Time-to-surgery paradigms: wait time and surgical outcomes in critically Ill patients who underwent emergency surgery for gastrointestinal perforation

BACKGROUND

Waiting time for emergency abdominal surgery have been known to be linked to mortality. However, there is no clear consensus on the appropriated timing of surgery for gastrointestinal perforation. We investigated association between wait time and surgical outcomes in emergency abdominal surgery.

METHODS

This single-center retrospective cohort study evaluated adult patients who underwent emergency surgery for gastrointestinal perforations between January 2003 and September 2021. Risk-adjusted restricted cubic splines modeled the probability of each mortality according to wait time. The inflection point when mortality began to increase was used to define early and late surgery. Outcomes among propensity-score matched early and late surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs).

RESULTS

Mortality rates began to rise after 16 h of waiting. However, early and late surgery groups showed no significant differences in 30-day mortality (11.4% vs. 5.7%), ICU stay duration (4.3 ± 7.5 vs. 4.3 ± 5.2 days), or total hospital stay (17.4 ± 17.0 vs. 24.7 ± 23.4 days). Notably, patients waiting over 16 h had a significantly higher ICU readmission rate (8.6% vs. 31.4%). The APACHE II score was a significant predictor of 30-day mortality.

CONCLUSIONS

Although we were unable to reveal significant differences in mortality in the subgroup analysis, we were able to find an inflection point of 16 h through the RCS curve technique.

TRIAL REGISTRATION

Formal consent was waived due to the retrospective nature of the study, and ethical approval was obtained from the institutional research committee of our institution (B-2110-714-107) on 6 October 2021.

[Perforated metastatic primary fibromyxoid sarcoma of the transverse colon]

BACKGROUND

Low grade fibromyxoid sarcoma (LGFMS) is considered a rare soft tissue tumor and has a tendency to arise from deep soft tissue of the trunk and lower extremities, the intraabdominal area is considered a rare location.

OBJECTIVE

To describe the first case of a LGFMS arising from the transverse colon with liver metastasis.

CLINICAL CASE

We describe a 57-years-old male patient with abdominal pain of sudden onset; at surgery he was found to have an abscessed tumor in the transverse colon that infiltrated to mesentery root. An extended left hemicolectomy was performed with ascending colon colostomy. Later on, a postoperative scan he was found to have metastatic liver disease.

CONCLUSIONS

This case is unique in terms of the location and presentation. It's a reminder of differential diagnosis of acute abdominal pain. To our knowledge is the first case of a LGFMS of the colon with synchronous liver metastasis.

Small bowel perforation and death caused by anaplastic thyroid carcinoma metastasis in a patient with concomitant colonic and bilateral breast carcinoma

Undifferentiated or anaplastic thyroid carcinoma (ATC) is rare and one of the most aggressive human malignancies. The tumor is usually voluminous and fast-growing and mostly affects older women. The most common sites of distant metastases are the lungs, brain, and bones. Herein, we describe the case of a 66-year-old woman with a history of bilateral breast carcinoma and ATC, who presented with an acute abdomen and subsequently died. At autopsy, an isolated metastasis of ATC in the small intestine leading to bowel perforation was found. Moreover, there was adenocarcinoma in the descending colon. The review of extra-abdominal malignancies metastasizing to bowel and coincidence of breast and thyroid carcinoma is included.

Sigmoid gallstone ileus: a challenging diagnosis

Gallstone ileus is a rare (1%–4%) complication of gallstone disease. Gallstones entering the gastrointestinal tract by penetration may cause obstruction at any point along their course through the tract; however, they have a predilection to obstruct the smaller-caliber lumen of the small intestine (80.1%) or stomach (14.2%). The condition is seen more commonly in the elderly who often have significant co-morbidities. Gallstone ileus causing large bowel obstruction is rare. We report the case of a 95-year-old woman who presented with a history of abdominal pain without fever, nausea, vomiting, or diarrhea. Computed tomography of the abdomen and pelvis with oral contrast revealed a high-density structure within the lumen of the distal sigmoid colon, initially suspected to be a foreign body. Medical management failed and surgical intervention was not possible. Autopsy revealed peritonitis and a rupture of the sigmoid colon at the site of a cylindrical stone found impacted in an area of fibrotic narrowing with multiple diverticula. A necrotic, thick-walled gallbladder had an irregular stone in its lumen that was a fracture match with the stone in the sigmoid. Adhesions, but no discrete fistula, were identified between the gallbladder and the adjacent transverse colon. The immediate cause of death was peritonitis caused by colonic perforation by the gallstone impacted at an area of diverticular narrowing. To our knowledge, such autopsy findings have not been previously reported.

Spontaneous perforation of small intestine followed by rupture of the cystic artery: the natural history of Vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos Syndrome (VEDS) is a rare autosomal dominant disorder caused by mutations in the COL3A1 or COL1A1 genes. Its mortality is secondary to sudden and spontaneous rupture of arteries or hollow organs. The genotype influences the distribution of arterial pathology with aneurysms of intra-abdominal visceral arteries being relatively uncommon. We describe the case of a young man with probable VEDS who died of a spontaneous rupture and dissection of the cystic artery. The patient initially presented with abdominal pain due to an unrecognized spontaneous perforation of the small intestine complicated by sepsis. We postulate that inflammatory mediators may have triggered the arterial rupture due to remodeling and weakening of vessel walls. The phenotype of the patient’s vascular damage included bilateral spontaneous carotid-cavernous sinus fistulae and dissection with pseudoaneurysm formation of large- and medium-sized arteries, predominantly the abdominal aorta and its branches. The autopsy uncovered a long history of vascular events that may have been asymptomatic. These findings along with a positive family history supported the VEDS diagnosis. Loeys-Dietz, Marfan, and familial thoracic aortic aneurysm and dissection syndromes were ruled out based on the absence of arterial tortuosity, eye abnormalities, bone overgrowth, and the distribution of vascular damage among other features. Interestingly, microscopic examination of the hippocampus revealed a focus of neuronal heterotopia, commonly associated with epilepsy; however, the patient had no history of seizures. The natural course of VEDS involves the rupture and dissection of arteries that, if unrecognized, can lead to a rapid death after bleeding into free spaces.

Hepatic Abscess Induced by Fish Bone Migration: Two Case Reports

Although foreign body ingestion is a common occurrence, perforation and penetration of the gastrointestinal tract is unusual and the development of a hepatic abscess is even more rare. The authors describe two cases of fish bone perforation of the gastrointestinal tract with hepatic perforation and abscess formation, from distinctive age groups and varying presentation, although both developed septic shock. The lack of history of ingestion of foreign bodies, non-specificity of both clinical presentation and complementary examinations all play a role in delaying the diagnosis and therefore in the prognosis itself.

Letter to the Editor: Colonic Perforation

N/A.

Target Sign: Endoscopic Sign of the Colonic Perforation

N/A.

Delayed Small Bowel Perforation with Findings of Severe Ischemia Following Blunt Abdominal Trauma

Background

Isolated small bowel perforation following blunt abdominal trauma (BAT) is an uncommon situation with high morbidity and mortality rates, and delayed small bowel perforation is even rarer. The pathophysiology of this condition is not clear in all cases. To the best of our knowledge, this is the first case report of delayed small bowel perforation following BAT with extensive portomesenteric vein gas.

Case Report

A 33-year-old male patient was admitted to the emergency department after a car accident. His initial abdominal CT showed no signs of posstraumatic injury. However, follow-up CT, performed after deterioration in his general condition, showed jejunal dilatation, intestinal intramural gas, portomesenteric vein gas, extensive intraperitoneal gas and intraabdominal free fluid. CT findings and emergent laparotomy findings were both compatible with small bowel ischemia-necrosis and perforation.

Conclusions

Delayed small bowel perforation following BAT is thought to occur secondary to mesenteric hematoma formation or mesenteric tear complications. Our patient did not have any mesenteric injury or hematoma on initial abdominal CT. We are not aware of any other case report of delayed small bowel perforation following BAT without signs of intraabdominal injury on initial imaging and extensive portomesenteric vein gas on follow-up imaging. Ischemic bowel necrosis was the main cause of portomesenteric vein gas in our case. Posttraumatic patients should be kept under medical observation and abdominal CT should be preferred for imaging in case of a deterioration in the general condition and laboratory findings or appearance of new abdominal complaints.

Iatrogenic Perforations During Colonoscopy In a Portuguese Population: A Study Including In and Out-Of-Hospital Procedures

INTRODUCTION

The risk of iatrogenic perforations in colonoscopy is not negligible. Experience with endoscopic closure of perforations is increasing and new devices for this purpose are being released, making endoscopy a therapeutic option. National data regarding iatrogenic perforations is scarce and the burden of iatrogenic perforations in out-hospital procedures is poorly characterized in the literature.

OBJECTIVE

Evaluation of iatrogenic perforations rate during colonoscopy, their characteristics, management and prognosis.

METHODS

Retrospective study of all patients with perforations secondary to in-hospital and non-hospital colonoscopies treated in a tertiary hospital between 01-01-2006 and 01-10-2014. Demographic, endoscopic, radiological and therapeutic data were analyzed.

RESULTS

Fifty-three perforations were identified, 20 occurring in colonoscopies performed in non-hospital environment (45% with therapeutic procedures) and 33 occurring in-hospital procedures (73% in therapeutic colonoscopies; representing 0.12% of all colonoscopies carried out in-hospital). Patients: male in 56%, average age of 71 years, history of previous abdominopelvic surgery in 31% and diverticulosis in 10%. Colonoscopy: elective in 93%, under deep sedation in 21%, with less than excellent/good bowel preparation in 56%. A resident was the first performer in 10 cases. Perforations: average size of 21 mm (4-130 mm), diagnosed during the procedure in 51% of cases and occurred in rectum-sigmoid transition in 58.5%. Regarding therapeutics, all patients with perforation occurring in non-hospital colonoscopies were managed by surgery. Concerning treatment of those in our unit: 2-conservative, 12-endoscopic (10 successfully), 21-surgical (including the 2 cases with failure of the endoscopic approach). Comparing endoscopic treatment (n = 10, G1) versus surgery (n = 21; G2): perforation size - 9 mm (G1) versus 28 mm (G2); perforation location - 7/10 in rectum-sigmoid (G1) versus 8/21 in rectum-sigmoid and 10/21 transverse/ascending colon/hepatic angle (G2). Morbidity: 1 infection in G1 and 13 complications in G2 (infection, hemorrhage, fistula). Mortality: no deaths in G1 and 2 deaths at 30 days due to septic shock in G2.

CONCLUSION

Perforations in colonoscopy are rare in our clinical practice. Endoscopic closure was effective, though limited to perforations found during the procedure. The mortality was relatively low and endoscopic management did not seem to worsen it. An additional effort is necessary in order to detect perforations during colonoscopy.

A Fatal Complication: Intestinal Perforation Secondary to Migration of a Biliary Stent

Background

Stent insertion is widely performed to restore biliary drainage in hepatic, biliary, and pancreatic obstructive conditions. Intestinal perforation due to the migration of these stents is an extremely rare late-term complication that is associated with a high rate of mortality. The current report aimed at presenting the radiological findings of a case of extraluminal biliary stent migration into the pelvic region that caused intestinal perforation.

Case Report

We report a case of an 85-year-old male with a history of previous stent insertion who presented with a sudden – onset severe abdominal pain. An abdominal multidetector computed tomography (MDCT) revealed a tubular foreign body density, compatible with intestinal perforation due to migration of the biliary stent.

Conclusions

Biliary stent insertion becomes a more common procedure. This serious complication must always be remembered in patients presenting with abdominal pain after stent insertion.

Spontaneous healing of gastric perforation after endoscopic ligation for gastric varices

Endoscopic variceal ligation (EVL) can be performed as an optional therapy for gastric variceal bleeding if endoscopic sclerotherapy (ES) is not readily available or if practitioners lack experience. EVL using an endoscopic pneumo-activated ligating device was performed on a 53-year-old male patient with liver cirrhosis who presented with hematemesis. Follow-up esophagogastroduodenoscopy (EGD) performed two days after the EVL showed gastric perforation at the EVL-procedure site on the gastric fundus. However, the patient refused emergency surgery, and therefore received only supportive management, including intravenous antibiotics. EGD 10 days later showed healing of the perforation site. This is the first report of a case of gastric variceal bleeding with development of a gastric perforation soon after EVL, which showed complete recovery with conservative therapy and without surgical intervention.

Perforation of Meckel's Diverticulum by a Peanut Presenting as a Mesentery Abscess

BACKGROUND

Perforation of Meckel's diverticulum by a foreign body in children is rarely reported and is usually associated with localized or generalized fibropurulent peritonitis.

CASE PRESENTATION

The authors encountered such a case in a 4-year-old boy with perforation of Meckel's diverticulum by a piece of peanut presenting as a mesentery abscess. The diverticulum was wide-based and histology showed a transmural perforation at the tip of the diverticulum.

CONCLUSION

Local inflammation due to irritation of the foreign body and progressive pressure necrosis at the tip of the diverticulum may be the pathogenesis of mesentery abscess. A search of the English literature did not reveal any similar case.

Enteropathy-associated T-cell lymphoma (type II): a Brazilian case report

Enteropathy-associated T-cell Lymphoma (EATL) is a rare form of aggressive T-cell lymphoma. It is more prevalent in men over 60 years and the prognosis is very poor. EATL is classified into two groups based on morphology, immunohistochemistry, and genetic profile. EATL type I is highly associated with celiac disease and is more common in Western countries. EATL type II predominates over type I in Asia, where celiac disease is uncommon. We report a case of a 78-year-old previously healthy white male who presented with a 2-month history of diarrhea, weight loss and edema. The abdomen was distended and painful, and a tumor mass was palpable in the hypogastrium. Laboratory tests showed hypoalbuminemia. Serological tests for HIV, viral hepatitis and HTLV-1 were negative. The chest radiography showed pneumoperitoneum, and an exploratory laparotomy revealed perforation of the small bowel. An advanced stage (Ann Arbor IV B/Lugano IIE2B) EATL type II was diagnosed. Four cycles of chemotherapy were interspersed with several complications (anthracycline-induced cardiotoxicity, chemotherapy-induced neutropenic fever and severe sepsis). Performance status progressively worsened and he died 6 months after the diagnosis. This is an illustrative report of a rare and aggressive primary intestinal lymphoma. To the best of our knowledge, this is the first report of EATL type II in Brazil.