Abdominal Washout Research Articles

Colonic Perforation Secondary to COVID-19 Induced Hemorrhagic Colitis in a Patient Heterozygous for Factor V Leiden.

Up to 17.6% of COVID-19 positive patients present with gastrointestinal symptoms and bowel wall abnormalities have been described in up to 31% of COVID-19 positive patients. Here, we present a case of a 40-year-old male diagnosed with COVID-19 complicated by hemorrhagic colitis leading to colonic perforation. CT scan of abdomen and pelvis demonstrated markedly distended descending and sigmoid colon with poorly defined wall, pneumatosis, and pneumoperitoneum. The patient was taken for emergent exploratory laparotomy for extended left hemicolectomy, partial omentectomy, transverse colostomy creation, abdominal washout, repair of small bowel, and appendectomy. The patient was brought back for repeat exploratory laparotomy with ICG perfusion assessment. Patient was found to be heterozygous for factor V Leiden mutation and was never vaccinated for COVID-19. Our case demonstrates a novel use for indocyanine green (ICG) to assess perfusion and underscores the importance of completing a thorough hypercoagulable evaluation following COVID-19 induced thrombotic event.

Post Prostatectomy Abdominal Pain

A 56-year-old man with a history of prostate cancer presented to the emergency department (ED) for abdominal pain, vomiting, and tenesmus. Four days before the presentation, he had undergone robotic radical prostatectomy. His examination was significant for diffuse abdominal tenderness without frank peritonitis. Although his vitals were initially normal, he became progressively more hypotensive despite fluid resuscitation and eventually required vasopressors. Laboratory evaluation revealed an anion gap metabolic lactic acidosis with a normal WBC count. Initial computed tomography of the abdomen and pelvis with intravenous contrast (Figure 1) showed mild nonspecific circumferential thickening of the distal rectum. Because of the patient’s clinical deterioration, he was sent for repeat computed tomography with rectal contrast (Figure 2), which revealed his diagnosis.Figure 2Computed tomography of the abdomen and pelvis with rectal contrast (axial view) showing rectal perforation, with the rectal contrast extending through a full-thickness defect at the 10 o’clock position of the lower rectum into the pelvis and peritoneal cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperative rectal perforation. The patient was treated with antibiotics and was immediately taken to the operating room for abdominal washout, which revealed 3 L of feculent material in the abdomen. He had a prolonged hospital stay and was discharged to a skilled nursing facility 1 month later. Postoperative rectal injury is a rare but known complication of robotic radical prostatectomy. Most cases are discovered and repaired during surgery. However, cases that are not diagnosed during surgery often have significant morbidity.1Wedmid A. Mendoza P. Sharma S. et al.Rectal injury during robot-assisted radical prostatectomy: incidence and management.J Urol. 2011; 186: 1928-1933Crossref PubMed Scopus (42) Google Scholar Therefore, a high index of suspicion is needed to diagnose postoperative rectal injuries, and it is one of the few instances when rectal contrast should be routinely considered.2Marres C.C.M. Engelmann E.W.M. Buskens C.J. et al.The importance of rectal contrast in CT assessment to detect anastomotic leakage after colorectal surgery.Colorectal Dis. 2021; 23: 2466-2471Crossref PubMed Scopus (2) Google Scholar Those cases identified in the ED will require admission and surgical consultation because their management requires bowel diversion with delayed fistula closure.

S2217 A Rare Case of Synchronous Double Volvulus of the Sigmoid Colon and Cecum

Introduction: Colonic volvulus is one of the leading causes of large bowel obstruction. Synchronous cecal and sigmoid volvulus is a rare presentation. Cecal volvulus and sigmoid volvulus have traditionally been thought of as separate clinical presentations with distinct clinical features, radiological findings, and treatment modalities. We focus on the classical radiological findings, uncharacteristic presentations, and definitive treatment to prevent recurrence, morbidity, and mortality. Case Description/Methods: A 67-year-old female with a past medical history of severe chronic constipation secondary to stercoral colitis presents to the emergency department complaining of abdominal pain for 5 days. Pain is diffuse, and associated with nausea and vomiting. The last colonoscopy performed 4 years ago, was normal. The patient was in immense pain and was not able to provide further information. On presentation, the patient was afebrile, BP 127/52, HR 73, RR 16 breaths/min. The abdomen was distended, and peritoneal sounds were auscultated in all quadrants but were worse in lower quadrants bilaterally. X-ray of the abdomen showed pneumoperitoneum and dilated bowel related to stercoral colitis. Subsequent CT abdomen showed small volume ascites, hollow perforated viscus, markedly distended cecum with peri-cecal inflammatory changes, and significant wall thickening with inflammation in the sigmoid colon secondary to concurrent cecal and sigmoid volvulus. The patient immediately underwent exploratory laparotomy, ileocecectomy with primary anastomosis, sigmoidectomy with primary anastomosis, and abdominal washout (Figure). Discussion: When evaluating acute abdomen, we propose consideration of synchronous large bowel volvulus is a rare and easily missed etiology of large bowel obstruction due to challenging radiological presentation. Even with detailed cross-sectional imaging like CT scan, it is possible to miss coexisting cecal volvulus due to massively enlarged sigmoid volvulus causing mass effect. The preferred treatment is total or subtotal colectomy with or without anastomosis on a case-to-case basis. This approach provides the advantage of avoiding the risk of recurrence and histopathological analysis to rule out underlying malignancy. Commonly, only one type of large bowel volvulus is found radiologically, it is advisable to pay attention to the possibility of coexisting cecal volvulus and a definitive diagnosis being made intraoperatively.Figure 1.: A. Chest X-ray showing gas under diaphragm; B. Volvulous with dilated caecum and Sigmoid colon on Abdominal X-ray; C. Scout film of the CT scan abdomen; D. Twisted Caecum with dilated sigmoid colon on axial film.

Septic shock from multiple intra-abdominal Streptococcus constellatus abscesses unamenable to percutaneous drainage

ABSTRACTStreptococcus constellatus are gram-positive cocci belonging to the Streptococcus milleri group that have a propensity to cause bacteremia and abscesses, especially in immunocompromised patients. Here, we report the case of a 39-year-old male who was initially admitted to the hospital for diabetic ketoacidosis. During the hospitalization, he developed sepsis and blood cultures grew Streptococcus constellatus. CT imaging revealed multiple hepatic abscesses. A periapical abscess of the left mandibular central incisor found on CT Scan of face was identified as the likely source of infection. IR-guided drainage was performed however the patient went on to develop septic shock despite attempted source control and IV antibiotic therapy. Repeat imaging showed persistent hepatic abscesses in addition to new intraperitoneal abscesses necessitating exploratory laparotomy, drainage and abdominal washout. Fluid cultures grew Streptococcus constellatus and common enteric flora. Our report highlights the need for high clinical suspicion in cases of Streptococcus constellatus bacteremia to obtain diagnostic imaging for any abscess formation. Prolonged antibiotic therapy is a must and imaging guided or surgical drainage may be needed.

Translocation of LVAD Pump and Driveline Causing Bowel Perforation

Introduction Left ventricular assist devices (LVADs) have known risks of device infection and gastrointestinal (GI) bleeding. We present the first known case of LVAD pump migration causing colonic perforation. Case Report A 67-year old man with ischemic cardiomyopathy status post HeartMate II LVAD implantation presented to the emergency department with melena. He was found to be in hemorrhagic shock requiring pressor support, with a hemoglobin of 5.2 g/dl. He had a history of chronic driveline infection with Stenotrophomonas maltophilia treated with long-term suppressive doxycycline and an outflow graft kink requiring stenting 7 months prior. His GI history was notable for recurrent GI bleeding secondary to colonic AVMs and polyps requiring multiple cauterizations and clips. His anticoagulation was periodically interrupted and restarted, as the patient had several readmissions for recurrent GI bleeding, until it was ultimately stopped 3 months prior. This admission, an abdominal CT showed erosion of the LVAD driveline into the transverse colon (Panel A). Subsequent colonoscopy identified the driveline within transverse colon lumen (Panel B). In conjunction with both cardiothoracic and abdominal surgery teams, the patient underwent robotic-assisted colonic exploration which revealed both driveline and LVAD pump had migrated into the colon. Patient underwent removal of the LVAD and primary colo-colonic anastomosis with abdominal washout. Laparoscopic omentopexy was performed to cover the intraabdominal LVAD components. His postoperative course was uncomplicated. Summary This case illustrates a rare but serious complication of LVAD and chronic device infection: migration of LVAD pump and driveline causing colonic perforation. Left ventricular assist devices (LVADs) have known risks of device infection and gastrointestinal (GI) bleeding. We present the first known case of LVAD pump migration causing colonic perforation. A 67-year old man with ischemic cardiomyopathy status post HeartMate II LVAD implantation presented to the emergency department with melena. He was found to be in hemorrhagic shock requiring pressor support, with a hemoglobin of 5.2 g/dl. He had a history of chronic driveline infection with Stenotrophomonas maltophilia treated with long-term suppressive doxycycline and an outflow graft kink requiring stenting 7 months prior. His GI history was notable for recurrent GI bleeding secondary to colonic AVMs and polyps requiring multiple cauterizations and clips. His anticoagulation was periodically interrupted and restarted, as the patient had several readmissions for recurrent GI bleeding, until it was ultimately stopped 3 months prior. This admission, an abdominal CT showed erosion of the LVAD driveline into the transverse colon (Panel A). Subsequent colonoscopy identified the driveline within transverse colon lumen (Panel B). In conjunction with both cardiothoracic and abdominal surgery teams, the patient underwent robotic-assisted colonic exploration which revealed both driveline and LVAD pump had migrated into the colon. Patient underwent removal of the LVAD and primary colo-colonic anastomosis with abdominal washout. Laparoscopic omentopexy was performed to cover the intraabdominal LVAD components. His postoperative course was uncomplicated. This case illustrates a rare but serious complication of LVAD and chronic device infection: migration of LVAD pump and driveline causing colonic perforation.

Pulsed Ultrasound of the Spleen Prolongs Survival of Rats With Severe Intra-abdominal Sepsis

BackgroundThe spleen is an important contributor to the uncontrolled, excessive release of proinflammatory signals during sepsis that leads to the development of tissue injury and diffuse end-organ dysfunction. Therapeutic pulsed ultrasound (pUS) has been shown to inhibit splenic leukocyte release and reduce cytokine production in other inflammatory disease processes. We hypothesized that pUS treatment inhibits spleen-derived inflammatory responses and increases survival duration in rats with severe intra-abdominal sepsis leading to septic shock. Materials and methodsRats with intra-abdominal sepsis, induced by cecal ligation and incision, underwent abdominal washout, intra-peritoneal administration of cefazolin, and then either no further treatment (control), splenectomy, or pUS of the spleen. Animals were observed for the primary endpoint of survival duration. ResultsSurvival curves were significantly different for all groups (P < 0.01). Median survival increased from 9.5 h in control rats to 19.8 h in pUS rats and 35.0 h in splenectomy rats (P < 0.01). At 4 h after cecal ligation and incision, the pUS group had decreased splenic contraction and leukocyte count (P = 0.03) compared with control, indicating reduced exodus of splenic leukocytes. In addition, elevation in plasma TNF-α and MCP-1 was significantly attenuated in the pUS group (P < 0.05 versus control). Splenic β2 adrenergic receptor levels and phosphorylated Akt were significantly more elevated in the pUS group (P < 0.01 versus control). ConclusionspUS significantly prolonged the survival duration of rats with severe intra-abdominal sepsis. This treatment may be an effective, noninvasive therapy that dampens detrimental immune responses during septic shock by activating β2 adrenergic receptor–Akt phosphorylation in the cholinergic anti-inflammatory pathway.

Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy.

Background: Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. Case Presentation: A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Conclusion: Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.

Necrotising fasciitis of the abdominal wall

A 53 year old gentleman, with a history of intravenous drug use, presented to the Emergency Department in septic shock with an acute abdomen. He had been recently treated with dalteparin for a deep venous thrombosis of his left leg. He was resuscitated with fluids and antibiotics, and cross-sectional imaging suggested a diagnosis of necrotising fasciitis of the abdominal wall. He was admitted to ITU, and a laparotomy, abdominal washout, muscle debridement and laparotomy was performed overnight. No bowel perforation or contamination was identified. Over the next few weeks he underwent multiple debridements, and a negative pressure abdominal dressing was utilised. After a prolonged rehabilitation phase he was discharged home to live independently. He is currently in discussion with the plastics team regarding reconstruction of his abdominal wall. We would like to stress the importance of consideration of necrotising fasciitis as a diagnosis in the context of a critically unwell and septic patient with a history of subcutaneous/intravenous medication usage.

Laparoscopic diverting loop ileostomy for spontaneous colon perforation in advanced ovarian cancer

ObjectiveNeoadjuvant chemotherapy for advanced ovarian cancer is associated with reduced morbidity in the elderly (Meyer et al., 2018). Spontaneous colonic perforation often leads to multisystem organ failure and death (Carter and Durfee, 2007; Rose and Piver, 1995). MethodsA 76-year old woman with stage IIIC disease initiated carboplatin AUC 5 and paclitaxel 175 mg/m2 with unanticipated development of profound neutropenia. She clinically deteriorated by day nine and CT scan revealed a large volume of free air. Emergent surgery was performed. ResultsDiagnostic laparoscopy confirmed the presence of intra-abdominal stool and extensive inflammatory exudate (Video). The likelihood of identifying the site of perforation appeared remote, but pelvic tumor encasement was highly suggestive of a sigmoid origin. The stool was evacuated, the exudate gently debrided and the terminal ileum partially mobilized. Copious irrigation was performed with drain placement and the pneumoperitoneum was decompressed. The right lower abdominal wall trocar incision was extended so that the ileal segment could be brought out and matured. She was discharged to rehab on postoperative day 2 to continue a two week course of broad spectrum antibiotics. Single-agent carboplatin was resumed within a month. Uncomplicated ileostomy takedown with parastomal hernia repair was performed between cycles five and six. The patient is currently in remission. ConclusionBowel perforation in the elderly, presenting with cachexia and treatment-induced pancytopenia for advanced ovarian cancer, is often a harbinger of early death. Selected patients may benefit from a minimally invasive approach by an experienced gynecologic oncologist instead of vertical laparotomy, abdominal washout, diversion and the potential sequelae of an open abdomen.

Successful Extracorporeal Membrane Oxygenation in the Management of Acute Respiratory Distress Syndrome and Cardiopulmonary Collapse Secondary to Amniotic Fluid Embolism

Background Amniotic fluid embolism (AFE) is one of the most devastating complications of pregnancy that typically manifests as acute cardiopulmonary collapse during delivery or in the postpartum period. The potential role of extracorporeal membrane oxygenation (ECMO) as a management technique in severe cases of AFE remains largely unknown given the limited literature available. In this report, we present the first case, to our knowledge, of successful implementation of ECMO as a life-saving measure in a case of hemorrhagic shock due to postpartum bleeding complicated by severe AFE leading to acute respiratory distress syndrome (ARDS) ultimately requiring tracheostomy. Case report A 37-year-old G3P0020 female with with known anti-cardiolipin antibodies being managed with low molecular weight heparin and aspirin during pregnancy was admitted to the hospital for induction of labor in the 39th week of gestation. A Caesarian section was completed, which was complicated by severe post-partum hemorrhage requiring massive transfusion, tranexamic acid and uterine tamponade. On post-operative day two, she developed hypoxic respiratory failure requiring intubation. The patient suffered from persistent desaturation on maximal ventilator settings becoming increasingly cyanotic with profoundly hypotensive. In addition, she experienced recurrent bleeding that necessitated emergent hysterectomy. Chest X-ray showed findings suggestive of ARDS. AFE was suspected due to the sudden dire hypoxia and hypotension, and she was subsequently placed on Veno-Venous (VV) ECMO. She required multiple trips to the operating room during this interval for exploration and abdominal washout due to intra-abdominal bleeding. Eventually, bleeding was controlled and vital signs began to show improvement. After 10 days, the patient was decannulated and taken off ECMO support. After a challenging and undoubtedly complicated hospital course, she was successfully discharged home with minimal sequelae. Conclusions The timely incorporation of ECMO reversed an ill-fated hospital course of a patient with suspected AFE that was complicated by severe hemorrhagic shock and ARDS with persistent hypoxia despite maximized ventilator settings and paralysis. Hemodynamic decompensation is often rapid but transient in cases of severe AFE, and we recommend early consideration of ECMO implementation given its vital utility in these critical moments.

Actinomyces neuii infection following ovarian cystectomy

Background: Abdominal Actinomyces infections are rare complications of surgery. A case of Actinomyces neuii presenting as a severe postoperative pelvic infection is described.Case: A 30 year-old nulligravid female was transferred from an outside hospital for a postoperative fluid collection, fever, leukocytosis, and abdominal pain following exploratory laparotomy and bilateral ovarian cystectomy. She rapidly decompensated requiring emergent exploratory laparotomy, bilateral salpingooophorectomy, and abdominal washout. Cultures isolated A. neuii. Following a prolonged ICU admission, she was treated with prolonged antibiotics and made a complete recovery.Conclusions: Rare pathogens, such as A. neuii, may cause severe infections following gynecologic surgery. Multidisciplinary care at tertiary care facilities is critical.

Role for laparoscopy in the management of bile duct injuries.

Common bile duct (CBD) injury is the most serious complication of laparoscopic cholecystectomy. Recently, laparoscopic techniques have been used in the management of postoperative bile leak and CBD injury; this literature has not been reviewed. We reviewed the literature on CBD injury, the approach to its diagnosis and management, and reports of laparoscopic management techniques. We combined this review with our experience in laparoscopic methods to highlight diagnostic and therapeutic options. Laparoscopic techniques can be used to prevent, diagnose and treat CBD injuries. Intraoperatively, CBD injury can be prevented in the case of short cystic duct with the use of a loop ligature or transfixing suture, and it can be diagnosed using intraoperative cholangiography or other visualization techniques. When CBD injury is suspected postoperatively, repeat laparoscopy can be used to control sepsis with abdominal washout; as a diagnostic tool to guide management; and, in some settings, as a therapeutic tool for suturing small duct leaks, drain insertion and postoperative endoscopic retrograde cholangiopancreatography with sphincterotomy. Definitive laparoscopic repair is possible when certain criteria are met. Open surgery should be considered when the CBD is small, the injury occurred more than 72 hours previously, injury or anatomy are complex, port positioning is awkward for repair, or local experience is limited with laparoscopic management. There is an emerging role for laparoscopy in the management of CBD injuries. More case reports and series are needed to show the safety and efficacy of this technique, encourage its wider adoption, and allow outcomes assessment on a larger scale.

THE CASE FILES

THE CASE FILES

Spontaneous Liver Laceration as an Initial Presentation of Systemic Amyloidosis

Spontaneous rupture of the liver is an extremely rare complication of systemic amyloidosis. A 50-yearold male was brought to the emergency room with a reported 8-10 hour history of progressive abdominal pain and distention. He denied any trauma history. Upon arrival, he was hypotensive and severely anemic with a hemoglobin of 4.6. He was admitted several weeks prior to admission with complaints of dyspnea on exertion with anemia, for which colonoscopy / capsule endoscopy / and EGD failed to identify a source. He was admitted to the intensive care unit and resuscitated with blood products. A CT scan performed revealed a grade 2 laceration of the liver with subcapsular hematoma and intrahepatic contusion. Despite resuscitation efforts with several blood products, aggressive fluid resuscitation, and intravenous antibiotics, the patient continued to show signs of active bleeding. He was taken to the operating room on several occasions for an exploratory laparotomy, abdominal washout, packing, and wound vac changes in attempts to control the bleeding. Hepatology was consulted to determine the etiology of his spontaneous liver laceration. Hepatology recommended that a biopsy be obtained, as an extensive chart review revealed chronically elevated alkaline phosphatase levels raising concern for a possible infiltrative disease. Intra-operative biopsy revealed extensive sinusoidal amorphous hyaline deposits consistent with amyloid. In addition, Congo Red Staining revealed regional congophilia in the hyaline deposits with apple green birefringence on polarizing microscopy, characteristic of amyloid. After meeting with his family and discussing the patients' poor prognosis, a decision was made to pursue comfort measures and the patient died shortly thereafter. We present this rare complication of amyloidosis and review the relevant up to date literature.Figure 1

Care of the open abdomen after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies.

A patient with a mucinous appendiceal cancer presents to the surgeon complaining of abdominal discomfort and nausea. Having undergone a prior right hemicolectomy, the patient has been disease free and on surveillance with clinical and carcinogenic antigen (CEA) monitoring. The CEA was noted to be elevated and a computed tomography scan revealed peritoneal nodules throughout the abdomen with a presumptive diagnosis of pseudomyxoma peritonei (progressive peritoneal implants from a mucinous primary). Several therapeutic options were offered and the patient selected to undergo cytoreductive surgery (CRS) with the potential to receive hyperthermic interoperative chemotherapy (HIPEC). Extensive resection was performed, including removal of the entire greater omentum, partial gastrectomy, and total pelvic exenteration with end colostomy and ileal conduit. Reassessment of the peritoneal cavity after the resections revealed almost complete cytoreduction. HIPEC was performed with mitomycin C and, after drainage and abdominal washing, the intestinal segments were anastomosed and the abdominal wall closed. Seven days postoperatively, an acute abdomen with septic shock developed as a result of a leak from the ileocolonic anastomosis. The patient returned to the operating room and an exploratory laparotomy, a small bowel resection, a resection of the ileocolonic anastomosis, and an abdominal washout were performed. Edema of the bowel caused by peritonitis resulting from the anastomotic leak necessitated delayed closure of the abdominal wall. A temporary abdominal closure using the ABThera™ Open Abdomen Negative Pressure Therapy system was applied and the abdomen was eventually closed.

Reply to: doi:10.1007/s00464-013-3395-4: Re: “Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe…” (2013 (27):4164–4170)

To the editor, We agree that it is best to avoid laparoscopic common bile duct exploration (LCBDE) in patients with small diameter bile ducts (amongst our 120 patients who underwent LCBDE, one had a diameter of 3 mm, 3 of 4 mm and 4 of 5 mm). However, exploration of these is possible with the use of a 3-mm choledochoscope or via a trans-cystic duct approach. Whilst single-stage LCBDE is not the preferable option in high-risk patients, at times it becomes unavoidable when the endoscopic approach to management of ductal stones has failed. In our experience, LCBDE with primary closure can be performed in both elective and emergency cases. We performed emergency LCBDE in ten patients and encountered a postoperative chest infection in one and urinary tract infection in another but no bile leaks or duct strictures. Clearly though, patients with cholangitis, deep jaundice and coagulopathy should be optimised preoperatively and consideration should be given to preoperative percutaneous transhepatic biliary drainage as a temporising measure before embarking on LCBDE. With the use of a transverse choledochotomy and interrupted 4–0 Vicryl suture closure of non-dilated bile ducts (\6 mm diameter) at LCBDE (n = 8), we have encountered no postoperative bile leaks or bile duct strictures. We agree that endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage have their application in the management of bile leak due to retained stones after LCBDE. However, re-laparoscopy has its role in patients with generalised abdominal signs and systemic disturbance as it facilitates a thorough abdominal washout as well as removal of retained duct stones with re-suturing of the bile duct. Nasobiliary drainage is not commonly adopted in the United Kingdom.

In situ aortic thrombosis secondary to intra-abdominal abscess

SummaryBackground:Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis.Case Report:We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus.Conclusions:While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.

Giant uterine leiomyomata

To present the case of a patient with giant uterine leiomyomata and review literature pertinent to the subject. Case report and literature review. A major university, tertiary-care hospital. One patient, with said pathology, who gave informed consent for exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-ophorectomy. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, reoperation with abdominal washout, and hemostasis for hemoperitoneum. Not applicable. Not applicable. Those with giant uterine leiomyomata are a very unique and tiny subset of the millions of women with fibroids. They should be treated similarly to older, more critically ill patients. Their optimal surgical management requires the careful attention to considerations and techniques not common to the typical myomectomy or hysterectomy.

The Role of Laparoscopy in Newborns Affected by NEC

For many years, laparoscopic procedures have been reported in the literature in pediatrics also. In this article, we report their experiences of the use of gasless laparoscopy in 8 newborns affected by necrotizing enterocolitis (NEC). From January 2007 to May 2008, 8 patients affected by stage 1-2 NEC were treated at the Department of Pediatric Surgery, Fondazione Policlinico Milan (Milan, Italy). Of those, 3 patients presented with a birth weight below 1.5 kg. All patients were submitted at gasless laparoscopy. In 6 of 8 patients, a covered perforation was detected; in 5 cases, the perforation was on the posterior wall of the ascending colon, and in 1, a perforation of the transverse colon was detected. In these 6 of 8 patients, the procedure was converted to formal laparotomy, with colonic resection and primary anastomosis. In 2 of 8 patients, a diffuse necrotizing enteritis of the small bowel was reported, without evidence of perforation; two drains were placed and continued abdominal washout with antibiotics solution was maintained for 48 hours, associated with systemic therapy. All patients were maintained on systemic antibiotic therapy for 7 days with regression of sepsis; all patients survived and were discharged in good general condition. At follow-up of 3 months, none of the patients presented with complications. We believe that the decision to perform a laparoscopy, despite the very low weight of the patient, was crucial in the management of nondetected perforation at X-ray. Retrospectively, laparoscopy would be the best option to define the presence of NEC without a perforation, which may only require washout of the cavity that can be also managed with this technique. We believe that laparoscopy can be easily managed also in newborns and small for gestational age neonates, reducing the morbidity of laparotomy for suspicion of perforation in patients affected by NEC who do not respond to medical treatment.

Neonatal Peritoneal Candidiasis Successfully Treated with Anidulafungin Add-On Therapy

To report the first successful use of anidulafungin and liposomal amphotericin B in an infant with peritoneal candidiasis. An 11-day-old term female infant with Hirschsprung enterocolitis and bowel perforation was transferred to our institution on day 4 of hospitalization with septic shock and abdominal compartment syndrome. Initial peritoneal culture at time of colectomy did not grow yeast; however, Candida albicans grew from cultures obtained on abdominal washout 2 days later even while the patient was on treatment with liposomal amphotericin B 5 mg/kg/day. Anidulafungin 1.5 mg/kg/day intravenous therapy was instituted, and within 4 days peritoneal cultures were negative. The patient slowly recovered and, after a prolonged hospitalization, she was discharged home on hospital day 68 on partial parenteral nutrition. Despite the rising incidence of fluconazole-resistant Candida spp., pediatric dosing guidelines, and an adult indication for echinocandin use in candidal peritonitis, there are no reports of echinocandin use for fungal peritonitis in pediatric patients. The echinocandins are rational choices when fluconazole resistance is a concern. Furthermore, the unique clearance profile of anidulafungin makes it an attractive choice in critically ill patients with hepatic and renal dysfunction; the Infectious Diseases Society of America has recommended that an echinocandin be first-line antifungal therapy for moderately or severely ill pediatric or adult patients. Peritoneal candidiasis is a common complication of bowel perforation in neonates. Anidulafungin's pharmacokinetic and antifungal properties make it a viable therapeutic option in the treatment of this disease in critically ill infants and children.