Intraperitoneal Leakage Research Articles

A CASE OF PERFORATION ON THE COLON CLOSE TO AN ARTIFICIAL ANUS PROBABLY CAUSED BY COLOSTOMY IRRIGATION

We present a rare case of perforation of the colon close to an artificial anus probably caused by colostoy irrigation with a review of the literaturs. A 37-year-old man undergoing an operation for a sigmoid colon cancer 6 years before had been controlling his artificial anus by himself by colostomy irrigation for 4 months. He was aware of a mild pain around the artificial anus after irrigation for the last one month. As the pain increased, he was admitted to the hospital. Tenderness and the symptom of peritoneal irritation were observed around the artificial anus. No free air was found by a simple X-ray film and CT scan, but the intraperitoneal leak of contrast medium was found in the adoral site of the artificial anus. He was diagnosed to have peritonitis due to perforation of colon close to artificial anus. Resection of the adanal colon including the perforated site and reconstruction of artificial anus were performed. The perforated site was located at about 7cm oral from the opening of the artificial anus. Histological examination revealed the tear of muscularis propria in the periphery of the perforated site. The site which had become less resistant to the load was probably perforated by the mechanical factor at the time of colostomy irrigation. It is suggested that attention should always be paid to the risk of colonic perforation as a complication of colostomy irrigation.

Fluoroscopically guided percutaneous gastrostomy: tube function and malfunction.

We describe our experience with fluoroscopically guided percutaneous gastrostomy, assessing in particular the functional performance of inserted tubes. We also examine the ability of radiological investigations to detect intraperitoneal gastrostomy leakage after the procedure. A functioning gastrostomy tube was established and maintained for as long as was required in 34 (89.5%) of 38 patients referred during a 21-month period. This necessitated further gastrostomy tube placements in 13 patients. On average, inserted gastrostomy tubes functioned for 10.75 weeks and during the review period a total of 34 malfunctioning tubes required replacement or removal. This was most commonly due to tube dislodgement, blockage, or intraperitoneal leakage. We found increasing pneumoperitoneum on sequential postprocedure erect chest films a reliable sign in the diagnosis of the latter complication. In conclusion, while we have been disappointed with aspects of individual tube function, our satisfactory overall functional success rate indicates that percutaneous gastrostomy is an effective method for establishing and maintaining enteral feeding. We also propose a protocol for the management of suspected intraperitoneal leakage based on the findings on postprocedure erect chest films.

Unusual Complication of Gastrostomy

Unusual Complication of Gastrostomy

An association between leakage of contrast seen on T-tube cholangiogram and subsequent biliary peritonitis.

Intraperitoneal leakage of bile can occur after routine cholecystectomy, following removal of the T-tube and following invasive diagnostic procedures, such as percutaneous transhepatic cholangiography and liver biopsy (Corbett et al, 1986; Lygidakis, 1986; Anderson et al, 1988). Spontaneous rupture of the common bile duct causing biliary peritonitis has been described (Kyzer et al, 1986). Bile is a cause of chemical peritonitis. Bacterial contamination of bile leads quite frequently to virulent septic peritonitis (McLaughlin, 1942; Schwartz, 1979). In a recent prospective study of the complications of T-tube drainage after choledochotomy and common bile duct drainage, three cases of biliary peritonitis occurred after removal of latex-rubber tubes in 36 patients (Gillett et al, 1985). PVC tubes, introduced in the 1960s, were known to cause an increased incidence of bile peritonitis (Anderson et al, 1988) after their removal, but it is now standard practice to use latex-rubber tubes.

Use of Synthetic Grafts in Failure of Conservative Management of Acute Cholecystitis: A New Approach

Failure of conservative treatment of acute cholecystitis to control infection of the gallbladder bile and/or increased tension within its lumen calls for emergency surgery. Since cholecystectomy in the emergency situation carries morbidity and mortality rates higher than those of the elective situation and cholecystostomy has the disadvantages of increased incidence of wound infection, prolonged hospital stay and the need for a second operation, this study was designed to examine whether at failure of conservative treatment of acute cholecystitis, drainage of the gallbladder into the second part of the duodenum by a synthetic tube graft is a convenient procedure. This procedure was performed in 6 consecutive patients (4 women and 2 men) without any complications, particularly intraperitoneal leakage and wound infection, and all patients were discharged home on the 5th postoperative day. A scintigraphic scan 6 weeks after the operation showed patency of the graft. All patients remained well without any complaints over follow-up for 1 year and expressed no interest in undergoing an elective cholecystectomy. It is, therefore, concluded that when the conservative treatment of acute cholecystitis fails, internal drainage of the gallbladder by a tube graft has advantages over both cholecystectomy and cholecystostomy.

Small bowel perforation during enteroclysis

Small bowel perforation with massive intraperitoneal leakage of barium occurred during the performance of enteroclysis in a 72-year-old woman. It is postulated that an ischemic segment of the partially obstructed ileum had ruptured because of rapid intraluminal flow of contrast material and increased abdominal pressure when the patient was rotated to a prone position.

Intraperitoneal bile leakage after cholecystectomy.

Intraperitoneal bile leakage after cholecystectomy.

新規非ステロイド性鎮痛，抗炎症薬Ｍｏｆｅｚｏｌａｃの薬理学的プロフィール

Pharmacological activities of mofezolac were investigated in experimental animal models and compared with those of indomethacin, ibuprofen, mefenamic acid, aspirin and aminopyrine. Mofezolac showed a potent suppression of various writhing models in mice or rats; and its potency was slightly lower than that of indomethacin, but was higher than those of the other reference drugs. Thus, mofezolac was especially active against chemically induced writhing and also in the phenylquinone induced intraperitoneal dye leakage reaction in mice. Mofezolac also has a potent inhibitory activity on the algesic responses induced by the mechanical stimulus of the inflammed tissue. Mofezolac exhibited a therapeutic effect comparable to indomethacin in the urate synovitis in dogs. Considering the anti-inflammatory and antipyretic actions, mofezolac was obviously less effective than indomethacin, and its potency was similar to that of ibuprofen. The ulcerogenic effect of mofezolac on the gastric mucosa was far weaker than that of indomethacin. In in vitro studies, the prostaglandin biosynthesis and platelet aggregation were inhibited to the same extent by both mofezolac and indomethacin. Accordingly, it may be considered that the actions of mofezolac are due to the inhibition of cyclooxygenase. Our result suggest that mofezolac can be a useful drug that shows a rapid pain-relieving activity in acute inflammations.

Percutaneous Endoscopic Stomas

Percutaneous endoscopic gastrostomy was introduced in 1980 as a method for the creation of a feeding gastrostomy without the need for laparotomy or general anesthesia. The technique originally described, the pull method, involves puncturing the apposed gastric and abdominal walls under endoscopic control. A suture is then passed from the exterior into the gastric lumen and grasped with a snare. The suture is pulled out of the mouth, affixed to the end of a gastrostomy tube, and then pulled back down into the stomach. The gastrostomy tube is thus pulled into the stomach, and its end exits the abdominal wall. Modifications of this technique have included pushing the gastrostomy tube over a guidewire (the push method) and direct puncture of the stomach under endoscopic control with an introducer and outer peel-away sheath. All of these methods have been used with good results. Complications have included infection of the abdominal wall and intraperitoneal leakage. These may be minimized by attention to detail. The indications for the method have been expanded to include gastric decompression, administration of unpalatable medications in children, and creation of a conduit for bile replacement. Careful judgment in patient selection is crucial if good results are to obtained. This technique also introduces the concept of percutaneous endoscopic fixation of a loop of bowel to the abdominal wall. This concept may be employed in other areas of the gastrointestinal tract.

Percutaneous endoscopic gastrostomy for enteral nutrition.

From January to October, 1986, at Wonkwang University Hospital in Iri, percutaneous endoscopic gastrostomy(PEG) was attempted in 26 patients and was successful in 24. This study was designed to review the technique and to evaluate the efficacy of PEG. The mean operation time was 22 minutes (range: 14 to 42 minutes). After feeding started, early positive nitrogen balance was achieved in all patients. All gastrostomies functioned well throughout the patient’s survival with the longest functioning at 10 month. There were no procedure-related deaths, and morbidity was lower and less severe as compared with large-bore nasogastric tube feeding. Complications included minor wound infection in two patients, stomal growth in one patient, leaks around the tube in two patients, and intraperitoneal leak in one patient. No patient developed aspiration pneumonia or required laparotomy for complications from PEG. The gastrostomy tube was easily removed endoscopically when treatment was completed. Feeding via a large-bore tube increased the risk of aspiration pneumonia (72%) and the feeding cost via a small-bore tube with elemental diet exceeded that of PEG by more than tenfold. This author’s experience with these 26 patients has led to the conclusion that PEG is safe, easy to perform, and effective means of creating feeding gastrostomy without laparotomy or general anesthesia. The authors suggest that PEG be the preferred route of alimentation in those patients who are unable to swallow for prolonged periods of time.

Percutaneous gastrostomy and gastroenterostomy: 1. Techniques derived from laboratory evaluation.

Various techniques, guidance systems, instruments, and the postmortem effects of percutaneous gastrostomy (PG) and percutaneous gastroenterostomy (PGE) were evaluated in 30 laboratory animals and five human cadavers. Methods to distend the stomach included air, fluid, intragastric balloon, and percutaneous needle inflation; a variety of trocar systems and catheters inserted by Seldinger technique (including those adapted from other uses and several designed specifically) were assessed. Fluoroscopy was the preferred guidance system, though sonography proved valuable (liver position, depth calculation to the stomach, localization of vessels to avoid), and the entire PG procedure was performed under sonographic guidance in four animals. Although the procedure was safe in most cases, several major complications did occur: laceration of a low-lying liver with exsanguination, malpositioned catheters in the lesser sac and adjacent to the spleen, and violation of the backwall of the stomach with laceration of celiac and splenic vessels. The animals and cadavers underwent autopsy. Autopsy revealed that firm gastrocutaneous tracts were formed by 7 days. There were few instances of wound infection, intraperitoneal fluid leakage, or evidence of trauma to the stomach when the catheters were well seated. Injury to the inferior epigastric artery is a potential hazard, and in cadaver dissections was located between the middle third and outer margin of the rectus abdominis muscle. Laboratory experience has been, and continues to be, an important means to improve and use new techniques for PG and PGE.

RETROPERITONEAL JEJUNOSTOMY

The classic jejunostomy for enteral feedings has several major complications including intraperitoneal leakage and intestinal obstruction. In some children, severe adhesions from previous surgery makes the finding and isolation of the proximal jejunum both tedious and hazardous.A jejunostomy may be easily placed into the retroperitoneal duodenojejunal flexure without entering the peritoneum. This is accomplished by a flank muscle splitting incision displacing the descending colon anteriorly and the kidney posteriorly. A Broviac catheter with a Dacron cuff is used as the conduit. The catheter is secured to the skin until fibrous adhesions have anchored the Dacron cuff.Four retroperitoneal jejunostomy tubes have been placed. The first tube was inserted with an incomplete Dacron cuff and "accidently" extracted on the day after surgery. The second tube was placed for temporary nutritional support until definitive surgery was performed. The tube was in place for 3 months with the patient gaining 2.4 kg. The third and fourth tubes were placed for permanent nutritional support and have been in for 4 and 2.5 months. The patients have gained 1.3 and 3.0 kg, respectively. Both tubes have been transected through carelessness, but easily repaired using the Broviac repair kit.

A technique for gastrostomy

A technique for gastrostomy has been described which includes circumferential, staggered interrupted sutures and an omental seal. The technique minimizes gastric necrosis and intraperitoneal leaks.

Experience with a modified Witzel gastrostomy without gastropexy.

The records of 161 adult patients who underwent a modification of the Witzel gastrostomy without gastropexy at Ellis Fischel State Cancer Hospital, Columbia, Missouri, between 1977 and 1980, are reviewed in detail and form the basis of this report. Six of these patients had gastrostomies on two different occasions. There was no mortality or major complication directly attributed to the procedure in this group of patients. Technical details are examined and considered most important in preventing intraperitoneal or extraperitoneal leak of gastric contents and migration of the catheter, the most commonly found complications of other techniques. Anterior gastropexy is considered unnecessary, thus simplifying the operation and eliminating gastric deformity and other related problems. The liberal indications of this procedure are discussed, and potential areas of technical pitfalls are reviewed. The personal experience of one of the authors (EMB) with 774 gastrostomies during a 15-year period using this technique confirms these conclusions. A random sample of 200 records of these patients were examined for complications of the operation. This study suggests that tube gastrostomy by the technique described is a reliable and safe procedure with wide applicability for patients undergoing major abdominal surgery. The relatively few complications are more than compensated for by the degree to which postoperative comfort and care are facilitated.

Successful Management of Ileal Conduit-Enteric Fistula: The Case Against Loopograms

The second reported case of ileal conduit-enteric fistula successfully managed with long-tube decompression and intravenous hyperalimentation is presented. Loopograms are not indicated unless excretory urography is contraindicated or intraperitoneal leakage is suspected.

A method for gastrostomy fixation

Gastrostomy, frequently indicated in pediatric surgery, and often of major therapeutic importance, is not without hazard, although the complications can be minimized by careful attention to technical details and appropriate tube care. Most serious complications result from leakage about the gastrostomy tube; 1 intraperitoneal leak may be fatal, but external leakage leads to wound breakdown, infection, dislodgement of tube, etc. The importance of a proper dressing has been emphasized, 1–5 and is probably the most critical factor in preventing complications. Recently, we have adopted a new method of fixation which is of particular advantage in the small neonate.

Ascites

A patient developed massive ascites 23 days after a renal transplant. Detailed investigation revealed that the ascites resulted from intraperitoneal leak of urine. The patient was treated successfully by surgical repair.

Ascites. An unusual manifestation of urinary leak in a renal allograft recipient.

A patient developed massive ascites 23 days after a renal transplant. Detailed investigation revealed that the ascites resulted from intraperitoneal leak of urine. The patient was treated successfully by surgical repair.

Radiation therapy and wound healing delay. Animals and man.

One of the adverse effects of radiation therapy is its interference with surgical wound healing. Although some of the earliest observations suggest that irradiation of a wounded area increased its healing rate, generally it has been accepted that radiation delivered either before or immediately after wounding the skin or other tissues would interfere with reconstitution of the structures and re-epithelialization. Many studies have investigated the particular characteristics of postoperative irradiation, and some have been concerned with the effects of preoperative radiotherapy. In considering any preoperative radiotherapy, it must first be noted that a surgical wound must heal without adverse reaction to the patient. A skin wound which does not completely reconstitute itself may not be life-threatening, but a non-reconstituted gastrointestinal anastomosis may result in intraperitoneal leakage of intestinal contents with disastrous results. It has seemed reasonable to review the characteristics of wound healing as applied to the problem of preoperative radiation therapy, and to this end studies have been undertaken in both animals and man. Two significant problems are immediately apparent. One concerns the effects of increasing doses of radiation and the second the effects of increasing the delay between administration of the radiation and the surgery. No animal study is directly applicable to man, as it is reasonable to presume a different response because of variations in tissue-healing characteristics and cell turnover time. In addition, single doses are the rule in most animal studies, while in man experience has proved the benefits of fractionation. Human Investigations The clinical material in this study consists of 225 patients with moderately advanced carcinoma of the head and neck given preoperative irradiation. In 214 of these, a radical surgical removal of the primary tumor was carried out, with an en bloc radical neck dissection when appropriate. The tumor origins of the resected specimens are indicated in Table I. The radiation doses varied in accordance with individual clinical problems, and the intervals between irradiation and operation were dependent on technical problems of acquiring rooms for the patients. In 11 patients the lesion was too far-advanced for surgery, and these received the highest radiation doses—5,500 to 6,500 rads. To assess wound healing, the patients were arbitrarily divided into two groups: (a) those with normal healing, i.e., complete healing within the first two weeks, and (b) those with delayed healing, i.e., with an open wound for more than two weeks. Table I shows, as would be expected, an association between wound-healing delay and extent of surgical involvement of both mucosa and cutaneous structures.

Intraperitoneal drains in surgery of the colon: Clinical evaluation of 454 cases

A review of 454 consecutive colectomies reveals a significantly higher morbidity in the patients with intraperitoneal leakage as compared to those without any drainage at all. There was one death in nine patients without drainage in whom an anastomotic leak developed. In five patients with leakage who had intraperitoneal drainage there were three deaths. It should be recognized that: (1) an intraperitoneal drain will not protect the suture line from leakage; (2) it need not prevent a diffuse peritonitis; and (3) by its interposition the drain may keep adjacent omentum or bowel from sealing an anastomotic leak.