Bowel Necrosis Research Articles

A prospective observational study on etiology and management influencing outcome in operatively managed cases of acute intestinal obstruction in adults

Background: Acute intestinal obstruction (IO) is an important cause for acute abdomen in surgery which presents as abdominal pain, vomiting, distension, and constipation depending on the level and extent of obstruction of gastrointestinal tract. Early diagnosis of acute IO with understanding of various etiologies, use of better diagnostic techniques, and skillful operative management and good postoperative care, carries a good outcome. Aims and Objectives: The objective of the study was to find out the prevalence of various etiologies of acute IO and to study the various post-operative morbidity and mortality. Materials and Methods: This was a hospital-based observational study in the Department of General Surgery of Calcutta National Medical College and Hospital among patients with a diagnosis of acute IO during the study period of December 2016-April 2018. Results: Acute IO commonly affects male with a male: female ratio 7:3 and the most common occurrence in the age group of 40–59 years (30%). The most common etiology was obstructed/strangulated hernia (36%), followed by large bowel neoplasm (18%), adhesion (16%), intestinal tuberculosis (12%), and volvulus (10%). The most common surgical procedure performed was the resection of gangrenous bowel and creation of stoma (30%), followed by prosthetic repair of hernia (28%). The mortality rate of the present study was 12%. The morbidity rate was 46%attributing mainly to respiratory complications (30.4%) and surgical site infections (26.08%). Conclusion: This study demonstrates that the pattern of IO differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role.

A single-center experience of post-transplant atypical hemolytic uremic syndrome.

Atypical hemolytic uremic syndrome (aHUS) is a genetic-based thrombotic microangiopathy (TMA) that is mediated by the activation of the alternative complement pathway. Heterozygous deletion in CFHR3-CFHR1 occurs in 30% of the general population and has not been classically linked to aHUS. Post-transplant aHUS has been associated with a high rate of graft loss. Herein, we report our case series of patients who developed aHUS after solid-organ transplantation. Five consecutive cases of post-transplant aHUS were identified at our center. Genetic testing was performed in all but one. One patient had a presumed TMA diagnosis before transplant. One heart and 4 kidney (KTx) transplant recipients were diagnosed with aHUS based on the clinical picture of TMA, acute kidney injury, and normal ADAMTS13 activity. Genetic mutation testing revealed heterozygous deletion in CFHR3-CFHR1 in 2 patients and a heterozygous complement factor I (CFI) variant of uncertain clinical significance (VUCS) (Ile416Leu) in a third. Four patients were on tacrolimus, 1 had anti-HLA-A68 donor-specific antibody (DSA), and another had borderline acute cellular rejection at the time of aHUS diagnosis. Four responded to eculizumab, and 1 out of 2 patients came off renal replacement therapy. One KTx recipient died from severe bowel necrosis in the setting of early post-transplant aHUS. Calcineurin inhibitors, rejection, DSA, infections, surgery, and ischemia-reperfusion injury are common triggers that could unmask aHUS in solid-organ transplant recipients. Heterozygous deletion in CFHR3-CFHR1 and CFI VUCS may be important susceptibility factors acting as the first hit for alternative complement pathway dysregulation.

Open thrombectomy for mesenteric vein injury and acute thrombosis. Is it the right way? A case report and review of literature

Mesenteric vein thrombosis following injury to the superior mesenteric vein (SMV) during abdominal surgery is rare but it is associated with poor outcome. Late detection of mesenteric vein thrombosis results in extensive bowel gangrene resulting in poor patient outcome. Thrombectomy is rarely attempted at the time of re exploration even if the SMV is found to have a thrombus. But evidence suggests that performing thrombectomy at the time of re exploration will reduce the length of bowel resection. In addition venous thrombectomy will also result in better patient outcome. This case describes a patient who developed superior mesenteric vein thrombosis in the immediate post laparotomy period following SMV injury. She was managed successfully with open thrombectomy and bowel resection.
 

Aborted living-donor liver transplantation in the real-world setting, lessons from 13 937 cases of Vanguard Multi-center Study of International Living Donor Liver Transplantation Group

There are exceedingly uncommon but clearly defined situations where intraoperative abortions are inevitable in living-donor liver transplantation (LDLT). This study aimed to summarize the cases of aborted LDLT and propose a strategy to prevent abortion or minimize donor damage from both recipient and donor sides. We collected data from a total of 43 cases of aborted LDLT out of 13 937 cases from 7 high-volume hospitals in the Vanguard Multi-center Study of the International Living Donor Liver Transplantation Group and reviewed it retrospectively. Of the 43 cases, there were 24 recipient-related abortion cases and 19 donor-related cases. Recipient-related abortions included pulmonary hypertension (n = 8), hemodynamic instability (n = 6), advanced hepatocellular carcinoma (n = 5), bowel necrosis (n = 4), and severe adhesion (n = 1). Donor-related abortions included graft steatosis (n = 7), graft fibrosis (n = 5), primary biliary cholangitis (n = 3), anaphylactic shock (n = 2), and hemodynamic instability (n = 2). Total incidence of aborted LDLT was 0.31%, and there was no remarkable difference between the centers. A strategy to minimize additional donor damage by delaying the donor’s laparotomy or trying to open the recipient’s abdomen with a small incision should be effective in preventing some causes of aborted LDLT, such as pulmonary hypertension, advanced cancer, and severe adhesions.

Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit.

Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.

<em>Hymenoptera</em> (wasps, bees and ants) envenomation; a neglected tropical disorder in Sri Lanka

Sri Lanka is a tropical agricultural country in which a huge number of insect species have been reported. Bees, wasps, and ants belong to the order Hymenoptera mostly living in a colony, and colony members attack humans aggressively when they are disturbed. However, Hymenopterans are important in many ways such as pollination service to the agricultural and wild plants, honey production, natural pest control for crops, and being members of the food chains. Therefore, we should help to conserve Hymenopterans while safeguarding ourselves from them.Unpublished data confirm that thousands of hospital admissions and 15-30 deaths after insect stings in Sri Lanka annually. When Hymenopterans are disturbed, they sting the victims and inject venom as a defense mechanism. Immunological reactions and toxic effects are common clinical presentations after the Hymenoptera sting. Fatal anaphylaxis, rhabdomyolysis, acute kidney injury, acute myocardial infarction (Kounis syndrome), bowel gangrene, cerebral infarction, acute pulmonary oedema, multi organ failure, limb ischaemia and haemolytic anaemia have been reported in Sri Lanka.

Small bowel transmural necrosis secondary to acute mesenteric ischemia and strangulated obstruction: CT findings of 49 patients

Rationale and objectivesTransmural bowel necrosis (TBN) is an uncommon surgical emergency that represents an endpoint of occlusive acute mesenteric ischemia (AMI), nonocclusive AMI and small bowel obstruction (SBO). According to limited evidence, each etiology of TBN might demonstrate a different CT finding. This investigation aimed to 1) identify overall CT findings of TBN, and 2) compare CT findings of TBN in each etiology. Materials and methodsForty-nine consecutive adults (mean age, 64.6 years; 26 men) with occlusive AMI, nonocclusive AMI or SBO, and pathologically proven TBN were enrolled. All had a CT scan within 24 h before surgery. Clinical information was compiled from medical records. CT examinations were re-reviewed by two radiologists with disagreements resolved by the third radiologist. Data were analyzed and compared. ResultsTransmural bowel necrosis were secondary to arterial AMI, venous AMI, combined arterial and venous AMI, nonocclusive AMI, and SBO in 6, 5, 2, 10, and 26 patients, respectively. The CT findings were ascites (93.9%), abnormal wall enhancement (91.8%), bowel dilatation (89.8%), mesenteric fat stranding (89.8%), abnormal wall thickness (71.5%), pneumatosis (46.9%) and intrinsic hyperattenuation of bowel walls (22.5%). Portovenous gas, mesenteric venous gas, and pneumoperitoneum were present in 4 patients (8.2%). Bowel wall thickness was the only CT findings that showed a statistically significant difference among the 5 etiologies of TBN (P = 0.046). ConclusionsMost common CT findings of TBN were ascites, abnormal bowel wall enhancement, dilatation, and mesenteric fat stranding. Wall thickness differentiated five etiologies, being most thickened in venous AMI and normal in arterial AMI.

Unenhanced CT-based predictive model to identify small bowel necrosis in patients with mechanical small bowel obstruction

ObjectivesTo investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model.MethodsFrom May 2017 to December 2021, the patients with mechanical SBO admitted to our hospital were retrospectively collected. Taking pathology-confirmed small bowel necrosis as the gold standard, the experimental group was composed of patients with small bowel necrosis confirmed by pathology, and the control group was composed of patients with no intestinal necrosis confirmed by surgery or successful conservative treatment with no recurrence of intestinal obstruction during 1-month followed-up.ResultsA total of 182 patients were enrolled in this study, 157 patients underwent surgery, of which 35 patients were accompanied with small bowel necrosis and 122 patients were not (33 patients with ischemic findings at surgery without necrosis). Finally, there were 35 patients in the experimental group and 147 patients in the control group. Multivariable logistic regression showed that increased attenuation of small bowel wall (P = 0.002), diffuse mesenteric haziness (P = 0.010), difference of CT value between mesenteric vessel and aorta (P = 0.025) and U-/C-shaped small bowel loop (P = 0.010) were independent risk factors for the diagnosis of mechanical SBO with small bowel necrosis. Through internal verification, the area under curve (AUC) of the predictive model reached 0.886 (95%CI: 0.824–0.947), and the calibration result was moderate.ConclusionMultiple features (increased attenuation of small bowel wall; difference of CT values between mesenteric vessel and aorta; diffuse mesenteric haziness; and U-/C-shaped small bowel loop) of unenhanced CT have clinical value in the diagnosis of mechanical SBO with small bowel necrosis. The predictive model based on these four features could achieve satisfactory efficiency.

A rare case of small bowel gangrene and perforation following high voltage electrical injury

This case is a 42-year-old male with an alleged history of electric shock. About 8 h after the insult, an ulcer in the right iliac fossa increased in size with fecal matter coming out. Contrast-enhanced computed tomography of the abdomen revealed a full thickness anterior abdominal wall defect with prolapse of a segment of the distal ileal loop, showing discontinuous wall and no wall enhancement suggestive of evisceration and perforation of bowel with gangrene.

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Idiopathic Small Bowel Volvulus: A Case Report

Idiopathic small bowel volvulus is a rare cause of acute intestinal obstruction by strangulation in adults and is defined by the twisting of a segment of the small bowel around its mesenteric axis with no obvious underlying congenital or acquired cause.
 This article reports the case of a 56-year-old patient, chronic smoker and cannabis user, who was admitted with febrile occlusive syndrome and generalized abdominal contracture.
 The abdominal CT scan showed a distension of the small intestines upstream of a probable small bowel volvulus, associated with signs of digestive distress.
 Surgical exploration revealed a large peritoneal effusion of distressed fluid, with a volvulus of the distal small bowel causing 1.80 m of small bowel and coecum necrosis from 2.20 ADJ without rotational abnormality or docking defect.

Mid-term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair Following Thoracic Endovascular Aortic Repair

The aim of this study was to evaluate the safety and durability of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR). Data were analyzed for 65 patients (20 men; 30.8%) undergoing open TAAA repair (TAAAR) at a median of 2.6 years after TEVAR. Outcomes were compared between patients with and without Marfan syndrome (MFS) (n = 39; 60%). Mean age at TAAAR was 41 ± 11 years. Before TAAAR, 27 patients (41.5%) underwent re-TEVAR. Type I endoleak was seen in 21 patients (32.3%), type II endoleak in 4 (6.2%), patent false lumen in 38 (58.5%), aortic rupture in 10 (15.4%), and graft infection in 2 (3.1%). TAAAs were Crawford extent I in 10 (15.4%), II in 23 (35.4%), III in 23 (35.4%), and IV in 9 (13.8%). Maximal TAA size was 72 ± 22 mm (Table). Emergent TAAAR was done in 11 (16.9%). Femoro-femoral bypass was used in 36 (55.4%) and circulatory arrest in 23 (35.4%). Endograft was explanted in 33 (50.8%). Stroke, paraplegia, and acute kidney injury occurred in five (7.7%), seven (10.8%), and seven (10.8%) patients, respectively. Operative mortality was 16.9% (11/65), due to stroke (n = 5), respiratory failure (n = 2), bowel necrosis (n = 1), low cardiac output (n = 1), and coagulopathy (n = 2). Endograft extraction was predictive of operative death (odds ratio, 5.63; 95% confidence interval, 1.11-28.52; P = .037). Clinical and computed tomography follow-up was complete in 100% (54/54) at a mean of 3.1 ± 1.4 years. Branch vessel events occurred in 11 patients at a median of 10 months (range, 0.4-18.3), including intercostal atrial (IA) dilation in six, IA stenosis in three, and iliac stenosis in one, exclusively seen in MFS (32.4% [11/34] vs 0; P = .004). Aortic graft infection occurred in two patients at 0.4 and 3.7 years, respectively; one died and one survived after medical therapy. Ascending aortic + total arch repair was done for retrograde type A dissection in two patients at 2.5 and 1.3 years, respectively. Late death occurred in four patients at 1.9 ± 1.7 years from aortotracheal fistula in two, and sepsis and stroke in one each. At 5 years, survival and freedom from reoperation were 73.6% and 95.7%, respectively, which did not differ significantly between MFS and non-MFS patients (P = .084 and P = .465, respectively). In this series of thoracoabdominal aortic aneurysm after TEVAR, open repair was safe and achieved favorable early and midterm outcomes. Endograft extraction predicted early mortality risk. Although not at increased risk of mortality and late reoperation, patients with MFS are prone to developing branch vessel dilation/stenosis early after open TAAAR.TablePatient profile, operative data, and late outcomes of thoracoabdominal aortic aneurysm repair (TAAAR) after thoracic endovascular aneurysm repair (TEVAR)VariableWhole series (n = 65)MFSP valueYes (n = 39)No (n = 26)Baseline characteristics Age, years41 ± 1134 ± 752 ± 8<.001 Male gender20 (30.8)18 (46.2)2 (7.7).001 Body mass index >25 kg/m221 (32.3)8 (20.5)13 (50).017 Hypertension34 (52.3)11 (28.2)23 (88.5).000 Smoking23 (35.4)8 (20.5)15 (57.7).003 Indications for prior TEVAR.001Type B aortic dissection43 (66.2)23 (59)20 (76.9)Type A aortic dissection18 (27.7)16 (41)2 (7.7)Penetrating aortic ulcer3 (4.6)0 (0)3 (11.5)Aortic rupture1 (1.5)0 (0)1 (3.8) Maximal proximal aortic size, mm30 ± 529 ± 431 ± 5.110 Maximal distal aortic size, mm72 ± 2266 ± 1580 ± 27.014Operative data Emergency repair11 (16.9)2 (5.1)9 (34.6).005 Distal perfusion strategy.019Simple aortic clamping9 (13.8)4 (10.3)5 (19.2).465Aorto-iliac bypass20 (30.8)17 (43.6)3 (11.5).007Femoro-femoral bypass36 (55.4)18 (46.2)18 (69.2).080Deep hypothermic circulatory arrest23 (35.4)9 (23.1)14 (53.8).017 Part or complete graft extraction33 (50.8)15 (38.5)18 (69.2).023 Clamp and ischemic times, minutesProximal aortic clamp time16 (0-21)17 (12-26)0 (0-17.5).026Intercostal artery38 (23-59)38 (21-57)39 (27-69).558Superior mesenteric artery33 (24-43)36 (24-45)28 (24-36).098Celiac artery, unprotected40 (30-57)45 (35-59)31 (25-39).006Maximal renal artery44 (35-52)45 (40-55)37.5 (28-46).008 Intercostal/lumbar artery reattachment52 (80)34 (87.2)18 (69.2).114 Reconstruction of subclavian artery15 (23.1)9 (23.1)6 (23.1)1.000 Reconstruction of right iliac artery37 (57.8)24 (61.5)13 (52).604 Cerebrospinal fluid drainage45 (69.2)31 (79.5)14 (53.8).053Early outcomes Operative mortality11 (16.9)5 (12.8)6 (23.1).325 Stroke5 (7.7)2 (5.1)3 (11.5).382 Paraplegia7 (10.8)2 (5.1)5 (19.2).106 Reoperation for bleeding8 (10.8)5 (11.6)3 (9.7)1.000 Acute kidney injury requiring dialysis7 (10.8)3 (7.7)4 (15.4).424 Pulmonary complications19 (29.2)7 (17.9)12 (46.2).025 Gastrointestinal dysfunction4 (6.2)2 (5.1)2 (7.7)1.000 Length of intensive care unit stay, days3.7 (1.7-5.6)3.5 (1.6-5.3)4.3 (2.4-7.1).090Late outcomes(n = 54, %)(n = 34, %)(n = 20, %) Follow-up duration, years3.1 ± 1.43.3 ± 1.32.7 ± 1.5.275 Late death4 (7.4)1 (2.9)3 (15).138 Late reoperation2 (3.7)2 (5.9)0 (0).525 Branch vessel dilation or stenosisa11 (20.4)11 (32.4)0 (0).004 5-year Kaplan-Meier survival, %73.6 (58.9-83.8)81.0 (59.7-91.7)61.5 (37.2-78.8).084 5-year freedom from reoperation, %95.7 (72.9-99.4)93.3 (61.3-99.0)100 (100).465MFS, Marfan syndrome; TAAAR, thoracoabdominal aortic aneurysm repair; TEVAR, thoracic endovascular aortic repair.Data are presented as mean ± standard deviation, median (interquartile range), number (%), or % (95% confidence interval).aRefers to aneurysmal dilation or stenosis (or occlusion) in abdominal aortic branches and the iliac arteries. 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Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

Gangrenous Bowel Obstruction Managed With Local Tumescent Anesthesia and MAC

Since the mid-1980s, Klein’s tumescent anesthesia has been used routinely in different surgical specialties such as cosmetic surgery, dermatology, vascular surgery, reconstructive plastic surgery, and breast surgery. The tumescent anesthesia technique was developed by Dr Jeffrey Klein, a board-certified dermatologist. The technique was first published in 1987. Tumescent means “swelling.” This technique involves injection of an ultra-dilute lidocaine and epinephrine solution into the surgical planes offering multiple advantages including, but not limited to, postoperative analgesia, reduced blood loss, and avoidance of general anesthesia. The standard liter of Klein’s solution contains lidocaine 1 g, epinephrine 1 mg, and sodium bicarbonate 12.5 mg. Multiple modifications and variations have been implemented and used over the years, an evolution from Klein’s original description. While tumescent anesthesia started in liposuction procedures, its application has now extended into a wider variety of procedures and specialties. In this article, we present a case of tumescent anesthesia in a critically ill general surgery patient who presented with an acute life-threatening surgical emergency. The patient was assessed to be a very high risk for general anesthesia, and after collaborative discussion between the surgical and anesthesia teams and taking informed consent from the patient, the decision was made to proceed with surgery under monitored intravenous sedation with tumescent anesthesia. The patient had an uneventful recovery and survived a very high mortality surgical emergency. He was subsequently discharged back to his nursing home in stable condition. Tumescent anesthesia has become tremendously popular in cosmetic surgery. Tumescent anesthesia allows patients to have surgical procedures in an ambulatory setting, avoid general anesthesia, and allow for better pain control postoperatively. While tumescent anesthesia is used in other specialties, the field of general surgery has not widely adopted tumescent anesthesia. Many general surgeons and anesthesiologists are not familiar with the technique and how to implement it in their practice. It is of utmost importance to understand the pharmacokinetics of tumescent solution and safe implementation. Tumescent anesthesia with monitored anesthesia care is here reported as an alternative to general anesthesia in the care of a moribund patient with multiple comorbidities requiring open abdominal surgery. Close cooperation between the surgeon and the anesthesiologist made the successful conduct of this case possible.

To identify the risk factors of sigmoid volvulus in cenral India tribal area population

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. 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. 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.SV predominates in older men. Most patients with SV have a history of alcohol abuse, a high-fiber diet, and low socioeconomic status.

Study of tumor necrosis factor receptor in the inflammatory bowel disease.

Ulcerative colitis (UC) and Crohn's disease (CD) are part of Inflammatory Bowel Diseases (IBD) and have pathophysiological processes such as bowel necrosis and enteric neurons and enteric glial cells. In addition, the main inflammatory mediator is related to the tumor necrosis factor-alpha (TNF-α). TNF-α is a me-diator of the intestinal inflammatory processes, thus being one of the main cytokines involved in the pathogenesis of IBD, however, its levels, when measured, are present in the serum of patients with IBD. In addition, TNF-α plays an important role in promoting inflammation, such as the production of interleukins (IL), for instance IL-1β and IL-6. There are two receptors for TNF as following: The tumor necrosis factor 1 receptor (TNFR1); and the tumor necrosis factor 2 receptor (TNFR2). They are involved in the pathogenesis of IBD and their receptors have been detected in IBD and their expression is correlated with disease activity. The soluble TNF form binds to the TNFR1 receptor with, and its activation results in a signaling cascade effects such as apoptosis, cell proliferation and cytokine secretion. In contrast, the transmembrane TNF form can bind both to TNFR1 and TNFR2. Recent studies have suggested that TNF-α is one of the main pro-inflammatory cytokines involved in the pathogenesis of IBD, since TNF levels are present in the serum of both patients with UC and CD. Intravenous and subcutaneous biologics targeting TNF-α have revolutionized the treatment of IBD, thus becoming the best available agents to induce and maintain IBD remission. The application of antibodies aimed at neutralizing TNF-α in patients with IBD that induce a satisfactory clinical response in up to 60% of patients, and also induced long-term maintenance of disease remission in most patients. It has been suggested that anti-TNF-α agents inactivate the pro-inflammatory cytokine TNF-α by direct neutralization, i.e., resulting in suppression of inflammation. However, anti-TNF-α antibodies perform more complex functions than a simple blockade.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis.

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

CLINICO-RADIOLOGICAL FEATURES IN CORROBORATION WITH INTRAOPERATIVE FINDINGS OF INTUSSUSCEPTION IN INFANTS-LESSONS LEARNED FROM CASES SERIES IN REMOTE SET UP DURING OVERSEAS DEPLOYMENT (EAST AFRICA)

The incidence rate of Intussusception is higher in some developing countries, which leads to a higher rate of complications in those areas especially in children. Plain abdomen radiograph is the initial radiological examination to be done in a case of acute abdomen in a peripheral set up. Ultrasound (USG) would be best modality for initial screening even in remote areas as it has the advantages of being non-invasive, rapid, and not only cost effective but also avoids radiation exposure and easily available even in peripheral set up in today’s era. Moreover, can be done bedside, even with less experienced readers. Here, in this case series, we are discussing the clinic-radiological and intraoperative features of in intussusception in infants, while we were deployed in remote areas of Eastern Africa with limited settings. This article highlights the importance of strong clinical suspicion and timely ultrasonographic evaluation as primary screening modality in suspected cases of intussusception. USG not only confirms the diagnosis with classical signs and appearances but also help rule out other conditions mimicking the diagnosis and will decrease the risk for bowel obstruction, perforation, necrosis, and death by aiding in timely surgical intervention. In addition to this, the lesson learned from this case series is that, assessment of length of segment of bowel telescoping into the other segment will aid in deciding mode of surgical intervention.

The Ileo-Sigmoid Knotting a Rare cause of Acute Intestinal Obstruction: About a Case

The ileosigmoid knotting is an exceptional clinical entity, it is a surgical emergency characterized by a strangulation of the small bowel by forming a knot around the base of the sigmoid colon with risk of rapid necrosis of the small bowel and colon. We report the case of a young women admitted for intestinal obstruction; and in which the diagnosis of ileo-sigmoid knotting was made on CT. Through this case and a review of the literature we will define the diagnostic, therapeutic and prognostic aspects of this rare clinical entity.

Utility of Serum L-lactate in Identifying Ischemia in Acute Intestinal Obstruction: A Prospective Observational Study.

Introduction In cases of intestinal obstruction, increasing luminal dilatation compromises bowel wall perfusion, eventually resulting in intestinal ischemia and bowel necrosis in advanced cases. Elevated L-lactate, as a biomarker of ischemia, may indicate the presence of bowel ischemia in cases of obstruction. The objective of this study was to evaluate the value of serum L-lactate measurement in predicting the presence of intraoperatively observed intestinal ischemia in patients with acute intestinal obstruction. Methods Patients diagnosed with acute intestinal obstruction were prospectively studied over an 18-month period. Serum L-lactate values were assayed twice: at the time of presentation and following appropriate fluid resuscitation. Receiver operating characteristic (ROC) curve analysis was applied to determine the predictive value of serum L-lactate in detecting intestinal ischemia. Results One hundred forty-four cases of intestinal obstruction were included in this study, of which 91 underwent operative intervention. Intestinal ischemia was identified in 52 cases and categorized intra-operatively as reversible (n = 33) and irreversible (n = 19). ROC analysis showed a good predictive value of serum L-lactate after fluid resuscitation for irreversible intestinal ischemia (area under the curve (AUC) = 0.884, 95% confidence interval (CI), 0.812-0.956). An L-lactate cut-off of 19.1 mg/dL following fluid resuscitation was determined to have a sensitivity of 89.5%, a specificity of 72.9%, a positive predictive value of 46.6%, and a negative predictive value of 96.3% for gangrenous bowel. Conclusion Serum L-lactate is a good predictive tool for identifying intestinal ischemia during the management of intestinal obstruction. Serum L-lactate after resuscitation showed better predictive value for ischemic bowel.