Beyond the Appendix Stump: A Rare Case of Appendicular Band Syndrome Causing Small Bowel Obstruction

The purpose of this randomized, open-label study was to assess the efficacy of the product Interceed absorbable adhesion barrier in the prevention of adhesion formation on the ovary after laparoscopic ovarian cystectomy. A total of 25 patients requiring laparoscopic bilateral ovarian cystectomy were enrolled into this study. After removal of ovarian cysts, peri-adnexal adhesions, and peritoneal irrigants, and the attainment of meticulous haemostasis, the random assignment of one ovary for wrapping with Interceed was revealed to the surgeon. The other ovary served as the untreated control. A follow-up laparoscopy was performed 8-30 weeks after the initial procedure in 17 patients. Significantly fewer adhesions formed at the Interceed treated ovaries compared with the control (untreated) ovaries (P < 0.05). In terms of adhesion-free outcome, 76% (13/17) of Interceed treated ovaries and 35% (6/17) of control ovaries were free of adhesions. A significant reduction was observed in the area of the sutured ovaries involved with adhesions when Interceed (6%) was used, compared with controls (20%). The reduction of adhesion formation was not related to the size of the cysts at the initial procedure. No adverse events were reported by any patient during the study. In conclusion, Interceed was found to be safe and effective in reducing the incidence of postoperative adhesion formation in patients undergoing laparoscopic ovarian cystectomy.

BackgroundLaparoscopic ovarian cystectomy is established as the standard surgical approach for the treatment of benign ovarian cysts. However, previous studies have shown that potential fertility can be directly impaired by laparoscopic ovarian cystectomy, diminished ovarian reserve (DOR), and even premature ovarian failure. Therefore, fertility-preserving interventions are required for benign gynecologic diseases. However, there are still little data on the time period required for recovery of ovarian reserve after the laparoscopic unilateral ovarian cystectomy, which is very important for the individualization of treatment protocols. This study aimed at investigating the time needed for the ovarian reserve to recover after laparoscopic unilateral ovarian non-endometriotic cystectomy.Materials and MethodsSixty-seven patients with unilateral ovarian non-endometriotic cyst from Zhoupu and Punan Hospitals who underwent laparoscopic unilateral ovarian cystectomy were recruited as a postoperative observation group (POG). Also, 69 healthy age-matched women without ovarian cyst who did not undergo surgery were recruited as a referent group (RFG). Ovarian reserve with the serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), estradiol (E2) levels, ovarian arterial resistance index (OARI), and antral follicle counts (AFCs) were measured on the third to fifth days of the same menstrual cycle. A postoperative 6-month follow-up of cases was performed.ResultsCompared with RFG, AFC of cyst side in the POG group showed no difference in the first, third, and sixth postoperative month (F = 0.03, F = 0.02, F = 0.55, respectively; p = 0.873, p = 0.878, p = 0.460, respectively). The OARI of cyst side in the POG group revealed no differences in the first, third, and sixth postoperative month (F = 0.73, F = 3.57, F = 1.75, respectively; p = 0.395, p = 0.061, p = 0.701, respectively). In the first month, the postoperative AMH levels significantly declined, reaching 1.88 ng/ml [interquartile range (IQR): 1.61–2.16 ng/ml] in POG and 2.57 ng/ml (IQR: 2.32–2.83 ng/ml) in RFG (F = 13.43, p = 0.000). For the data of AMH levels stratified by age, the same trend was observed between less than 25 and more than 26 years old. At this same time interval, the postoperative rate of decline was significantly lower compared to the preoperative one in POG (32.75%). The same trend was observed between the POG and RFG groups (26.67%).ConclusionsThe optimal time for recovery of ovarian reserve after laparoscopic unilateral ovarian cystectomy is estimated to be 6 months.

Stump appendicitis is defined as interval inflammation of any residual appendicular tissue, after an appendicectomy. We present a systematic review of case series and case reports on stump appendicitis, emphasising on risk factors, diagnosis and surgical management. The English literature (1945-2018) was reviewed, using PubMed, Embase and GoogleScholar, combining the terms "appendix", "appendicitis", "stump", "residual", "recurrent" and "retained". In total, 127 studies were included, describing 164 patients (males 59%, mean age 36 ± 17years). Index surgery was open in 59% and laparoscopic in 38%. It was described as "difficult" or "complicated" in 31%. 20% of patients reported episodes of recurrent abdominal pain during the time interval between index and stump appendicitis (range 2weeks to 60years, median 2years). Right lower quadrant pain was the most frequent complain (88%), leukocytosis was found in 56%, whereas 92% of patients underwent imaging testing, which was diagnostic or highly suspicious in 67.5%. Mean delay between beginning of symptoms and surgery was 2.4 ± 2.3days. The operative approach was open in 61% and laparoscopic in 35% of cases. The operation was characterised as "difficult" or "complicated" in 45%. In the majority (88%), a completion stump appendicectomy was performed, with 11% requiring more extensive procedures. Mean length of resected stump was 3.1 ± 1.6cm (range 0.5-10cm). Stump appendicitis may occur following both open and laparoscopic approach, when the residual stump is > 0.5cm. Its clinical significance lies in the delayed diagnosis, leading to higher incidence of complications and the need for more extensive surgery.

Pelvic adhesions are one of the major factors which significantly and adversely affect surgery outcome due to intra- and postoperative morbidity and reduce future female fertility. Using a rodent model, we evaluated the efficacy of aspirin, a non-steroidal anti-inflammatory drug, in the prevention of adhesion formation. A total of 72 female Wistar rats received a standardized primary traumatic lesion to the right uterine horn. They were randomly divided into eight groups: group I (control) had no treatment and group II received a single pre-operative 0.70 mg aspirin. All the succeeding groups (III-VIII) received aspirin in doses of 0.35, 0.70, or 1.40 mg every 6 h for either 48 or 96 h in addition to the pre-operative aspirin (0.70 mg). All animals were killed 4 weeks later and adhesions were assessed using a modified adhesion scoring scale. The lowest adhesion score was found in the group treated with 0.35 mg of aspirin for 96 h, and the highest was found among the groups treated with either 0.70 or 1.40 mg for 48-96 h respectively (P < 0.05). These results are in line with the hypothesis that administration of a low dose of aspirin selectively inhibits the production of thromboxane A2, whereas basal prostacyclin biosynthesis is preserved. This phenomenon might contribute to reducing postoperative adhesion formation in a rat model. Thus, future studies into the prevention of adhesion formation may require the additional use of a non-steroidal anti-inflammatory drug, for which aspirin deserves further attention, before extrapolation into human therapy.

Effect of bevacizumab on postoperative adhesion formation in a rat uterine horn adhesion model and the correlation with vascular endothelial growth factor and Ki-67 immunopositivity

This study was to investigate and analyze the impact of laparoscopic ovarian endometriosis cystectomy on ovarian reserve function. A total of 20 patients undergone with laparoscopic unilateral ovarian teratoma (mature cystic teratoma) cystectomy and 80 cases with ovarian endometriosis cyst given laparoscopic ovarian cystectomy were regarded as the control group and the research group, respectively. Patients in the research group were divided into four group, group A (n=20, unilateral ovarian endometriosis cyst, cyst diameter 0.05. No statistical significance was indicated on hormone levels among groups when ages and types of bilateral ovarian endometriosis cyst were observed in layering, showing p>0.05. Comparing the control group, infertile patients before operation in group A, group B and group presented a higher postoperative pregnancy rate, showing p<0.05; but postoperative pregnancy rate in group D was lower than that in the control group, showing p<0.05. Laparoscopic ovarian endometriosis cystectomy suggested certain influences on ovarian reserve function. Most patients could recover at 1 y postoperatively and the postoperative pregnancy rate for fertile patients could be significantly enhanced by adding gonadotropin releasing hormone agonist, a medicine after the operation.

Impact of prior abdominal surgery on postoperative prolonged ileus after ileostomy repair

The aim of this study was to assess the efficacy of intraperitoneal different combinations for postoperative pain relief in patients undergoing laparoscopic unilateral ovarian cystectomy. We conducted a double-blind randomized controlled trial that enrolled patients who were included to undergo laparoscopic unilateral ovarian cystectomy. Patients received one of the following combinations (30 patients each): group I: received bupivacaine plus magnesium sulfate, group II: received bupivacaine plus hydrocortisone, group III: received magnesium sulfate plus hydrocortisone, and group IV: received saline 0.9% only. The primary outcomes in the present study were the severity of postoperative abdominal and shoulder pain assessed by visual analog scale (VAS) every two hours till the end of the first day, and time for first postoperative analgesia requirement. Group I had statistically significant lower abdominal static and dynamic pain scores than the other groups till 18 hours postoperatively (P<0.001). In addition, group II had statistically significant lower abdominal static and dynamic pain scores than group III in the most of assessment points (P<0.05). The time for first required analgesics was significantly longer in group I (336.2±67.54 minutes) than other groups (P<0.001). The proportion of patients who required two or more doses of ketorolac was significantly lower in group I than other groups (P<0.001). The proportion of patients with nausea or vomiting was not significantly different across study's groups (P>0.05). Intraperitoneal bupivacaine-magnesium combination provides better analgesia and reduces postoperative morphine consumption than bupivacaine-hydrocortisone or magnesium-hydrocortisone combinations after laparoscopic ovarian cystectomy.

After completing this article, readers should be able to: 1. Describe the epidemiology and pathophysiology of gastroesophageal reflux (GER) in preterm neonates. 2. Delineate the associations of GER with apnea, chronic lung disease, behavior, and growth of preterm infants. 3. Review the investigations used to evaluate GER in preterm infants. 4. Describe nonpharmacologic and pharmacologic therapies for GER. Gastroesophageal reflux (GER) is a normal physiologic event occurring across the age spectrum. It may contribute to a variety of disorders, including esophagitis, feeding problems, and airway disease in all age groups. (1) A large number of symptoms and signs have been purported to be caused by GER despite a lack of data showing a clear association between a specific symptom and GER. In preterm infants, empiric therapy often is administered using agents of unproven efficacy and safety to treat symptoms that likely are unrelated to GER. In a survey on management practices for GER in preterm infants, common treatment strategies included positioning (98%) and slopes (96%), histamine 2 (H 2) receptor antagonists (100%), feed thickeners (98%), antacids (96%), prokinetics (79%), proton pump inhibitors (PPIs) (65%), and dopamine receptor antagonists (53%). (2)(3) The safety, efficacy, and appropriate dosing recommendations for most medical therapies remain uncertain in neonates. In this review, we attempt to summarize the current literature regarding physiology, pathophysiology, and diagnostic and management strategies for GER pertinent to the neonate, with an emphasis on the preterm infant. GER describes the retrograde movement of stomach contents (air or feeding, liquid or semisolid, acid or alkaline, enzymes or bile salts) into the esophagus. GER disease (GERD) occurs when GER causes symptoms or signs such as pain, poor weight gain, esophagitis, hematemesis, and airway symptoms, including apnea, aspiration, recurrent pneumonia, chronic lung disease (CLD), or large airway inflammation. However, any of these symptoms or signs …

RETIRED: Adhesion Prevention in Gynaecological Surgery

Seizure-like symptoms are rare in older patients without brain damage. Small bowel obstruction is a common clinical disorder for older patients that can cause electrolyte disturbances and nutritional disorders. Hypomagnesemia is a frequently overlooked electrolyte disorder. Moreover, magnesium deficiency can lead to severe seizure-like symptoms. An 85-year-old man was admitted to the hospital with weakness and slow movement. Shortly after hospitalization, he experienced incomplete small bowel obstruction; thus, parenteral nutrition and intravenous esomeprazole were administered. When intestinal obstruction was relieved, the patient suddenly experienced seizure-like symptoms three times, and 24-h electroencephalogram did not capture any epileptiform pattern. After excluding other causes, we considered serum magnesium deficiency as a diagnosis. Low serum magnesium levels were related to a shortage of absorption due to small bowel obstruction, excess excretion of renal dysfunction, and the use of proton pump inhibitor. However, the exact mechanism underlying the hypomagnesemia-induced seizure-like activity remained unclear. After adjusting the nutritional support and magnesium supplementation, the patient's serum magnesium level returned to normal, and he was free of seizure-like activity. Hypomagnesemia is often asymptomatic, but it can lead to severe seizure-like symptoms. It is important to pay attention to the serum magnesium level and nutritional intake in patients with an incomplete small bowel obstruction.

Purpose of investigation: To examine changes in anti-Müllerian hormone (AMH) levels following laparoscopic ovarian endometriotic cystectomy with abdominal wall lifting. Materials and methods: This prospective cohort study analyzed 32 patients with endometriomas who underwent laparoscopic surgery between October 2014 and December 2016 in private and university hospitals. We measured blood AMH levels at baseline and at 1, 3, 6, and 9 months following a cystectomy. We also examined the correlations of AMH levels with age at time of surgery, bilateral cysts, cyst diameter, and Douglas fossa occlusion. Main outcome measures include the ovarian reserve based on AMH levels. Results: Compared to baseline (2.14 ± 1.66 ng/mL), AMH levels were significantly reduced at 1 (1.22 ± 1.08 ng/mL) and 3 (1.18 ± 1.02 ng/mL) months post-surgery. However, there were no significant differences between baseline and 6 (1.35 ± 1.02 ng/mL) or 9 (1.37 ± 0.95 ng/mL) months post-surgery. AMH levels were significantly reduced in patients aged ≥ 35 years (1.10 ± 0.98 versus 3.15 ± 1.85 ng/mL, P = 0.001), those with bilateral cysts (1.58 ± 0.98 versus 3.15 ± 1.85 ng/mL, P = 0.006), and those with pouch of Douglas occlusion (1.16 ± 0.90 versus 2.93 ± 1.60 ng/mL, P = 0.002). Conclusions: Abdominal wall lifting yielded the same AMH level changes as insufflation, suggesting that their effects on recurrence and preservation of the ovarian reserve following ovarian cystectomy are comparable. Abdominal wall lifting should be proactively considered when performing laparoscopic surgery for patients with endometriosis. If the ovarian reserve is preserved in the long term despite transient postoperative reduction in the ovarian reserve, physicians should consider surgery with consideration of postoperative artificial reproductive therapy for these patients who desire to have children.

The incidence of bowel obstruction in pregnancy is approximately 1 in 17 000 deliveries and is not increased in comparison to the non-pregnant population1. Approximately 50% of cases result from postsurgical adhesions, including those associated with Cesarean delivery1, 2. Small bowel obstruction is considered a catastrophic complication of pregnancy with a reported overall risk of fetal loss of 17% and a maternal mortality rate of 2%2. Sonography has been demonstrated to be superior to plain radiography in the assessment of non-pregnant patients with suspected small bowel obstruction3, however, diagnosis is considered more difficult during pregnancy2. Here we describe two cases of maternal small bowel obstruction diagnosed during pregnancy by point-of-care transabdominal ultrasound. A 30-year-old primiparous woman presented at 27 weeks' gestation, complaining of abdominal discomfort, nausea, vomiting and obstipation. Her medical history included right salpingectomy for a tubal pregnancy. Transabdominal ultrasound examination was performed and the fetus was considered appropriate in size for gestational age (AGA). Markedly dilated loops of maternal small bowel containing fluid and edematous bowel wall were observed (Figure 1). Prominent ‘to and fro’ peristalsis was visualized in the small bowel and free fluid was noted in the cul-de-sac. Maternal small bowel obstruction was suspected and was confirmed by computed tomography. Following unsuccessful conservative treatment, laparotomy was performed and a mechanical obstruction due to adhesions was identified and released. On the third postoperative day, the patient delivered precipitously a 1260-g infant. Both mother and infant were well at the time of writing. A 26-year-old primiparous woman presented at 34 weeks' gestation with worsening abdominal discomfort, nausea, vomiting and obstipation. Her medical history included laparoscopic cholecystectomy and right ovarian cystectomy. Serum levels of aspartate aminotransferase and alanine aminotransferase were elevated at 113 U/L and 175 U/L, respectively. Qualitative urine dipstick analysis revealed proteinuria of 2+ and ketonuria of 4+. Transabdominal ultrasound examination showed the fetus to be AGA. Sonography of the maternal upper abdomen revealed numerous dilated loops of small bowel, edematous small bowel walls (Figure 2), marked ‘to and fro’ peristalsis and free fluid in the peritoneal cavity. Small bowel obstruction was suspected and was confirmed by magnetic resonance imaging. The patient received 4 L of intravenous fluids and concurrently manifested hypertension, leading to a suspected diagnosis of pre-eclampsia. Following failed conservative treatment of the bowel obstruction, she was scheduled for exploratory laparotomy. Prior to surgery, elevated blood pressure of 170/110 mmHg confirmed severe pre-eclampsia. The patient requested and underwent Cesarean delivery of an infant weighing 2260 g. Following repair of the uterine incision, an internal hernia with an incarcerated segment (hyperemic, edematous, with punctate lesions and prenecrotic appearance) of small bowel, located within previous surgical adhesions, was released. Both mother and infant did well. Abdominal ultrasound performed at the patient's bedside (‘point of care’) for the diagnosis of small bowel obstruction is a recent application in the emergency room4. Specific sonographic findings associated with small bowel obstruction include diameter of the small bowel > 25 mm, small bowel wall edema, ‘to and fro’ peristalsis, intra-abdominal fluid and the presence of a sonographic transition point (defined as the location between dilated small bowel proximal to the obstruction and decompressed small bowel distal to the obstruction)5. In both our cases, all of these sonographic signs of small bowel obstruction, other than depiction of the transition point, were present despite the gravid uterus. In both patients, the transition/obstruction points that were confirmed at surgery were posterior to the gravid uterus, thus were obscured to transabdominal sonographic assessment. A systematic search (PubMed, MEDLINE) of articles published between 1966 and 2016 in English medical literature, utilizing the search terms ‘pregnancy’, ‘small bowel obstruction’, ‘mechanical ileus’, and ‘point-of-care sonography’, indicates that the diagnosis of small bowel obstruction during pregnancy utilizing point-of-care sonography has not been reported previously. Our cases suggest that point-of-care sonography, now advocated for patients with suspected small bowel obstruction, may also be beneficial in pregnant patients at relatively advanced gestational ages. D. M. Sherer*†, M. Dalloul†, A. Schwartzman‡, A. Strasburger§, R. A. Farrell†, H. Zinn¶ and O. Abulafia§ †Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA; ‡Department of Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA; §Department of Obstetrics and Gynecology, Division of Gynecological Oncology, State University of New York (SUNY), Downstate Medical Center,Brooklyn, NY, USA; ¶Department of Radiology, State University of New York (SUNY), Downstate Medical Center,Brooklyn, NY, USA *Correspondence. (e-mail: [email protected])

BACKGROUND: A differentiated risk-adjusted surgical approach to characteristic adhesion patterns causing late small bowel obstruction (SBO) aims at low recurrence rates while maintaining a low 30-day mortality. METHODS: From 1978 to 2001, 159 patients were treated according to a pertinent protocol. Operative and outcome data were entered into a prospectively maintained database. Primary end points were 30-day mortality and recurrence of complete SBO necessitating repeat surgery, secondary end points were the incidence of incomplete SBO responding to conservative measures and long-term survival. RESULTS: Overall 30-day mortality was 1.9%: 5.9% after SBO caused by single bands (type 1), nil after SBO caused by isolated matting of jejunum or midgut (type 2) treated by resection and 1% after SBO due to ileal (type 3a) or total adhesions (type 3b), respectively, both treated by lysis, bowel repair and splinting (not statistically significant). The overall recurrence rate of complete SBO was 1.9%: 7% for type 1, nil for type 2 and 1% for type 3 (2% for 3a and nil for 3b); not statistically significant. For incomplete SBO the overall rate was 6%: nil for type 1, 3.4% for type 2 and 8.6% for type 3 (12% for 3a and 4.6% for 3b); not statistically significant. The median overall survival time was 196 months. CONCLUSIONS: Adhesion-type-adjusted repair procedures of different complexity rendered equally favorable outcomes of late SBO in patients presenting with different adhesion patterns.

The role of the peritoneal cavity in adhesion formation