examination of the abdomen revealed mural thickening and enhancement of the cecum with haziness and linear areas of high attenuation in the pericecal fat tissue. A colonoscopy showed, the clear presence of a sharp 5.5-cm-long chicken bone perforating the cecal wall at the antemesenteric site close to the Bauchini valve.

INTERVENTIONS

A quarter of the bone that had penetrated the cecal wall was pulled out with a flexible colonoscopy using a polypectomy snare. Due to the form and length of the bone, it was withdrawn through the entire colon, using pointed end trailing.

OUTCOMES

The patient was discharged three days after colonoscopy with normal laboratory results and without any pain.

LESSONS

In cases where sharp foreign bodies stuck into the large bowel, it is highly advisable to try to remove them via colonoscopy, before deciding to resolve the issue through a surgical intervention.

Acute perforated appendicitis after blunt abdominal trauma: A report from a 7-year-old

Individually, trauma and appendicitis are some of the most common conditions in clinical practice, particularly in emergency medicine. In rare cases, trauma and appendicitis may co-exist, imposing a dilemma of whether these are only coincidence or appendicitis develops because of trauma. We report here a case of acute perforated appendicitis after a blunt abdominal trauma caused by a horse hoof kick to the abdomen in a 7-year-old boy. We also discussed the potential pathophysiologic mechanisms behind and reviewed the literature on this rare condition.

Comparison of Acute Abdominal Surgical Outcomes of Extremely-Low-Birth-Weight Neonates according to Differential Diagnosis

BACKGROUND

Improvements in perinatal intensive care have improved survival of extremely-low-birth-weight (ELBW) neonates, although the risk of acute abdomen has increased. The differential diagnosis resulting in abdominal surgery can be categorized into necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), meconium-related ileus (MRI), and meconium non-related ileus (MNRI). The purpose of this study was to review our experience with abdominal surgery for ELBW neonates, and to evaluate characteristics and prognosis according to the differential diagnosis.

METHODS

Medical records of ELBW neonates treated between 2003 and 2015 were retrospectively reviewed.

RESULTS

Of 805 ELBW neonates, 65 (8.1%) received abdominal surgery. The numbers of cases by disease category were 29 for NEC, 18 for SIP, 13 for MRI, and 5 for MNRI. Ostoma formation was performed in 61 (93.8%) patients; primary anastomosis without ostoma was performed in 4 (6.2%). All patients without ostoma formation experienced re-perforation of the anastomosis site. Seven patients had 30-day postoperative mortality (6 had NEC). Long-term survival of the surgical and non-surgical groups was not statistically different. NEC was a poor prognostic factor for survival outcome (P = 0.033).

CONCLUSION

Abdominal surgery for ELBW neonates is feasible. Ostoma formation can lead to reduced complications compared to primary anastomosis.

A dramatic and rare complication: bowel perforation following abdominal liposuction

AIM

The purpose of this study is to analyze a rare and under-reported complication of abdominal liposuction and the role of laparoscopy.

CLINICAL CASE

We report a case of bowel perforation after 7 days of abdominal liposuction and bilateral mastopexy. The patient presented clinical and radiological findings of bowel obstructive syndrome and bilateral peripheral pulmonary embolism. An emergency diagnostic laparoscopy was performed and confirmed the diagnosis of bowel perforation.

DISCUSSION

Bowel perforation is a known but under-reported comSOD Romaplication of abdominal liposuction, and it is characterized by a difficult diagnosis. The clinical presentation is characterized by a difficult diagnosis and severe complications. Bowel obstructive syndrome was constant, as our case and also peritonitis was never frank. This is an important point because it is one of the reasons for diagnostic delay. The development of laparoscopic surgery has changed the way to manage such conditions, where the diagnosis was doubt. In particular, when an acute abdomen occurs, laparoscopy may have three different roles: to confirm or not the diagnosis, to facilitate and guide a subsequent laparotomy or, finally, to entirely treat the disease.

CONCLUSION

The bowel perforation is a dramatic and underestimated complication of abdominal liposuction. Diagnosis is complex. A clinical and radiological investigation should be quickly performed. In doubtful cases, an emergency laparoscopy can confirm the diagnosis and guide a possible subsequent laparotomy.