Hollow Organ Perforation Research Articles

Infusion therapy for sepsis

Background. Sepsis is a life-threatening organ dysfunction syndrome caused by the dysregulatory response of the organism to infection. Treatment of septic shock (SS) requires massive infusion therapy (IT), as it is necessary to restore volemia as quickly as possible. Other goals of IT are the restoration of electrolyte balance, normalization of acid-base state and organ perfusion.
 Objective. To describe IT in sepsis.
 Materials and methods. Analysis of literature sources on this topic; own multicenter prospective open research. 68 patients with abdominal SS source (intestinal obstruction, perforation of hollow organs, infected pancreatitis, etc.) who underwent IT were involved.
 Results and discussion. In case of SS it is obligatory to start infusion of crystalloid solutions in a dose of 30 ml/kg during the first 3 hours of resuscitation. Current treatment guidelines suggest early aggressive fluid recovery within 6 hours of onset of shock. Delaying an increase in volemia cannot be allowed. If stabilization of the clinical condition cannot be achieved by initial fluid resuscitation, close monitoring should be initiated to avoid fluid overload, as both hypovolemia and hypervolemia increase mortality. Indicators such as blood pressure, heart rate, central venous pressure, dynamic parameters (lower extremity lifting test (LELT), volume load bolus test), lactate content, daily fluid balance should be monitored. Achieving a negative fluid balance during at least one of the first 3 days of SS treatment is a predictor of the favorable prognosis. According to the own study, LELT showed a weak correlation with the results of the infusion probe. This may be related to the increase in intra-abdominal pressure in the studied patients. Despite a number of disadvantages, crystalloids are the basis of SS treatment. The use of hydroxyethyl starch solutions in sepsis is not recommended; they can be used only in limited groups of patients. Albumin is the only safe colloid solution that can be used in patients with SS and hypoalbuminemia, but there is no evidence of the benefits of its routine use in sepsis. Analysis of patient data divided into Reosorbilact, Volutenz, Ringer malate and 0.9 % NaCl (all solutions – “Yuria-Pharm”) found that the most effective solutions for cardiac output were Reosorbilact and Volutenz.
 Conclusions. 1. Treatment of sepsis and SS requires massive IT. 2. The goals of IT include the restoration of volemia, normalization of electrolyte balance and acid-base status, normalization of organ perfusion. 3. During the first 3 hours of resuscitation in SS, it is advisable to restore the fluid volume within 6 hours from the onset of shock. 4. If stabilization of the clinical condition has not been achieved, close monitoring should be initiated to avoid fluid overload. 5. The most effective solutions for the increase of cardiac output are Reosorbilact and Volutenz.

Autoplasma as a Hemostatic Agent for Endoscopic Surgery of Hollow Organs

Introduction. To maximize the effectiveness of hemostatic technologies, it is necessary to optimize local hemostasis through hybrid and controlled approaches, as well as to improve the conditions for tissue surgical dissection preventing perforation of hollow organs. This study is aimed at assessing the efficacy of stopping bleeding and the safety of resection of digestive hollow organs in experimental models of trauma to abdominal organs in laboratory animals.Materials and methods. Experiments were carried out in vivo on 20 rabbits. All animals were divided into 4 experimental groups (5 animals each): I — the control group, in which no methods for stopping bleeding were used; II — the group, in which infiltration of the wall of a hollow organ with saline solution was used; III — the group, in which physical hemostasis was applied using an electrosurgical unit and an argon plasma coagulation apparatus; IV — the group, animals in which underwent controlled local biological hemostasis using autoplasma. Prior to laparotomy, 2–3 ml of whole blood was taken from the rabbit’s ear for preliminary preparation of autoplasma. The prepared autoplasma was introduced into the area of resection or other operation of the mucous membrane of the rabbit’s digestive tract.Results and discussion. Although no statistical difference in the time of stopping bleeding was observed between the control (I) and saline (II) groups, one more episode of bleeding was noted in group II. Preventive local administration of autoplasma (group IV) was established to have a high hemostatic potential. As expected, electrocoagulation was more effective than saline; however, hemostasis achieved by means of argon plasma coagulation is characterized by rapid formation of a necrotic zone, which may lead to undesirable consequences in the long-term period.Conclusion. Preventive local administration of autoplasma and recombinant human protein has a high hemostatic potential in animals. In comparison, electrocoagulation is less effective due to the rapid filling of the pathological focus with blood.

The Emergency Surgery Score accurately predicts the need for postdischarge respiratory and renal support after emergent laparotomies: A prospective EAST multicenter study.

The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. Prognostic and epidemiological, level III.

Classic Ehlers\u2013Dalnos syndrome presenting as atypical chronic haematoma: a case report with novel frameshift mutation in COL5A1

BackgroundEhlers–Danlos syndrome (EDS) is a group of inherited connective tissue disorders characterized by skin hyperextensibility, joint hypermobility and soft tissue vulnerable to blunt injury. Early recognition and diagnosis are crucial to patients to provide appropriate treatment, as well as to screen for life-threatening conditions such as aortic dissection and hollow organ perforation. The diagnosis of EDS is made based on clinical presentations, skin biopsy, and electron microscopy findings. To date, mutations in at least 20 genes have been found to cause the Ehlers-Danlos syndromes. However, EDS is still underestimated due to lack of awareness of its variable clinical presentations. Here we reported an EDS case with atypical initial presentation and a novel genetic mutation.Case presentationThis 4-year-old Taiwanese male patient presented with easy bruising, multiple ecchymoses, joint hypermobility, hyperextensible skin, and prolonged pretibial haematoma. He was initially suspected of a bleeding tendency due to coagulation disorders. The coagulation test results were normal. DNA sequencing was performed for molecular diagnosis. Subsequently, the diagnosis of classical EDS was made by identifying a novel frameshift mutation in COL5A1 [NM_000093.4:c.4211_4212delAG, p.Gln1404Arg]. This mutation in the type V collagen gene COL5A1 contributes to the phenotype of classical EDS. This novel frameshift mutation may disturb the structural stability of collagen V and interfere with its heparin binding capacity, explaining the chronic haematoma.ConclusionThe reported case showed the unusual features of chronic haematoma. This novel frameshift mutation and its phenotype correlation can provide useful information for practitioners about early recognition in Ehlers–Danlos syndrome.

Rectal perforation following endorectal prostate MRI: an unexpected complication

BackgroundProstate cancer is a common cancer among men in developed countries. Prostate magnetic resonance imaging (MRI) has been widely employed for early diagnosis of prostate cancer and recommending a treatment plan. The incidence of rectal perforation during endorectal prostate MRI is rare and has never been reported before. Herein, we present a case of rectal perforation after a prostate MRI examination that was subjected to emergency surgical intervention because of the acute presentation of generalized peritonitis. Patients with systemic comorbidities are reportedly at greater risks of encountering colonoscopic perforation. Endorectal prostate MRI is a safe diagnostic modality, but inadequate lubrication of the endorectal coil or over-insufflation of the balloon during the procedure may also lead to serious complications such as hollow organ perforation. Early surgery will be necessary should peritoneal symptoms persist.Case presentationIn 2015, a 56-year-old man came to our ER due to acute abdominal pain after he finished his MRI exam. The exam indicated diffuse tenderness over his abdomen and at the ER, his abdominal CT (computerized tomography) was checked. The images revealed extraluminal air in the perirectal fat and the pneumoperitoneum. In response, exploratory laparotomy, simple closure of rectal perforation, and loop-S colostomy were performed and the patient was discharged 1 month after operation.ConclusionsProstate MRI is a secure procedure with few complications. Clinicians must keep in mind the possibility of perforation when using ultrasound probe. Hollow organ perforation can result in serious morbidity or death. As a result, patients need to be informed of the complications of prostate MRI. When performing the procedure, clinicians must be cautioned about the potential problems for patients with high-anesthetic risk.

A retrospective cohort study of 304 patients with gastrointestinal stromal tumors in mackay memorial hospital

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs often occur in middle-aged and older individuals. The main morphologic type of GISTs is the spindle cell type. Immunohistochemistry and genotyping can help to identify GISTs from other subgroups of sarcoma. Materials and Methods: This retrospective study collected 304 patients over a 10-year period (from January 2009 to June 2019) who were diagnosed with GISTs based on the pathological database of our hospital. We retrospectively analyzed the clinical manifestations and treatment strategies. Results: Anemia or gastrointestinal bleeding was the most common symptom (36.5%), followed by gastrointestinal discomfort (32.6%) and incidental findings (21.4%). Ruptured tumors with hollow organ perforation increased the mortality risk. Liver metastasis and peritoneal seeding were the most two common patterns of recurrence. GISTs arising in adults are characterized by the near-universal expression of CD117/KIT antigen. Early surgery with margin-free resection is the best strategy for GISTs without metastasis. Routine lymph node dissection is not recommended. Laparoscopic surgery is feasible and safe for GISTs in the gastrointestinal tract. Endoscopic submucosal dissection to treat GISTs is suitable for small tumors with very low-to-intermediate risk in the stomach. Postoperative treatment with tyrosine kinase inhibitors can prolong recurrence-free survival after surgery. Conclusion: Surgical resection is the preferred treatment for patients without metastasis. Administration of tyrosine kinase inhibitors such as imatinib is recommended for unresectable, metastatic, or recurrent GISTs. Postoperative follow-up by computed tomography to detect early recurrence is recommended.

C-Reactive Protein in the Prediction of Localization of Gastrointestinal Perforation

Aim: Information regarding the localization of the anatomic site of gastrointestinal (GI) tract perforation is essential for the following surgical procedure. The purpose of this study was to evaluate the significance of C-reactive protein (CRP) and other circulating markers for the prediction of the localization of intra-abdominal hollow organ perforation. Methods: Measurements of serum markers were analyzed in 423 patients with GI tract perforations, who were divided according to the intraoperative diagnosis into colorectal and upper GI tract perforation groups. Results: Levels of CRP were higher in patients with colorectal perforations than in upper GI tract perforations (p < 0.001). Moreover, high levels of CRP were associated with increased mortality of patients with hollow organ perforations (p = 0.009), which was largely driven by the subset of patients with perforations of the upper GI tract (p = 0.001). Conclusion: Increased CRP levels predict worse clinical outcome in patients with intra-abdominal hollow organ perforations and are associated with perforations in the colorectal tract. Thus, CRP might be a useful marker for preoperative risk stratification and prediction of the localization of the perforation site.

Analysis of malpractice claims: The Franco-Belgian "Cœlio Club" experience.

Malpractice claims are a regularly increasing concern in gastrointestinal surgery. The goal of this study was to compare the current status of claims in two different French-speaking communities by a retrospective descriptive study of surgeons' experiences, from the beginning of their practice up until December 31 2014. Data included the number, the reasons, and the results of medicolegal claims and their jurisdictions. Forty-three surgeons participated in this study. Two hundred medicolegal claims were analyzed. The mean number was 5.8 per surgeon. Bariatric surgery, colorectal surgery and parietal surgery were the most exposed. Forty-six (23%) faults were noted, while no fault was pronounced in 139 (69.5%) cases. The main reasons for lodging complaints were nosocomial infections, anastomotic leaks, poor postoperative care, hollow organ perforation, peripheral neurologic complication, and insufficient preoperative information. Forty-four percent of the complaints were analyzed by the conciliation and compensation commissions and 43.5% by the High Court. In the French-speaking group, there were 13 complaints, two of which gave rise to compensation. French surgeons are highly exposed to complaints: in French law, clumsiness or technical maladdress is considered as a fault. The patient should be informed preoperatively of all possible severe risks of a medical procedure. In Belgium, complications are exceptional and are considered random therapeutic events. Adhering to the recommendations emanating from the French High Authority of Health and Learned Societies as well as accreditation issued by the same High Authority should allow to decrease the number of undesirable events related to care and malpractice.

Connexin-43-dependent ATP release mediates macrophage activation during sepsis.

Bacterial spillage into a sterile environment following intestinal hollow-organ perforation leads to peritonitis and fulminant sepsis. Outcome of sepsis critically depends on macrophage activation by extracellular ATP-release and associated autocrine signalling via purinergic receptors. ATP-release mechanisms, however, are poorly understood. Here, we show that TLR-2 and -4 agonists trigger ATP-release via Connexin-43 hemichannels in macrophages leading to poor sepsis survival. In humans, Connexin-43 was upregulated on macrophages isolated from the peritoneal cavity in patients with peritonitis but not in healthy controls. Using a murine peritonitis/sepsis model, we identified increased Connexin-43 expression in peritoneal and hepatic macrophages. Conditional Lyz2cre/creGja1flox/flox mice were developed to specifically assess Connexin-43 impact in macrophages. Both macrophage-specific Connexin-43 deletion and pharmacological Connexin-43 blockade were associated with reduced cytokine secretion by macrophages in response to LPS and CLP, ultimately resulting in increased survival. In conclusion, inhibition of autocrine Connexin-43-dependent ATP signalling on macrophages improves sepsis outcome.

Perforated Peptic Ulcer Happened after Robotic Assisted Pylorus-preserving Pancreaticoduodenectomy and Review of Literature

Introduction: Marginal ulceration is one of common complications in patient who received pylorus-preserving pancreaticoduodenectomy (PPPD). The variation of incidence rate was wide and it was related with different reconstruction method. In this presentation, we will share our experience on a case of perforated peptic ulceration 21months after robotic PPPD and review the literature. Method: An 80-year-old man presented with watery diarrhea followed by acute abdominal pain for two days. Physical examination revealed hypoactive bowel sounds, muscle guarding, diffused rebounding pain. Computed abdominal tomography scan with contrast showed pneumoperitoneum and small amount ascites, wall thickening at anastomosis of jejunum and proximal efferent loop. He was diagnosed with hollow organ perforation. His medical history was panbronchiolitis under Erythromycin 500mg QD, type 2 diabetes mellitus under insulin control for 8 years, HbA1c: 6.9% and periampullary vater tubular adenoma with foci of high grade dysplasia post robotic-assisted PPPD with reconstruction by Traverso’s method 21 months ago. Post-operative antacid medication was administered for 4 months. Result: The patient received emergent exploratory laparotomy. A 0.5 cm ulcerative perforation over anterior wall of jejunal side of gastro-jejunosotmy was noted during surgery. Simple closure of perforation and feeding jejunostomy were performed for this patient. After surgery, pantoprazole was administered. The patient was discharged on the 14th day after emergent surgery. The incidence of marginal ulceration after PPPD with reconstruction by Traverso’s method was 6.9% in several studies. From July 2017 to March, 2019, total 230 patients received robotic PPPD. There are 3 cases of marginal ulceration with perforation after robotic PD at our hospital, incidence rate was 1.3% (3/230). Conclusion: Since marginal ulcer could be one of the complications and even lead to perforation after robotic PD, routine antacid medication is recommended for each patient undergoing a major operation such as robotic PD although done by minimal invasive approach.

The Role of Laparoscopy in Abdominal Trauma: A 10-Year Review

Laparoscopy is accepted in penetrating abdominal trauma (PAT), but its role in blunt trauma (BAT) remains a controversial one. Our study assessed the utility of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma between December 2006 and January 2016. We analysed the indication for laparoscopy, type of lesions, TL, conversion rate, complications and length of hospital stay. 49 patients had a DL: 42 males and 7 females, with a mean age of 36.1+-13.3. We had 20 PAT and 30BAT. The indications for laparoscopy were: diagnosis of penetration in PAT, suspicion of hollow organ injury or diaphragm injury, active bleeding in organ injuries in BAT. 11/48 of preoperative ultrasounds and 4/48 of CT's were false negative. In 3 of 20 PAT, DL was negative and in 4 nontherapeutic. There were 4 TL's and 7 conversions. The main injuries in BAT were: 9 hollow organ perforations, 6 mesenteric lacerations, 2 diaphragmatic and 2 splenic injuries. There were 10 TL's, 9 conversions and 14 TL. The operative time and length of hospital stay was higher in the conversion group. There were 6 complications and 3 mortalities. There were no missed injuries. An unnecessary laparotomy was avoided in 18/49 cases (36.73%). In selected cases of PAT and BAT with equivocal clinical and imaging diagnosis, laparoscopy is a useful tool with therapeutic role, that reduces unnecessary laparotomies, complication rate and hospital stay.

Clinical and Therapeutic Aspects of Perforated Peptic Ulcer in Joseph Ravoahangy Andrianavalona University Hospital Center

Despite the introduction of H2 receptor and proton pump antagonists into the therapeutic arsenal of the Peptic Ulcer Disease, gastric perforation remains the most common surgical emergery for the upper gastrointestinal tract. The present study aims to describe the particularities of the management of Perforated Peptic Ulcer which underwent surgery in the University Hospital Center Joseph Ravoahangy Andrianavalona Antananarivo (CHU-JRA) and to identify its morbidity and mortality factors. This is a retrospective analysis performed over a period of 33 months from January 2017 to September 2019 on Perforated Peptic Ulcer operated in CHU-JRA. Demographic, clinical and therapeutic parameters were studied and analyzed in relation to the morbidity and mortality rate. Altogether 158 patients operated for perforated Gastric or Duodenal Ulcer were included with an age ranging from 16 to 78 years old, a mean age of 39.05±15.03 years and a Sex Ratio estimated to 18.75. Repeated unexplored epigastralgia was noted in 70.89% of cases and 33.54% of patients used NSAIDs and/or corticosteroids before the onset of the pain. At admission, 9.4% of cases were immediately in shock. A laparotomy for exploration and repair was performed for a suspicion of a hollow-organ perforation on a X-ray of an Unprepared Abdomen. Antral perforation predominated in our serie (75.95%) and the main repair procedure consisted in a simple surgical suture. To conclude, our stude reflects the difficulty of the management of Peptic Ulcer Disease and its complications in our daily practice. Strenghtening the awareness of the population about the potiential severity of this disease is essential.

A rare case of fever as the main symptom of Crohn's disease manifestation

Crohn's disease is a chronic, recurring gastrointestinal tract disease of unknown etiology with alternating periods of exacerbations and remissions; however, some patients can have a fulminant disease with predominance of fever. In some cases, extraintestinal manifestations of the disease (arthritis, sacroiliitis, aphthous stomatitis) come to the fore. This paper presents a clinical case of a 46 years old patient Z., who was treated in the Republican Clinical Hospital (Kazan, Russia). His past history was remarkable for a painful ulceration of the oral mucosa about 1.5 months ago, after a planned replacement of a removable prosthesis on the lower jaw. The patient was diagnosed with decubital ulcer of the oral mucosa in the right retro-molar area; malignancies were excluded, and anti-inflammatory therapy was initiated. Then he had fever of up to 39.5 °C and abdominal pains. The infectious causes of fever were excluded, abdominal ultrasound showed no free fluid in the abdominal cavity, and macroscopic segmental erosive-ulcerative changes of the colon, specific for Crohn's disease were found at colonoscopy. Intravenous prednisolone was initiated, with augmentation of infusions and administration of protein and antibacterials. The next day abdominal pain became more severe, with vomiting, abdominal distension, Blumberg's sign; blood pressure was 90/60 mm Hg and heart rate 120 beats per minute. Abdominal ultrasound showed free fluid in the abdominal cavity; dilated intestine loops with horizontal fluid levels were seen at X-ray. The diagnosis was advanced peritonitis, hollow organ perforation, and emergency laparotomy was performed that showed multiple perforations of the colon and sigmoid, diffuse fibrinous-purulent fecal peritonitis. Colectomy and end ileostomy were performed. Despite intensive therapy in the intensive care unit, the patient's general condition continued to worsen, and two days after the operation, with deterioration of cardiovascular failure, he died. Based on the histological examination of the colon and the autopsy results, the diagnosis of Crohn's disease was confirmed. Thus, the presence of febrile fever, as the leading syndrome, without any intestinal symptoms, should be included in the differential diagnostic list of symptoms of Crohn's disease.

The Role of Noncontrast CT in the Evaluation of Surgical Abdomen Patients

Acute surgical abdomen is commonly encountered in the ED and CT is widely used as an informative diagnostic tool to evaluate potential surgical indications. However, the adverse effects of contrast material used in CT scanning have been documented. We sought to delineate the role of noncontrast CT in the evaluation of patients with acute surgical abdomen. Between August 2015 and December 2015, patients with nontraumatic surgical abdomen who underwent preoperative CT were enrolled in the current study. The patients for whom the CT results permitted surgical decision-making were the focus of this study. The disease entities included acute appendicitis, acute cholecystitis, hollow organ perforation, mechanical bowel obstruction, intra-abdominal abscess that could not be drained percutaneously, and ischemic bowel disease. The results of contrast-enhanced and noncontrast CT were compared and analyzed. The surgical conditions identifiable by noncontrast CT were recorded. In total, 227 patients were enrolled in the study. In 90.7 per cent of patients overall, the findings indicating the need for surgical treatment were visualized on both the noncontrast and contrast-enhanced images (acute appendicitis: 89.3%, acute cholecystitis: 89.7%, hollow organ perforation: 97.4%, bowel obstruction: 100%, intra-abdominal abscess: 100%, and ischemic bowel disease: 55.6%). Noncontrast CT provides benefit for critical decision-making. Body mass index may affect the accuracy of noncontrast imaging in the evaluation of patients with surgical abdomen. In some specific situations, contrast enhancement remains necessary.

Mo1154 ENDOSCOPIC TREATMENT OF ACUTE NONVARICEAL UPPER AND LOWER GASTROINTESTINAL HAEMORRHAGE WITH AN OVER-THE-SCOPE CLIP (OTSC)

The OTSC (Ovesco) is an endoscopic clip system used to treat bleeding, fistula, hollow organ perforation and postoperative complications. This study describes the endoscopic procedure for the treatment of acute nonvariceal upper and lower gastrointestinal haemorrhage using an OTSC. Within six years (2011 to 2017), 48 patients (median 75.5 years, 61-92 years, m = 29, w = 18) were treated with emergency OTSC for acute bleeding. There were 34 treatments in the upper gastrointestinal tract and 14 in the lower gastrointestinal tract. 18 patients had Forrest Ia bleeding, 22 patients had Forrest Ib bleeding and 8 patients showed Forrest IIa bleeding. For OTSC placement, endoscopic PE forceps (Boston Scientific) were used. There were no other local therapies. All OTSC applications were performed by the same investigator. In all 48 patients a successful OTSC application and thus a primary hemostasis could be achieved. No endoscopic emergency examination with OTSC care lasted longer than 20 minutes. Twenty-six patients (15 Forrest Ia, 9 Forrest Ib) received follow-up endoscopy after 2 days, with the clip showing in situ and no bleeding stigmata. The remaining 22 patients were not immediately followed up with a clinically normal course. The use of the OTSC system in emergency endoscopy for acute bleeding is a safe and very effective treatment with primary hemostasis. The application of the OTSC system is associated with a short examination time.

Transanal protrusion of subdural peritoneal shunt in the setting of appendicitis

Abstract Complications from shunts placed in the peritoneum, either ventriculoperitoneal or subdural, are varied. Perforation of hollow organs and subsequent natural orifice protrusion is a rare but well known complication. We report a case of a transanal protrusion of a subdural peritoneal shunt in the setting of previous abdominal pain possibly consistent with acute appendicitis. While a report of transanal protrusion of a ventriculoperitoneal shunt via the appendix has been reported this is the first report where abdominal inflammation was also present. While patients with hollow organ perforation have been described as being managed conservatively after externalization of the proximal shunt and removal of the distal shunt, we managed our patient with an operation given our concern for appendicitis.

Problems of diagnostics and treatment of gastrointestinal perforations in patients with acute intestinal infections

The results of treatment of 97 patients with perforations of the hollow organs of the gastrointestinal tract were analyzed, 31 acute intestinal infections of which were verified. Clinical features of perforation of hollow organs on the background of acute intestinal infection have been revealed. A comparative analysis of clinical and instrumental methods for diagnosing perforations in patients with intestinal infections and without them was carried out. The most sensitive in identifying perforations of hollow organs in patients with acute intestinal infections instrumental methods of investigation were diagnostic laparoscopy (100%) and radiography of abdominal organs (80%). It was established that the combination of the two diseases contributes to the growth of diagnostic errors, increase in the number of common forms of peritonitis and development of the syndrome of mutual aggravation. Analysis of surgical interventions showed that in patients with confirmed diagnosis of acute intestinal infection the primary surgical interventions in most patients resulted in the formation of laparostoma with programmed relaparotomy, in connection with the presence of contraindications for the formation of a primary interintestinal anastomosis. Postoperative complications in the study groups developed in 61,3; 41.7 and 23,8% of cases, respectively. In patients with confirmed diagnosis of acute intestinal infection, lethality was 32,3%, in patients with atypical flow of perforations of hollow organs, simulating the symptoms of acute intestinal infection - 16,7 and 14,3% - in patients with perforations of hollow organs without concomitant acute intestinal infection. The results of the research testify to the relevance of the problem under study and the need to optimize therapeutic-diagnostic algorithm for this category of patients.

Features of the flow of perforations of hollow organs of the abdominal cavity in infectious patients

In the work of the particularities of clinical course of perforation of hollow organs and peritonitis in conjunction with infectious diseases in patients on treatment in infectious and surgical department compared to patients receiving treatment of perforation of hollow organs in “normal” surgical hospital. Analyzed the differences in the level and nature of perforations, types of peritonitis, infectious diseases have reasons for late diagnosis of these complications.

Massive Idiopathic Pneumoperitoneum in Children: A Case Report

The pneumoperitoneum is the abnormal presence of free air in the peritoneal cavity. In most cases it is related to the perforation of hollow organs. Nevertheless there are cases of pneumoperitoneum without obvious causes called idiopathic. We report a case of massive pneumoperitoneum of radiological discovery in a patient of 16 years old boy, sickle-cell of type SS, during the exploration of an angiocholitis. It was medically treated successfully. No obvious etiology had been found. This particular situation is a dogma which runs up against the classic interventionist spirit; therefore each of pneumoperitoneum needs to be studied case by case. The presence of signs of peritoneal irritation allows surgical exploration. Otherwise, laparoscopy seems to be a minimally invasive surgical method and allows a visual diagnosis by eliminating a hollow organ perforation.

Laparoscopy for perforated gastroduodenal ulcers

To assess laparoscopy in diagnosis and treatment of patients with perforated gastroduodenal ulcers. There were 273 patients with perforated gastroduodenal ulcers who underwent laparoscopy at the Sklifosovsky Research Institute for Emergency Care in 2010-2016. Sample included patients with clinical and instrumental diagnosis of perforated gastroduodenal ulcers, suspected hollow organ perforation including perforated ulcer and other acute abdominal diseases followed by perforated ulcer. Laparoscopy confirmed diagnosis of perforated gastroduodenal ulcer in 82.5% of patients with clear preoperative diagnosis and in 54.2% of patients with suspected perforated ulcer. Video-assisted closure of the ulcer is possible in 81.7% of patients. Any endoscopic procedure should be started from diagnostic measures. Diagnostic laparoscopy followed by curative laparotomy in 14.6% of patients was able to clarify diagnosis, suture technically difficult perforated ulcer and prevent possible complications.