Contrast Enema Research Articles

25, 50 and 75 years ago

25, 50 and 75 years ago

Iliopsoas abscess secondary to ingested metallic foreign body in a child

In most cases, ingested foreign bodies pass in alimentary tract silently. Rarely, ingested foreign bodies enter vermiform appendix. However, when it happened, they cannot reenter alimentary tract and may result in an inflammatory process. We report a case of iliopsoas abscess secondary to ingested metallic foreign body penetrating appendix. A 2-year-old child presented to our unit with her mother complaining that her child developed fever, repeated vomiting, and abdominal distension after one week of accidently ingestion of a rusty veil pin. Abdominal examination revealed right iliac tenderness and rebound tenderness. Abdominal ultrasound and multi-slice computer topography (MSCT) with intravenous contrast and gastrograffin enema revealed right iliopsoas abscess and metallic foreign body piercing appendicular wall with its tip seen in the iliopsoas abscess. We do appendectomy via transabdominal approach with good drainage of the abscess cavity. We discharged our patient on the fifth day postoperatively. The ingestion of inedible and indigestible objects is frequent in children. In most cases, ingested foreign bodies (FB) pass in alimentary tract silently. Rarely, ingested foreign bodies enter vermiform appendix and if it happened it may result in devastating complications as iliopsoas abscess. The is necessary to increase awareness of potential complications of ingested foreign bodies, especially in children.

Diagnostic efficacy of high-frequency ultrasound and X-ray contrast enema in colonic strictures after necrotizing enterocolitis: a retrospective study

To compare the efficacy of high-frequency ultrasound and X-ray contrast enema in the diagnosis of colonic strictures after necrotizing enterocolitis. This study included pediatric patients who developed progressive abdominal distension or constipation after conservative treatment for necrotizing enterocolitis at our hospital between June 2012 and April 2020. All patients had high-frequency ultrasounds and X-ray contrast enema, and we used surgery, pathology, and telephone return visits as the reference standard. Patients with colonic strictures were confirmed by surgery and pathology. A patient was considered without colonic stricture if no stricture was reported or did not have related symptoms during telephone return visits. The areas under the Receiver operating characteristic (ROC) curves were used as evaluation indexes to compare the differential efficacy of high-frequency ultrasound and X-ray contrast enema. A total of 81 patients have been included in this study. Among them, 49 patients were diagnosed with colonic strictures after necrotizing enterocolitis. The AUCs for high-frequency ultrasound and X-ray contrast enema were 0.990 vs 0.938, respectively (p > 0.05). The diagnostic efficacy of high-frequency ultrasound was similar to that of X-ray contrast enema, furthermore this study also demonstrates the benefits of using high-frequency ultrasound to identify colonic strictures after necrotizing enterocolitis.

MRI diagnose post-operative anastomotic leak in patients with rectal cancer: preliminary experience

BackgroundAnastomotic leakage (AL) is one of the most serious postoperative complications after colorectal anastomosis. This study aims to evaluate the feasibility and diagnostic accuracy of magnetic resonance imaging (MRI) in the early detection of AL in patients with clinically suspected AL after rectal anterior resection.MethodsThis was a prospective study including patients who underwent anterior resection and postoperative MRI examination. AL was diagnosed by comprehensive indictors, which were mainly confirmed by clinical signs, symptoms, and retrograde contrast enema (RCE) radiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of diagnosing AL with MRI were calculated.ResultsIn total, 347 patients received anterior resection for rectal cancer, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination. The median time interval from surgery to MRI was 10 days (3–21 days). The median distance from anastomosis to anal verge was 4.0 cm (2.0–10 cm), and 11 patients underwent diverted ileostomy. Eighteen patients had an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL in the MRI examination. The overall sensitivity and specificity were 94.4% (95% CI 70.6% to 99.7%) and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). For patients who had anastomosis less than 5 cm, the diagnostic accuracy of MRI was 93.7% (15/16). T2-weighted imaging with fat suppression can effectively reveal the leak track.ConclusionsThe accuracy of plain MRI examination in diagnosing AL was favorable for patients with a suspected AL. T2-weighted imaging with fat suppression was the best imaging modality to diagnose AL. A multicenter prospective study with more samples is needed to further determine the safety and feasibility of MRI in the diagnosis of AL.

Primary Trans-anal Endorectal Pull Through for The Management of Hirschsprung Disease: Our Experience of 20 Cases

Hirschsprung’s disease can be defined in terms of the aganglionic part of the colon and the definitive treatment is a one-stage trans-anal endorectal pull-through surgery. Objectives: To find out the efficacy and safety of this one-stage pull-through. Mostly the surgery is done in early childhood or the neonatal period, as the case is less frequently reported in older children and adolescents. Methods: A retrospective study was conducted including 16 males and 4 females. 20 cases including children of 6 months to 14 years, all were diagnosed with Hirschsprung’s disease in the study duration of two years. The diagnostic criteria of these patients included; Clinical history of delayed passage of meconium, contrast enema, and rectal biopsy. Definitive variables were; Age, sex, and length of the aganglionic part of the colon. Results: All the patients included in the study had distended abdomens and persistent constipation. All of them have an aganglionic colon, a diagnosing feature of Hirschsprung’s disease. All patients underwent the trans-anal endorectal one-stage pull-through. The average operative time recorded was 150 minutes. Post-operative complications were also recorded including anastomosis leakage (only in one case; for that a diversion colostomy was done), anastomotic stenosis or stricture (not reported in any case), enterocolitis and perineum irritation (In four cases), Transient fecal incontinence is a major complication (11 cases had transient fecal incontinence which resolved spontaneously with 1 to 2 weeks). No death had been recorded. Conclusion: For the treatment of Hirschsprung’s disease, primary trans-anal endorectal pull-through is a safe and efficient technique.

Distal colo-colonic intussusception caused by Burkitt's lymphoma

Intussusception in the pediatric population is most commonly identified in children under two years of age in the ileocecal region. Our case is a rare example of distal colo-colonic intussusception in a seven-year-old male. After air contrast enema reduction of the intussusception, he was found on fluoroscopic images and CT scan to have an intraluminal lead point in the splenic flexure that resulted in almost immediate recurrence and was unresectable endoscopically. He underwent a laparoscopic-assisted partial left colectomy. Final pathology confirmed the diagnosis of Burkitt's lymphoma. There is a paucity of guidance with regards to colo-colonic intussusception with suspicion for a pathologic lead point. Based on our experience, after reduction by air enema, we recommend imaging, colonoscopy with either resection or biopsies, and surgical resection if necessary to remove the lead point and establish a tissue diagnosis. Based on both the high likelihood of lymphoma and its responsiveness to chemotherapy, we recommend grossly negative margins with lymph node sampling rather than traditional oncologic resection with complete lymphadenectomy.

Functional constipation refractory to medical management: The colon is the problem

BackgroundManagement of refractory constipation in children has not been standardized. We propose a protocolized approach which includes a contrast enema, anorectal manometry and exclusion of Hirschsprung disease (HD). For those without HD or with normal sphincters, an assessment of the colonic motility may be needed. The subgroups of dysmotility include (1) slow motility with contractions throughout, (2) segmental dysmotility (usually the sigmoid), or (3) a diffusely inert colon. We offered a Malone appendicostomy in all groups with the hope that this would avoid colonic resection in most cases. MethodsPatients with medically refractory constipation were reviewed at a single institution (2020 to 2021). For patients without HD or an anal sphincter problem, assessment of colonic motility using colonic manometry was performed followed by a Malone appendicostomy for antegrade flushes. ResultsOf 196 patients evaluated for constipation refractory to medical management, 22 were felt to have a colonic motility cause. These patients underwent colonic manometry and Malone appendicostomy. 13 patients (59%) had a slow colon but with HAPCs throughout, 5 (23%) had segmental dysmotility, and 4 (18%) had a diffuse colonic dysmotility. 19 (86%) responded well to antegrade flushes with 17 reporting no soiling and 2 having occasional accidents. 3 patients (14%) failed flushes and underwent a colon resection within 6-month following Malone procedure. ConclusionWe propose a protocol for medically refractory constipation which provides a collaborative framework to standardize evaluation and management of these patients with antegrade flushes, which aids in avoidance of colonic resection in most cases. Level of evidenceLevel IV

CT scan for early diagnosis of anastomotic leak after colorectal surgery: is rectal contrast useful?

Computed tomography (CT) scan with rectal contrast enema (RCE-CT) could increase the detection rate of anastomotic leaks (AL) in the early postoperative period following colorectal surgery, compared to CT scan without RCE. The aim of this study was to assess the benefit of RCE-CT for the early diagnosis of AL following colorectal surgery. Patients who had a RCE-CT for suspected AL in the early postoperative period following colorectal surgery with anastomosis between January 2012 and July 2019 at the Dijon University Hospital were retrospectively included. All images were reviewed by two independent observers who were blinded to the original report. The reviewers reported for each patient whether an AL was present or not in each imaging modality (CT scan, then RCE-CT). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were then calculated to determine the diagnostic performance of each modality. One hundred and thirty-nine patients were included. RCE-CT had an increased NPV compared to CT scan (82% vs 77% (p = 0.02) and 84% vs 68% (p < 0.0001) for observers 1 and 2, respectively). RCE-CT had an increased sensitivity compared to CT scan (79% vs 48% (p < 0.0001) for observer 2). RCE-CT had a significant lower false-negative rate for both observers: 18% vs 23% (p = 0.02) and 16% vs 32% (p < 0.0001). RCE-CT improved the detection rates of AL in the early period following colorectal surgery. RCE-CT should be recommended when a CT scan is negative and AL is still suspected.

Pictorial review: radiological diagnosis of anastomotic leakage with water-soluble contrast enema after anterior resection of the rectum.

For patients who have undergone colorectal surgery, anastomotic leakage is a serious and challenging complication with a variable rate ranging between 1.8% and 19.2%. Postoperative anastomotic leaks after colorectal surgery can have severe consequences for patients, particularly ones who present with few or no symptoms. Computed tomography and/or water-soluble contrast enema (WSE) are the most frequently utilized imaging methods to identify and diagnose anastomotic leaks early. WSE is a safe and complication-free procedure that allows to identify the presence of otherwise unrecognized anastomotic leaks, both in asymptomatic and symptomatic patients. Fluoroscopic rectal examination using a water-soluble contrast agent for postoperative patients is never an easy examination to perform since it requires careful preparation, skill, and knowledge. Four morphological types of anastomotic dispersion have been described: "saccular type", "horny type", "serpentine type" and "dendritic type". Among 4 types of leakage, dendritic and serpentine types are more frequently followed by clinical symptoms and none of the dendritic type resolves spontaneously. On the other hand, the saccular and horny types have a better prognosis after healing of the loss and subsequent restoration of the ostomy as they consist of a cavity that provides a sort of physical barrier to the spread of inflammation. The aim of this pictorial essay was to illustrate the spectrum of imaging findings of morphological types of radiologic leakages on WCE in patients with colorectal surgical anastomosis. We have also tried to provide tips and tools to enable identification of radiological leakages on retrograde WCE, particularly of the smallest leaks which can be more easily missed.

Diagnostic value of the microcolon using ultrasonography in small bowel atresia

BackgroundMicrocolon helps diagnose small bowel atresia (SBA) using contrast enema. However, there are no ultrasonography (US) microcolon criteria for diagnosing SBA. Therefore, this study aimed to evaluate colon accuracy and other characteristics for diagnosing SBA by US, using surgical or clinical information as the reference standard.MethodsUS was performed on 46 neonates aged ≤ 7 days old. In the study group (n = 15), neonates with SBA were confirmed following surgery. In the study group without SBA (n = 15), neonates with other gastrointestinal problems besides SBA were confirmed by surgical or clinical follow-up. Sixteen neonates without gastrointestinal problems were classified as the control group. The colonic diameter was measured, and colonic gas was sought and observed. Statistical analysis was performed to compare US parameters between the study group and other two groups. The optimal cut-off value of the colonic diameter for SBA diagnosis was obtained using receiver operating characteristic analysis.ResultsColonic diameters (0.5 cm) in the study group (interquartile ranges [IQR], 0.5–0.6 cm) was significantly smaller than that in the group without SBA (0.9 cm; IQR, 0.8–1.2 cm) (P < 0.001) and in the control group (1.2 cm; IQR, 0.8–1.35 cm) (P < 0.001). Optimum cut-off value for diagnosing SBA was 0.65 cm (sensitivity, 90.3%; specificity, 86.7%; accuracy, 89.1%) for the colonic diameter. Combining microcolon and gas-negativity showed the best performance in SBA diagnosis using US, with increased accuracy (91.3%).ConclusionA colon < 0.65 cm in diameter should be called a microcolon; combining US with gas-negativity is an essential diagnostic basis for SBA.

Do preoperative factors predict success of antegrade continence enemas in children?

IntroductionAntegrade continent enemas (ACE) procedures are one treatment option in children with medically refractory constipation or encopresis and predicting success is difficult. We hypothesize that there are preoperative factors that can be identified to help with patient selection and family counseling. MethodsWe conducted a retrospective study of children who underwent a cecostomy or appendicostomy for an ACE program between 2015 and 2021. Underlying diagnosis, pre-operative bowel regimen and imaging were analyzed. Patients were reviewed for success at 3-, 6- and 12-months post-procedure. Data was analyzed with Fisher's Exact, Kruskal-Wallis and logistic regression where applicable with significance defined as p < 0.05. ResultsForty-three children were identified; 28 were male, 15 were female, mean age at time of operation was 8 years old. 76% were considered successful at 3-months, 86% at 6-months, and 87% at 12-months post- procedure. Univariate analysis showed that a pre-ACE retrograde enema program predicted success at 3-months (94% vs. 64% p = 0.03) but no difference at 6- or 12-months. At one year after ACE procedure there was a significant reduction in number of enteral medications (2 to 0, p < 0.01) and 94% of patients were on one or fewer at one year follow-up. Age, gender, weight at time of operation, contrast enema, anorectal manometry and colonic transit time results were not predictive of outcomes. ConclusionIn this study, we characterized expected time to success in our population as well as identified use of a pre-operative retrograde enema program as a potential predictor of success at 3-months in children undergoing an ACE procedure. Level of evidenceIV. Type of studyPrognosis study.

Determining the Correct Resection Level in Patients with Hirschsprung Disease Using Contrast Enema and Full Thickness Biopsies: Can the Diagnostic Accuracy be Improved by Examining Submucosal Nerve Fiber Thickness?

BackgroundIntraoperative resection level in patients with Hirschsprung disease (HD) is determined by contrast enema, surgeon's intraoperative judgement and full thickness biopsy (FTB) identifying ganglia. This study aims to evaluate diagnostic accuracy of contrast enema and FTB in determination of resection level and whether this can be improved by measuring submucosal nerve fiber diameter. MethodsWe retrospectively analyzed contrast enema and intraoperative FTBs obtained in our center, determining diagnostic accuracy for level of resection. Gold standard was pathological examination of resection specimen. Secondly, we matched transition zone pull-through (TZPT) patients with non-TZPT patients, based on age and length of resected bowel, to blindly compare nerve fibers diameters between two groups using group comparison. ResultsFrom 2000–2021, 209 patients underwent HD surgery of whom 180 patients (138 males; median age at surgery: 13 weeks) with 18 TZPTs (10%) were included. Positive predictive value of contrast enema was 65.1%. No caliber change was found in patients with total colon aganglionosis (TCA). Negative predictive value of surgeon's intraoperative judgement and FTB in determining resection level was 79.0% and 90.0% (91.2% single-stage, 84.4% two-stage surgery) respectively. Mean nerve fiber diameter in TZPT was 25.01 µm (SD= 5.63) and in non-TZPT 24.35 µm (SD= 6.75) (p = 0.813). ConclusionDetermination of resection level with combination of contrast enema, surgeon's intraoperative judgement and FTB results in sufficient diagnostic accuracy in patients with HD. If no caliber change is seen with contrast enema, TCA should be considered. Resection level or transition zone cannot be determined by assessment of submucosal nerve fiber diameter in FTB. Type of Studyclinical research paper.

Development, Validation, and Evaluation of the Pediatric Inflammatory Crohn’s Magnetic Resonance Enterography Index From the ImageKids Study

Cross-sectional imaging is important in the assessment of transmural inflammation in Crohn's disease (CD). Small bowel involvement is often more extensive in pediatric CD, requiring a panentering measuring tool. We undertook to develop a magnetic resonance enterography (MRE)-based index that would measure inflammation in all segments of the intestine, without rectal contrast. Children with CD underwent ileocolonoscopy and MRE and half were prospectively followed for 18 months when MRE was repeated. Item generation and reduction were performed by a Delphi panel of pediatric radiologists, a systematic literature review, a cross-sectional study of 48 MREs, and a steering committee. Formatting and weighting were performed using multivariate modeling adjusted by a steering committee. MREs were read locally and centrally. Reliability, validity, and responsiveness were determined using several clinimetric and psychometric approaches. Thirty items were initially generated and reduced to 5 using regression analysis on 159 MREs: wall thickness, wall diffusion weighted imaging, ulcerations, mesenteric edema, and comb sign. In the validation cohort of 81 MREs, the weighted global PICMI correlated well with the radiologist global assessment (r= 0.85; P < .001) and with the simple endoscopic score in a subsample with ileocolonic disease (r= 0.63; P < .001). Interobserver and test-retest reliability were high (interclass correlation coefficients, 0.84; 95% confidence interval [CI], 0.79-0.87; and 0.81, 95% CI, 0.65-0.90, respectively; both P < .001). Excellent responsiveness was found at repeated visits (n= 116 MREs; area under the receiver operating characteristic curve 0.96; 95% CI, 0.93-0.99). Transmural healing was defined as PICMI ≤10 and response as a change of >20 points with excellent discriminative validity (area under the receiver operating characteristic curve= 0.96; 95% CI, 0.93-0.99). The PICMI is a valid, reliable, and responsive index for assessing transmural inflammation in pediatric CD. It scores the entire bowel length and does not require intravenous contrast or rectal enema and, therefore, is suitable for use in children. (ClinicalTrials.gov, Number: NCT01881490.).

Can Infant Dyschezia Be a Suspect of Rectosigmoid Redundancy?

Infant dyschezia is a functional gastrointestinal disorder that occurs in children less than nine months of age. This disorder causes much anxiety among parents who consult different physicians when suspecting major intestinal problems. The aim of this study is to verify whether infant dyschezia involves an anatomic abnormality (redundancy) of the colon. In this retrospective study (48 months) we analyzed all the children younger than 9 months who came to our attention through the suspicion of gastrointestinal abnormality (Hirschsprung’s disease, anorectal malformations, colonic disorders or constipation). They all had a complete medical history, clinical examination and diagnostic tests, such as blood samples, suction rectal biopsy, a study of stool characteristics and, finally, a contrast enema. In cases with infant dyschezia, different colonic sizes and rectosigmoid length were measured, which created a ratio with the diameter of the second lumbar vertebra. These values were compared with those reported in the literature as normal for the age of one year. Of the 24 patients evaluated (mean age 4 months), 9 were excluded for different diagnoses (aganglionic megacolon, hypothyroidism, constipation). The comparison of the ratios obtained in the remaining 15 cases showed a significantly higher rectosigmoid length (redundancy) in children with dyschezia, 18.47 vs. 9.75 (p < 0.001). The rectosigmoid redundancy, a congenital anomaly already reported as a cause of refractory constipation, may be present in children with infant dyschezia.

Ileocecal valve-sparing surgery for duplication cysts in the terminal ileum: two case reports and literature review

BackgroundDuplication cysts close to the ileocecal valve are usually treated with ileocecal resection. However, loss of the ileocecal valve will lead to problems, especially in infants. Mucosectomy of the cyst would be a better alternative that preserves the ileocecal valve. We report two cases of duplication cyst in the terminal ileum successfully treated with mucosectomy.Case presentationCase 1. A 3-month-old boy with bilious emesis and abdominal distention was referred to our hospital with a diagnosis of small bowel obstruction caused by an abdominal cyst. Computed tomography revealed a cystic mass compressing the terminal ileum and causing mechanical small bowel obstruction. His general condition deteriorated quickly; emergency laparotomy was performed. Although the small intestines were dilated and partially twisted, there was no necrosis. Following intestinal decompression, a cystic mass adjacent to the terminal ileum was confirmed on the mesenteric side. Cyst mucosectomy was performed to preserve the ileocecal valve. Case 2. A 5-month-old boy with sudden onset of hematochezia was referred to our hospital with a diagnosis of intussusception. Following unsuccessful contrast enemas, emergency surgery was performed. A cystic mass adjacent to the terminal ileum was confirmed; there was no intussusception. Cyst mucosectomy was performed. Both patients had an uneventful postoperative course.ConclusionsCyst mucosectomy, which preserves the ileocecal valve, is safe and effective for treating duplication cysts in the terminal ileum.

Delayed Repeat Contrast Enema for Treatment of Pediatric Intussusception.

Ileocolic intussusception is a common cause of pediatric bowel obstruction. Contrast enema is successful in treating the majority of patients, and if initially unsuccessful, approximately one-third may be reduced with repeat enemas. We sought to study protocol implementation for delayed repeat enema in pediatric patients not reduced completely by an initial contrast enema. Our aims were to assess repeat enema success rates and outcome differences in preprotocol and postprotocol patients with respect to (1) intussusception recurrence, (2) surgical intervention and complication rates, and (3) length of stay. We performed a retrospective review of treatment and clinical outcomes prior to and following protocol implementation for repeat enema for intussusception at two tertiary pediatric referral hospitals. The preprotocol period was defined from 2/2013 to 2/2016, and the postprotocol period was from 8/2016 to 11/2019. There were 112 patients in the preprotocol group, with 74 (66%) having successful reduction following the first enema. Of the 38 patients without successful reduction, 16 (42%) patients underwent repeat enema, and five were successful (31%). The postprotocol group included 122 patients, with 84 (69%) having successful first reduction. Of the 38 patients that failed, 25 patients (66%) underwent repeat enema, of which 13 (52%) were successful. Compared to preprotocol patients, postprotocol patients had significantly more enemas repeated and a trend toward fewer surgical interventions. Protocol implementation of repeat delayed enemas was significantly associated with an increased rate of repeat enemas at our institutions and reduced need for operative intervention during the index stay.

Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema

IntroductionContrast enemas are often made prior to stoma reversal in order to detect distal intestinal strictures distal of the stoma. If untreated these strictures can cause obstruction which might necessitate redo-surgery. However, the value of contrast enemas is unclear. Therefore, we aim to evaluate the contrast enema's diagnostic accuracy in detecting strictures in children with a stoma. MethodsYoung children (≤3 years) treated with a stoma between 1998 and 2018 were retrospectively included. The STARD criteria were followed. Patients treated for anorectal malformations and those that died before stoma reversal were excluded. Surgical identification of strictures during reversal or redo-surgery within three months was used as gold standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) reflected diagnostic accuracy. ResultsIn 224 included children, strictures were found during reversal in 10% of which 95% in patients treated for necrotizing enterocolitis. Contrast enema was performed in 68% of all patients and detected 92% of the strictures. In the overall cohort, the sensitivity was 100%, specificity 98%, PPV 88% and NPV 100% whilst the AUC was 0.98. In patients treated for NEC, the sensitivity was 100%, specificity 97%, PPV 88% and NPV 100% whilst the AUC was 0.98. ConclusionStrictures prior to stoma reversal seem to be mainly identified in patients treated for NEC and not in other diseases necessitating a stoma. Moreover, the contrast enema shows excellent diagnostic accuracy in detecting these strictures. For this reason we advise to only perform contrast enemas in patients treated for NEC. Level of EvidenceII

Surgical treatment approach of patients with a complicated form of the diverticular disease in combination with colon cancer

The aim was to make a retrospective analysis of the results of surgical treatment of patients with the complicated diverticular disease in combination with colon cancer. We analyzed retrospectively the medical data of 206 patients who underwent surgical treatment of the complicated diverticular disease for the period 1998–2018. Among them, 26 patients still had malignant neoplasms of the colon. The diagnoses were established using the instrumental diagnostic methods (colonic contrast enema and colonoscopy) and were confirmed by the intraoperative findings and the histological analysis. At the same time, in all operations performed, despite the cancer location and the complicated diverticular disease forms, the oncological principles were observed and the prevalence of the inflammatory diverticular process was taken into account.

Prevention and management of anastomotic leakage after colorectal surgery: A Swiss national consensus

Abstract Objective Anastomotic leakage (AL) is one of the most feared complications of colorectal surgery. Despite surgical improvements, AL incidence remains significant and guidance on its prevention and management is lacking. The aim of the study was to achieve a Swiss nationwide consensus on clinical prevention and management of AL. Methods A three-step Delphi consensus meeting was performed in 2020 involving 78 Swiss surgeons from 40 centers. A steering-group drafted the questions, gathered best available evidence which was discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement. Results The three consensus meetings were attended by 66, 57 and 37 surgeons, respectively. Surgeons’ median experience was 14 years, with 47% performing &amp;gt;50 colorectal resections yearly. Consensus was reached on routine use of preoperative nutritional screening (100%) using nutritional scores (88%) and &amp;gt;10% weight loss (95%). but not low BMI (63%) or low albumin (64%). Consensus was reached for no bowel preparation (BP) prior to right colectomy (RC) (76%) and for mechanical BP with oral antibiotics prior anterior resections (AR) (70%). No consensus was found on BP prior left colectomy (LC). Respondents favored a side-to-side anastomosis (76%) after RC, with extra-corporeal confection (70%), without consensus on the anastomosis being stapled or hand-sewn; an end-to-end (73%), stapled (80%) anastomosis after LC and a stapled anastomosis (86%) after AR, irrespective of the anastomosis configuration type. Anastomotic control with transanal leak-test was supported by 92%, while ICG control did not reached consensus (67%). After TME, routine diversion was favored (73%), irrespective of neoadjuvant therapy (94%) or not (70%). Consensus was reached on routine postoperative CRP monitoring (94%). CT-scan with rectal contrast enema was the preferred investigation for suspected AL after RC or LC (82%) and AR (76%). Conservative management of AL, provided appropriate clinical state, was an acceptable option after LC (72%), AR with stoma (95%), but not after RC (59%) or AR without stoma (53%). Conclusion Consensus was reached on several clinical aspects for prevention and management of AL among Swiss colorectal surgeons, providing national guidance. Further data is required on intraoperative aspects of anastomosis confection and control to ensure broader consensus.

Methicillin-resistant Staphylococcus aureus enterocolitis in a 16-month-old boy: a case report

BackgroundMethicillin-resistant Staphylococcus aureus enterocolitis is a rare disease that typically affects immunocompromised adults. Most cases of pediatric enterocolitis are caused by Gram-negative bacteria, Gram-positive Clostridiodes difficile, or viruses. This is the first published case report of a toddler with methicillin-resistant Staphylococcus aureus enterocolitis.Case presentationA 16-month-old non-Hispanic White boy with no past medical or psychosocial history initially presented to the emergency room with abdominal pain and emesis. Past family history was pertinent only for his father having a history of constipation. He was diagnosed with intussusception and underwent successful contrast reduction on hospital day 0. The following day, the patient had recurrent symptoms and a repeat contrast enema showed no evidence of recurrent intussusception. A computed tomography scan was obtained, which was concerning for possible recurrence with compromised bowel. He was taken to the operating room for operative reduction and underwent an ileocecetomy with primary handsewn end-to-end anastomosis. His postoperative course was complicated by an anastomotic leak on hospital day 6 necessitating reoperation and creation of an end ileostomy with mucous fistula. He received intravenous metronidazole, ceftriaxone, and ceftazidime antibiotics during his hospital course. On postoperative day 12, the patient developed a sudden increase in ileostomy output, and stool cultures were obtained. His symptoms persisted despite diet modifications, stopping antibiotics, and initiating loperamide. Three days later, stool cultures resulted negative for Escherichia coli, Salmonella, Shigella, Campylobacter species, and Clostridiodes difficile but were positive for methicillin-resistant Staphylococcus aureus. The patient was started on a 10-day course of oral vancomycin and discharged home in good condition 4 days later. After 12 weeks, the patient underwent reversal of the ostomy and is doing well at the 1 month postoperative follow-up, now 5 months from his initial surgery.ConclusionsTo our knowledge, this is the first published report of a toddler being diagnosed with methicillin-resistant Staphylococcus aureus enterocolitis. Because methicillin-resistant Staphylococcus aureus enterocolitis is rare and has overlapping symptoms with more common gastrointestinal pathologies, it is often misdiagnosed. When a patient presents with diarrhea or high ostomy output along with fecal cultures negative for Clostridiodes difficile and other common pathogenic agents, methicillin-resistant Staphylococcus aureus should be considered.