Bowel Ischemia Research Articles

MP53-07 INTERNAL HERNIA WITH VOLVULUS AFTER MAJOR ABDOMINAL RECONSTRUCTIONS IN PEDIATRIC UROLOGY–A POTENTIALLY DEVASTATING COMPLICATION

You have accessJournal of UrologyCME1 Apr 2023MP53-07 INTERNAL HERNIA WITH VOLVULUS AFTER MAJOR ABDOMINAL RECONSTRUCTIONS IN PEDIATRIC UROLOGY–A POTENTIALLY DEVASTATING COMPLICATION Jennison N. Cull, Cynthia A. Sharadin, Deborah L. Jacobson, Glen A. Lau, Patrick C. Cartwright, M. Chad Wallis, David E. Skarda, Robert A. Swendiman, and Anthony J. Schaeffer Jennison N. CullJennison N. Cull More articles by this author , Cynthia A. SharadinCynthia A. Sharadin More articles by this author , Deborah L. JacobsonDeborah L. Jacobson More articles by this author , Glen A. LauGlen A. Lau More articles by this author , Patrick C. CartwrightPatrick C. Cartwright More articles by this author , M. Chad WallisM. Chad Wallis More articles by this author , David E. SkardaDavid E. Skarda More articles by this author , Robert A. SwendimanRobert A. Swendiman More articles by this author , and Anthony J. SchaefferAnthony J. Schaeffer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and antegrade continence enema (ACE) creation may create a space between the reconstruction and the anterior/posterior abdominal wall. This can result in internal herniation, closed loop obstruction, and volvulus. We aim to determine the incidence and describe the presentation, mechanism, and outcome of this complication. METHODS: This single-institution, retrospective cohort study identified patients who underwent EC, APV, and/or ACE between 1/2011 and 4/2022. Operative records for any subsequent exploratory laparotomy were reviewed. The primary outcome was internal herniation of bowel into the potential space between the reconstruction and the anterior/posterior abdominal wall. RESULTS: 143 patients received 241 procedures and were followed for a median of 68 (SD: 38) months. 19 patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/241). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. These complications occurred between 19 months and 9 years (median 5 years) after the index procedure. One complication was caused by small bowel sliding under the mesentery of the EC. A second was caused by bowel herniating through/around the APV mesentery and a third by herniation through/around the ACE mesentery; these two hernias also volvulized. The etiology of one internal herniation is unknown (Table 1). 3 patients required resection of ischemic bowel and 2 required takedown of the involved urologic reconstruction. One patient died intraoperatively from cardiac arrest. CONCLUSIONS: Internal herniation caused by small or large bowel sliding through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 241 reconstructions over 11 years. The ischemia resulted in bowel resection and takedown of the urologic reconstruction or death. If possible, the surgeon should close these potential spaces. Source of Funding: Dr. Schaeffer is supported in part by NIH K08DK119535 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e714 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennison N. Cull More articles by this author Cynthia A. Sharadin More articles by this author Deborah L. Jacobson More articles by this author Glen A. Lau More articles by this author Patrick C. Cartwright More articles by this author M. Chad Wallis More articles by this author David E. Skarda More articles by this author Robert A. Swendiman More articles by this author Anthony J. Schaeffer More articles by this author Expand All Advertisement PDF downloadLoading ...

Retained Foreign Body, Still a Reality and Consequence of Non-use of the WHO Surgical Safety Check Lists in Tropical Surgery

Adhesions are a major cause of acute abdomen in previously operated patients. The presence of a retained foreign body in the abdomen is a leading factor in the development of post-operative adhesion. It is, therefore important to take all necessary measures to avoid retained foreign bodies in the abdomen, as this increases the risk of developing post-operative adhesions and complications. A 32yr old female with a relevant past surgical history of an emergency laparotomy indicated for a ruptured ectopic pregnancy presented as an emergency 3 months after the above surgery at a tropical regional hospital with signs of generalized peritonism, following a brief history of sudden onset of lower abdominal pains. A diagnosis of bowel obstruction was made. Resuscitation was done, followed by an emergency exploratory laparotomy. It revealed the presence of a retained foreign body (gauze in our case), surrounded by multiple adhesion around the ileo-cecal junction with 2 meters of ischemic small bowel. Adhesion lysis was done, foreign body was extracted, the ischemic bowel was resected, and an end-to-end anastomosis was performed using Lambert’s technique. The patient had a smooth recovery. Implementing the effective use of the WHO surgical checklists before incision and before closing the abdomen will prevent foreign body retention, hence reducing post-operative complications. Keywords: Adhesions, Bowel obstruction, Retained foreign body.

To Identify the Risk Factors of Sigmoid Volvulus In Central India Tribal Area Population

Background: Sigmoid volvulus is a condition in which the torsion of the sigmoid colon around its mesenteric axis leads to acute colonic obstruction that is not timely and properly treated, leading to life-threatening and morbid complications such as bowel ischemia, gangrene and perforation. The aim of the study is to analyze the risk factor of SV, clinical signs and symptoms, treatment, complications and outcomes when it presents as a surgical emergency in a tribal area in central India. Methods: This is a prospective, single-center, cohort study of 24 patients presenting to the government with features of SV. medical college Shahdol [tribal area of central India] from June 2022 to November 2022. All data formulated in frequency charts. Results: we develop a prediction model for the high incidence of SV, its presentation and treatment in patients from the trunk region. 21 patients (87.5%) were male and 3 patients (12.5%) were female. The age of the patients varied between 30-80 years, most of them between 50-70 years. The main risk factors were [1] old age, [2] male gender, [3] rural residence, [4] low socioeconomic status, [5] pure vegetarian diet, [6] abuse [mc-alcohol], [7] chronic constipation, [8] chronic pain medication user [9] associated comorbidity [mc-hypertension] [10] high fiber diet, have a higher chance of this. The most common symptoms were absolute constipation and generalized abdominal distension followed by abdominal pain. The most common symptoms were tenderness followed by tachycardia and then fever. All patients were examined by clinical symptoms, plain X-ray of the upright abdomen and blood tests. Vomiting, the most common postoperative complication, followed paralytic ileus. Among the patients, 6 had distended gangrenous SV, 15 patients were found to have distended non-gangrenous, and 3 patients had perforated gangrenous sigmoid colon volvulus. Mostly treated with sigmoidectomy with stoma followed by resection with colorectal anastomosis with flatus bypass. Most patients were discharged, only 3 [12.8%] patients died. Conclusions: SV predominates in older men. Most patients with SV have a history of alcohol abuse, a high-fiber diet, and low socioeconomic status.

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review.

Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades. This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality. There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation. Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Neonatal necrotizing enterocolitis due to COVID-19. A case report.

Digestive symptoms have been reported in an important proportion of children with COVID-19, and the clinical expression of critical patients with COVID-19 is thought to result from progressive increase of inflammation and an unusual trend of hypercoagulation. We report a newborn received with abdominal distension, green vomiting and imaging suggestive for enterocolitis. He had a close contact with COVID-19 and the PCR for SARS-CoV-2 came back positive. Despite the supportive measures, his condition deteriorated and a surgery was decided. The surgical exploration found an ischemic bowel. The therapeutic measures were ineffective as the child passed away a few hours after surgery despite the resuscitation treatment performed. The confirmed enterocolitis happening within the period of acute infection by SARS-CoV-2, the NEC was likely a manifestation of COVID-19.

Small bowel segment with Meckel’s diverticulum volvulus related to short mesodiverticular band: a case report

BackgroundMeckel’s diverticulum is a remnant of the omphalomesenteric duct and occurs in only about 2% of people. Mesodiverticular band is the congenital remnant of the vitelline artery and is an even less often occurring phenomenon.Presented caseWe present the case of a 56-year-old Caucasian male who was admitted to the emergency department with a very intense, sudden abdominal pain, without past abdominal surgery history. Contrast enhanced computed tomography showed a possibly ischemic closed loop of the small intestine. Urgent laparotomy was performed, during which bloody content in the peritoneal cavity and torsed loop of the small intestine with Meckel’s diverticulum were found. The bowel loop and Meckel’s diverticulum were ischemic. At the tip of Meckel’s diverticulum there was a broken fibrous band extending to mesentery with pulsating artery. We did segmental resection of small intestine including Meckel’s diverticulum and primary end-to-end anastomosis. The patient had an unremarkable postoperative hospital stay and was discharged home after 5 days.ConclusionIn our case, we describe a patient with the volvulus of a segment of small bowel and Meckel’s diverticulum, which eventually led to small bowel obstruction and ischemia. It was a very rare case that required urgent surgical treatment.

Fibrin Glue Sac Filling for Preventing Type II Endoleak, Short-Term Outcomes of a Prospective Randomized Controlled Trial

Objective: Type II endoleak (T2EL) worsens the long-term results of endovascular aneurysm repair (EVAR). How to prevent T2ELs remains controversial. This study aimed to evaluate the efficacy and safety of fibrin glue sac filling (FGSF) to prevent T2ELs after EVAR. Methods: A prospective randomized controlled trial was conducted. Patients were randomly divided into group A (standard EVAR + FGSF) and group B (standard EVAR). The follow-up plans included outpatient or telephone consultation at 1 and 3 months and computed tomography (CT) angiography at 6 months, 1 year, and once a year after EVAR. Results: A total of 64 abdominal aortic aneurysm (AAA) patients were randomized to the 2 groups. All patients were followed up for more than 6 months. The 2 groups showed similar baseline characteristics. The rate of T2ELs on immediate angiography in group A (9.6%) was significantly lower than that in group B (33.3%, p=0.033). Moreover, the sac area change was significantly reduced in group A at 6 months after EVAR (p=0.021). However, T2EL incidence was similar at the 6-month (p=0.055) and 1-year (p=0.057) follow-ups, and AAA diameter change was also similar at 1 year. There were similar operation times, radiation doses, severe adverse events (SAEs), and reinterventions between the 2 groups. Conclusion: Fibrin glue sac filling could prevent short-term type II endoleaks and promote AAA shrinkage after 6 months. The FGSF procedure is swift and straightforward; however, patients are at risk of bowel ischemia, especially after previous bowel resections or concomitant superior mesenteric artery (SMA) disease. Clinical Impact Standard endovascular aneurysm repair (EVAR) couldn’t prevent type II endoleak (T2EL). In this study, we found fibrin glue sac filling (FGSF) could prevent T2EL and promote AAA shrinkage in a short term. And the FGSF procedure is easy, it will be a useful supplement to standard EVAR for clinicians. And FGSF might have potential usefulness on ruptured aneurysms, although without direct evidence.Fibrin glue is often used to hemostasis and tissue adhesion in surgical patients and burn patients, we firstly carry out a randomized controlled study and prove that fibrin glue sac filling could prevent T2EL and promote sac remodeling.

Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)

The optimal calorie and protein intakes at the acute phase of severe critical illness remain unknown. We hypothesised that early calorie and protein restriction improved outcomes in these patients, compared with standard calorie and protein targets. The pragmatic, randomised, controlled, multicentre, open-label, parallel-group NUTRIREA-3 trial was performed in 61 French intensive care units (ICUs). Adults (≥18 years) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned to early nutrition (started within 24 h after intubation) with either low or standard calorie and protein targets (6 kcal/kg per day and 0·2-0·4 g/kg per day protein vs 25 kcal/kg per day and 1·0-1·3 g/kg per day protein) during the first 7 ICU days. The two primary endpoints were time to readiness for ICU discharge and day 90 all-cause mortality. Key secondary outcomes included secondary infections, gastrointestinal events, and liver dysfunction. The trial is registered on ClinicalTrials.gov, NCT03573739, and is completed. Of 3044 patients randomly assigned between July 5, 2018, and 8 Dec 8, 2020, eight withdrew consent to participation. By day 90, 628 (41·3%) of 1521 patients in the low group and 648 (42·8%) of 1515 patients in the standard group had died (absolute difference -1·5%, 95% CI -5·0 to 2·0; p=0·41). Median time to readiness for ICU discharge was 8·0 days (IQR 5·0-14·0) in the low group and 9·0 days (5·0-17·0) in the standard group (hazard ratio [HR] 1·12, 95% CI 1·02 to 1·22; p=0·015). Proportions of patients with secondary infections did not differ between the groups (HR 0·85, 0·71 to 1·01; p=0·06). The low group had lower proportions of patients with vomiting (HR 0·77, 0·67 to 0·89; p<0·001), diarrhoea (0·83, 0·73 to 0·94; p=0·004), bowel ischaemia (0·50, 0·26 to 0·95; p=0·030), and liver dysfunction (0·92, 0·86-0·99; p=0·032). Compared with standard calorie and protein targets, early calorie and protein restriction did not decrease mortality but was associated with faster recovery and fewer complications. French Ministry of Health.

Male with abdominal distention and abnormal chest x-ray.

A 48-year-old man receiving chemotherapy for glioblastoma multiforme presented for generalized weakness and fecal incontinence, which he described as “dribbling drops” of liquid stool. Physical examination showed dry mucous membranes, bowel sounds in the right upper quadrant, diffuse abdominal tenderness without peritoneal signs, suprapubic fullness, and a large amount of clay-like stool in the rectal vault. Dehydration was suggested by sodium of 148 mmol/L and osmolarity of 313 mOsm/kg on serum chemistries. Chest radiograph (Figures 1 and 2) was obtained, followed by computed tomography (Figure 3). Chilaiditi's sign occurs when the bowel is interposed between the right hemidiaphragm and the liver. It occurs in less than 1% of the population and is more common in elderly males and those with chronic constipation, cirrhosis, obesity, or chronic lung disease.1 When symptoms of abdominal pain, nausea, vomiting, or respiratory distress occur, it is known as Chilaiditi's syndrome. Our patient was admitted for serial abdominal examinations, and he responded to conservative management with bladder decompression with Foley catheter and enemas. Surgery may be required if obstruction, volvulus, or bowel ischemia is suspected. Chilaiditi's sign is an important mimic of pneumoperitoneum. Haustral markings may be seen on plain films. Inverting the image or changing the penetration may assist in visualizing haustra. Air will not move if the patient is repositioned for additional images. Computed tomography is diagnostic. Distinguishing factors on ultrasound have also been described.2

A160 A SARCOMATOID CARCINOMA OF THE COMMON BILE DUCT PRESENTING AS PAINLESS JAUNDICE AND EXTRAHEPATIC BILIARY OBSTRUCTION

Abstract Background Sarcomatoid carcinomas are extremely rare tumors made of epithelial and mesenchymal elements. They have been found in various organs, but presence in the common bile duct (CBD) has only been reported a handful of times. Insight regarding the clinical history, histopathology, treatment, and prognosis is limited. The majority of CBD sarcomatoid carcinomas have occurred in elderly women, including this case. Surgical resection is the mainstay of treatment and the roles for chemotherapy and radiation therapy are undetermined. Prognosis is variable, but generally poor. Purpose Additional information regarding sarcomatoid carcinomas of the CBD will aid in establishing a timely diagnosis and may alter treatment options and prognosis. We aim to add to the limited literature surrounding this rare CBD neoplasm. Method A 71-year-old female presented with painless jaundice, decreased appetite, and weight loss. Initial investigations showed an alkaline phosphatase (ALP) of 3075 U/L, aspartate transaminase (AST) of 507 U/L, alanine aminotransferase (ALT) of 298 U/L, total bilirubin of 325.5 µmol/L, and direct bilirubin of 254.1 µmol/L. Initial computed tomography (CT) scan done showed marked intra- and extrahepatic biliary ductal dilation with appropriate tapering and the presence of a distal CBD hyperdensity. Tissue biopsy obtained by endoscopic retrograde cholangiopancreatography (ERCP) was suspicious for a malignant peripheral nerve sheath tumor. The differential also included synovial sarcoma and sarcomatoid mesothelioma. Result(s) After multidisciplinary discussion involving hepatobiliary surgery, medical oncology, and radiation oncology, pancreaticoduodenectomy was performed; there was no role for neoadjuvant/adjuvant chemotherapy/radiation therapy. Final pathology revealed a well circumscribed mass with a narrow attachment to the posterior CBD, measuring 5.6 x 3.2 x 2.8 cm. Immunohistochemistry showed mixed differentiation with sarcomatoid, squamous, and glandular components, consistent with a sarcomatoid carcinoma. H3K27me3 expression was lost in neoplastic cells. Immunostaining showed strong expression of vimentin and weak expression of CD34, calretinin, CK5 and EMA. Post-operative course was complicated by pancreaticojejunal leak, surgical wound infection, myocardial injury, and esophageal stricturing. 14-weeks post-pancreaticoduodenectomy the patient was found to have C.difficile infection and a perforated viscus, exact location of which was not visible on imaging. Emergent laparotomy revealed a gastroduodenal leak and diffuse small bowel ischemia. The patient passed away shortly after emergent surgery. Conclusion(s) This case illustrates a rare presentation of sarcomatoid carcinoma within the CBD and highlights some of the diagnostic challenges, limited management strategies, complications, and potential poor prognosis of the disease. Further research is required to guide diagnosis and management, and ultimately improve patient outcomes. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Real-time quantification of intestinal perfusion and arterial versus venous occlusion using laser speckle contrast imaging in porcine model.

Real-time intraoperative perfusion assessment may reduce anastomotic leaks. Laser speckle contrast imaging (LSCI) provides dye-free visualization of perfusion by capturing coherent laser light scatter from red blood cells and displays perfusion as a colormap. Herein, we report a novel method to precisely quantify intestinal perfusion using LSCI. ActivSight™ is an FDA-cleared multi-modal visualization system that can detect and display perfusion via both indocyanine green imaging (ICG) and LSCI in minimally invasive surgery. An experimental prototype LSCI perfusion quantification algorithm was evaluated in porcine models. Porcine small bowel was selectively devascularized to create regions of perfused/watershed/ischemic bowel, and progressive aortic inflow/portal vein outflow clamping was performed to study arterial vs. venous ischemia. Continuous arterial pressure was monitored via femoral line. LSCI perfusion colormaps and quantification distinguished between perfused, watershed, and ischemic bowel in all vascular control settings: no vascular occlusion (p < 0.001), aortic occlusion (p < 0.001), and portal venous occlusion (p < 0.001). LSCI quantification demonstrated similar levels of ischemia induced both by states of arterial inflow and venous outflow occlusion. LSCI-quantified perfusion values correlated positively with higher mean arterial pressure and with increasing distance from ischemic bowel. LSCI relative perfusion quantification may provide more objective real-time assessment of intestinal perfusion compared to conventional naked eye assessment by quantifying currently subjective gradients of bowel ischemia and identifying both arterial/venous etiologies of ischemia.

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Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study.

Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3days; p < 0.001), similar median hospital LOS (19 vs. 14days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.

Diagnosis and surgical management strategy for pediatric small bowel obstruction: Experience from a single medical center.

Identifying Bowel strangulation and the approach and timing of surgical intervention for pediatric SBO are still uncertain. In this study, 75 consecutive pediatric patients with surgically confirmed SBO were retrospectively reviewed. The patients were divided into group 1 (n = 48) and group 2 (n = 27) according to the presence of reversible or irreversible bowel ischemia, which was analyzed based on the degree of ischemia at the time of operation. The results demonstrated that the proportion of patients with no prior abdominopelvic surgery was higher, the serum albumin level was lower, and the proportion of patients in which ascites were detected by ultrasonography was higher in group 2 than that in group 1. The serum albumin level was negatively correlated with ultrasonographic findings of the fluid sonolucent area in group 2. There were significant differences in the choice of surgical approach between group 1 and group 2. A symptom duration of >48 h was associated with an increased bowel resection rate. The mean length of hospital stay was shorter in group 1 than that in group 2. In conclusion, immediate surgical intervention should be considered in patients with a symptom duration of >48 h or the presence of free ascites between dilated small bowel loops on ultrasonography. Laparoscopic exploration is recommended as first-line treatment in patients with stable status.

Transverse colon volvulus post colonoscopy: a case report

Colonic volvulus accounts for 15-20% of large bowel obstructions. A very small percentage of colonic volvulus occur in the transverse colon and splenic flexure (&lt;5%). Colonic volvulus is a surgical emergency and requires urgent decompression to prevent bowel ischaemia and perforation. The incidence of colonic volvulus post colonoscopy is rare, and aetiology is believed to be secondary to insufflation in the context of a non-fixed/mobile segment. We present a case of a 75-year-old man who presented to the emergency department with abdominal pain following a colonoscopy. Computer tomography (CT) imaging of his abdomen demonstrated an acute volvulus of the transverse colon. He proceeded to a diagnostic laparoscopy where the volvulus had resolved. The transverse colon was noted to have redundancy, but both the caecal pole and splenic flexure were fixed. The decision was made not to respect the bowel. Transverse colon volvulus is a rare occurrence, and accurate assessment and investigation of patients presenting with obstructive bowel symptoms is essential to allow prompt surgical management and prevent ischaemia and bowel wall perforation.

Intestinal ischemia in COVID-19 patients: A case series

Introduction: COVID-19 is associated with increased coagulability, resulting in thromboembolic complications, such as intestinal ischemia. Diagnosis of bowel infarction can be challenging due to the severity of illness and the laboratory changes associated with the COVID-19 infection itself. Case Series: In a retrospective monocentric study, we performed an in-depth analysis of the clinical course of intestinal ischemia in COVID-19 patients. Biochemical analysis of coagulation status and predictors of ischemia was performed. We identified five patients with intestinal ischemia, between March 2020 and January 2021. Mean time-to-onset of intestinal ischemia from COVID-diagnosis was 31 days (range 16–56). Intestinal ischemia was confirmed by contrast-enhanced computed tomography (CT) scan. D-dimer, Fibrinogen, C-reactive protein (CRP), and lactate dehydrogenase (LDH) were elevated prior to the ischemic event, but no recurrent pattern could be distinguished in our case series. Lactate levels demonstrated a marked increase at the time of ischemia in our series. No consistent findings were made for prothrombin time (PT) and activated partial thromboplastin time (aPTT) and creatin kinase. Extent of bowel ischemia varied between limited to the ileocecal region (two patients), additional ischemia of small and large bowel (two patients) and extensive ischemia of entire intestinal tract (one patient). Four patients (80%) required an ileostomy. Planned relook surgery was performed in three patients (60%). Three (60%) patients died. Conclusion: In the five days prior to an intestinal ischemic event in COVID-19 patients, we did not identify a clear pattern in commonly used markers for coagulation status and ischemia. However, lactate levels showed a recurrent pattern of clear increase leading up to the ischemic event and rapid normalization after surgery. Unfortunately, our patient numbers were too small to draw definitive conclusions.

“A RETROSPECTIVE STUDY OF SURGICAL EMERGENCIES DURING COVID 19 PANDEMIC DUE TO THROMBOTIC COMPLICATIONS IN SVS INSTITUTE”

Background: To know the incidence of thrombotic events leading to surgical emergencies in covid patients in SVS Medical college and hospital, during covid pandemic. A structured retrospective study was conducted during rst and se Methods: cond wave of pandemic in our institute. Data of the patients who presented to the casualty with surgical emergencies such as acute bowel ischemia, acute ischemia limb ,Deep vein thrombosis, Portal vein thrombosis, was collected and diagnosis was established by consecutive analysis of all investigations performed. Results: Of all the abdominal emergencies eight cases, one case of bilateral lower limb ischemia, one case of unilateral upper limb ischemia, ten cases of Deep vein thrombosis were found to be positive for covid 19. Conclusion: The incidence of surgical emergencies during covid 19 pandemic due to thrombotic complications in our institute over a period of 2yrs is 3.83%

ICG fluorescence angiography is useful in guiding intra-operative surgical decision making in necrotizing enterocolitis

Background: Necrotizing enterocolitis (NEC) is a devastating condition in premature babies and surgical resection of the necrotic bowels is often required. Herewith, we reported the application of Indocyanine green fluorescence angiography (ICG-FA) as a novel approach to assist intra-operative decision.Methods: Between July 2021 and June 2022, ICG-FA was used in 3 patients with severe NEC requiring bowel resection. Their clinical presentations and operative findings were presented.Results: All babies were born at or before 32 weeks of gestation and the body weight at operation ranged from 1.14 to 1.5 kg. NEC developed on day 7 to day 10 of life. In all patients, ICG at a dosage of 0.1 mg/kg was injected intravenously before bowel resection . In case 1,a baby with intra-operative diagnosis of NEC totalis, ICG-FA demonstrated bowel perfusion in 25 cm proximal jejunum that was regarded as necrotic by inspection. Case 2 was a baby with severe inflammation affecting the entire bowel. The indistinguishable boundary between inflamed and ischemic bowel was made clear with ICG-FA and a life-long end colostomy was avoided. In case 3, the decision for primary anastomosis was supported by ICG-FA showing adequate perfusion at the resected ends. In all cases, there was no adverse reactions reported.Conclusion: ICG-FA is helpful in intra-operative decision during surgery for NEC. It is safe and informative regarding the intestinal perfusion. It helps to promote a more precise bowel resection and facilitate primary anastomosis.

MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents

ObjectivesTo evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI).MethodsThis 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients’ medical records. Subgroup comparisons were performed.ResultsNinety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition.ConclusionsMDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs.Key Points• In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches.• VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT.• An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.

Iliac Branch Devices in the Repair of Ruptured Aorto-iliac Aneurysms: A Multicenter Study

Purpose: To evaluate the outcomes of preserving the internal iliac artery (IIA) with iliac branched devices (IBDs) during acute endovascular repair of ruptured aortoiliac aneurysms. Material and Methods: This is a multicenter retrospective review of all consecutive patients undergoing acute endovascular repair of ruptured aortoiliac aneurysm with an IBD at 8 aortic centers between December 2012 and June 2020. A control group was used where the IIA was intentionally occluded from the same study period. The main outcome measures were 30-day mortality, major adverse events, technical success, and clinical success. Secondary outcomes were buttock claudication, primary patency, primary-assisted and secondary patency of the IBD, occurrence of endoleak types I/III, and reintervention. Values are presented as numbers and percentages or interquartile range in parenthesis. Results: Forty-eight patients were included in the study: 24 with IBD and 24 with IIA occlusion. There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. Twenty (83%) of them were hemodynamically stable during the procedure as opposed to 14 (58%, p=.23) with the IIA occlusion. Technical success was achieved in all cases with a procedure time of 180 (133–254) minutes, 45 (23–65) of which were from IBD. There were 2 (8%) deaths during the first 30 days and 2 (8%) major complications unrelated to the IBD, whereas in the IIA occlusion, the figures were 10 (42%) and 7 (29%), respectively. No patient in the IBD group developed buttock claudication compared to 8 (57%, p<.0001) in the IIA occlusion group; 1 (4%) patient developed bowel ischemia on both groups, with 1 in the IIA occlusion group needing resection. The median follow-up duration was 17 months (interquartile range 2–39) for the IBD group, with a primary patency of 60±14% at 3 years that went up to 92±8% with reinterventions (8 reinterventions in 6 patients). When the first 90 days were disregarded, there were no differences in survival between the groups. Conclusion: IBD is a valid alternative for maintaining the pelvic circulation for endovascular aortic aneurysm repair of ruptured aortoiliac aneurysms. The technical success and midterm outcomes are very satisfactory but require patient selection particularly regarding hemodynamic stability. The reintervention rate is considerable, mandating continuous follow-up. Clinical Impact This multicenter study demonstrates that ruptured aortoiliac aneurysms do not necessarily require mandatory occlusion of hypogastric arteries. Iliac branch devices are shown to be a valid alternative in highly selected cases, with good midterm results, even if reinterventions are required in a significant proportion of patients.