Intraperitoneal Leakage Research Articles

Wrapping of the omental pedicle flap around the T-tube for the early postoperative biliary endoscopic intervention

Background: The placement of t-tube and postoperative biliary endoscopic intervention through T-tube tract is not an uncommon practice in the management of residual choledocholithiasis. In this study, we have evaluated the safety and feasibility of artificial T-tube tract for the early postoperative biliary endoscopy and early intervention through it, which was made by wrapping of the omental pedicle flap around the T-tube. Methods: A total of 230 cases of choledocholithiasis who underwent open common bile duct exploration and t-tube insertion according to new surgical technique in our hospital from January 2009 to January 2014 were analyzed retrospectively. T-tube imaging was taken after 2 weeks and for normal imaging T-tube was removed and biliary endoscopy was performed at 2-3 weeks. Results: Of 230 patients, 78 (33.9%) were male and 152 (66.1%) were female; 68 (29%) patients were with comorbidity. All groups underwent early postoperative endoscopy and early intervention at 2-3 weeks (an average of 17.9 ± 2.2 days). The result was statistically significant at (P <0.05). The residual stone were found in 27 patients (11.7%) and also noticed firmed, matured t-tube tract without any incidence of bile leakage. Conclusions: Wrapping of the omental pedicle flap around the T-tube is a simple, practical and safe procedure to make strong artificial T-tube tract for the early biliary endoscopic intervention, It has shortened the time of postoperative biliary endoscopy from 4-6 to 2-3 weeks without any incidence of intraperitoneal bile leakage.

Pseudo-Renal Failure with Severe Hyponatremia due to Spontaneous Bladder Rupture

Spontaneous bladder rupture is rare. Such an occurrence may appear similar to renal failure because the resulting urine leakage into the peritoneal cavity and absorption across the peritoneum increases serum creatinine although glomerular filtration rate is normal. A 46-year-old man presented with abdominal distension for 7 days after consuming a large volume of alcohol. Initial laboratory tests showed a blood urea nitrogen level of 174.3 mg/dL, serum creatinine of 11.49 mg/dL, and serum sodium of 105 mmol/L. Abdominal distension resolved after draining 5,200 mL of urine through a bladder catheter. Computed tomography cystography revealed intraperitoneal leakage of contrast dye from the left dome of the bladder, suggesting an intraperitoneal bladder rupture. Azotemia was completely normalized on the third day of hospitalization. This case shows that pseudo-renal failure should be considered when caring for a patient with unexplained azotemia and ascites. (Korean J Med 2015;89:102-106)

Delayed Endoluminal Vacuum Therapy for Rectal Anastomotic Leaks after Rectal Resection in a Swine Model: A New Treatment Option

Anastomotic leaks are a dreaded surgical complication following colorectal operations. Creation of a temporary proximal diverting ileostomy is used in high-risk anastomoses, however, additional surgical risk is accumulated with its creation and reversal. Endoluminal vacuum therapy has been shown to seal anastomotic defects in the prophylactic setting in a pig model and we hypothesized it could be utilized in a delayed fashion to rescue subjects with an active anastomotic leak. Yorkshire pigs underwent rectal resection, intentional leak confirmed by fluoroscopy, and endoluminal vacuum therapy device placement to low continuous suction. Following treatment, a contrast enema and necropsy was performed for gross and histopathology. Pigs underwent 2 (or 5) days of free intraperitoneal leak prior to device placement and 5 (or 7) subsequent days of endoluminal vacuum therapy. Six of seven early-treated pigs sealed their anastomotic defect, while two of the four treated pigs in this extended group sealed the defect. Endoluminal vacuum therapy is feasible and well tolerated in a pig model, and it has been shown to seal a significant number of freely leaking anastomoses in the early period (86%). This technology warrants further study as it may provide a noninvasive means to treatment of anastomotic leaks.

Management of Anastomotic Leak: Lessons Learned from a Large Colon and Rectal Surgery Training Program

Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.

Pre-therapy Laparoscopic Feeding Jejunostomy is Safe and Effective in Patients Undergoing Minimally Invasive Esophagectomy for Cancer

ObjectiveLaparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DesignThis research is a retrospective case series. SettingThis study was conducted in a university tertiary care center. PatientsBetween August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. Main Outcome MeasuresThe outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. ResultsOne hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. ConclusionA laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

Mo1208 Laparoscopic Gastrostomy Is Safer Than Percutaneous Endoscopic Gastrostomy in Children: Results of a Systematic Review and Meta-Analysis

Background: A gastrostomy is frequently performed in children who require long-term enteral feeding. Nowadays gastrostomy placement is a minimally invasive procedure via either percutaneous endoscopic gastrostomy (PEG) or laparoscopic assisted gastrostomy (LAG). Both procedures are widely used in pediatric patients. However, no consensus exists on which type of approach is best practice in these patients. Aim: The aim of this study was to determine if PEG or LAG is the most effective and safe procedure in pediatric patients requiring a gastrostomy Method: A systematic review and meta-analysis was performed according to the guidelines in the PRISMA-statement. PubMed, EMBASE, and the Cochrane Library were searched to identify eligible articles. Results were pooled in meta-analyses and expressed as risk ratios (RR). Results: Our extensive literature search provided 2,342 articles. After title, abstract and full-text screening five original studies comparing PEG to LAG placement in children were identified. All studies had retrospective study designs. The completion rate (PEG 98%; LAG 100%) and time to full-enteral feeds (PEG 0.7 and LAG 0.8 days) of both procedures were similar. No studies reported data comparing the efficacy of feeding via the gastrostomy or its effect on developing gastroesophageal reflux (GER). Major complications, such as intraperitoneal leakage (RR 0.28; p=0.36; after tube exchange RR 3.14; p=0.28) and persistence of the gastrocutaneous fistula after removal of the gastrostomy tube (RR 0.94; p =0.92 ) were as frequently encountered after both PEG and LAG. However, PEG was associated with significantly more adjacent bowel injury (RR=5.55; p= 0.05), early tube dislodgement (RR=7.44; p=0.02), and complications requiring reintervention under general anesthesia in the operating room (RR=2.79; p=0.0008). The risk of developing minor complications was similar after both PEG and LAG placement. Conclusion: This systematic review and meta-analysis demonstrates a lack in studies comparing the effect of PEG and LAG on the efficacy of feeding via the gastrostomy tube and postoperative GER. However, major complications such as adjacent bowel injury, early tube dislodgements and complications requiring reintervention under general anesthesia in the operating room were significantly less frequent after LAG. Therefore, we conclude that LAG is the safest approach and should be the first choice in children requiring gastrostomy placement.

Natural Orifice Transluminal Endoscopic Surgery and Upper Gastrointestinal Tract

Since the first transgastric natural orifice transluminal endoscopic surgery was described, various applications and modified procedures have been investigated. Transgastric natural orifice transluminal endoscopic surgery for periotoneoscopy, cholecystectomy, and appendectomy all seem viable in humans, but additional studies are required to demonstrate their benefits and roles in clinical practice. The submucosal tunneling method enhances the safety of peritoneal access and gastric closure and minimizes the risk of intraperitoneal leakage of gastric air and juice. Submucosal tunneling involves submucosal tumor resection and peroral endoscopic myotomy. Peroral endoscopic myotomy is a safe and effective treatment option for achalasia, and the most promising natural orifice transluminal endoscopic surgery procedure. Endoscopic full-thickness resection is a rapidly developing natural orifice transluminal endoscopic surgery procedure for the upper gastrointestinal tract and can be performed with a hybrid natural orifice transluminal endoscopic surgery technique (combining a laparoscopic approach) to overcome some limitations of pure natural orifice transluminal endoscopic surgery. Studies to identify the most appropriate role of endoscopic full-thickness resection are anticipated. In this article, I review the procedures of natural orifice transluminal endoscopic surgery associated with the upper gastrointestinal tract.

Bladder perforation in augmentation cystoplasty during urodynamic investigation: A case report and review of the literature

BackgroundSpontaneous bladder rupture is a known complication of augmentation cystoplasty. We report the second case of bladder rupture during filling cystometry many years after bladder augmentation and the first case occurring in a patient with an autoaugmentation cystoplasty. In addition, the management and outcome for a bladder perforation in an autoaugmentation cystoplasty will be discussed. CaseA 20-year-old male with a history of an L4 myelomeningocele underwent an autoaugmentation cystoplasty for neurogenic bladder dysfunction and decreased bladder wall compliance five years previously. He self catheterized four times daily. During filling cystometry, detrusor pressure increased to 60 cm H2O with 300 mL filling. Detrusor pressure then rapidly decreased to 20 cm H2O without evidence of external leakage. The infusion was immediately stopped and X-ray showed intraperitoneal leakage of contrast material. Serial abdominal examination demonstrated worsening abdominal distension. Exploratory laparotomy revealed a 2 cm perforation within the autoaugment portion of the bladder. ConclusionAn autoaugmentation cystoplasty improves bladder compliance and capacity with the use of native urothelial tissue. Although perforation after autoaugmentation has not been previously reported, caution must be used during urodynamic evaluation in patients with decreased bladder wall compliance and augmentation cystoplasty.

Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display

This article reviews the pattern of anastomotic leak after robot-assisted laparoscopic radical prostatectomy (RALRP) on MDCT cystography with multiplanar reformatting and 3D display and discusses key surgical procedures to explain intraperitoneal leak and the incidence and clinical significance of anastomotic leak. RALRP is a minimally invasive surgery for localized prostate cancer, and its use has increased recently. Intraperitoneal extension of vesicourethral anastomotic leak after RALRP can occur, which is not associated with radical retropubic prostatectomy. MDCT cystography is a fast and accurate method for detection and evaluation of the extent of anastomotic leak after RALRP.

Pseudo‐acute kidney injury with recurrent ascites due to intraperitoneal urine leakage

Pseudo‐acute kidney injury with recurrent ascites due to intraperitoneal urine leakage

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push-type gastrostomy tubes using a rupture-free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Percutaneous CT and fluoroscopic gastrostomy placement of push-type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Twenty-one patients (14 men, 7 women; age range, 55-78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25-75). The average follow-up time interval was 221 days (range, 10-920 days). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow-up periods. Percutaneous CT and fluoroscopic-guided gastrostomy with push-type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.

Two Unusual Gastrointestinal Foreign Bodies

Swallowed foreign bodies are common in the pediatric age group, but fortunately, the majority of them pass spontaneously without any adverse effects. Tube gastrostomy is an excellent method to provide prolonged enteral feeding. It is, however, associated with complications, namely, intraperitoneal leak and distal migration of the gastrostomy tube causing gastric outlet obstruction. This paper describes two unusual gastrointestinal foreign bodies, one was swallowed, while the other one was a complication of a tube gastrostomy.

Sp698 EUS-Guided Sutured Gastroplexy for ERCP in Patients with Roux-en-Y Gastric Bypass: A Novel Single-Setting Minimally Invasive Approach to Post-Bariatric ERCP

ERCP in patients with Roux en Y gastric bypass anatomy is a technical challenge. The various options available to access major papilla include deep enteroscopy and surgically or radiologically placed gastrostomy tube. Deep enteroscopy is not successful in reaching papilla in all patients and does not allow the use of a side viewing duodenoscope with an elevator making biliary and pancreatic cannulation difficult. Surgically or radiologically placed gastrostomy tube have their own associated risks and invasiveness. Also, one has to wait for a period of few weeks after gastrostomy tube placement to allow the gastric wall to adhere to the abdominal wall before proceeding with ERCP. At our institution we have developed a novel way of EUS guided, fluoroscopic assisted access of gastric remnant followed by sutured gastropexy and subsequent ERCP, all in one session. We describe a series of three such cases. The echo-endoscope was inserted trans-orally and advanced to the gastric pouch or the Roux limb. The remnant stomach was identified using sonographic features and was punctured across the pouch or roux limb wall using a 19G needle pre-loaded with 0.025 guidewire. Radio-opaque contrast injection and fluoroscopy were used to confirm needle position. After advancing guidewire the remnant stomach was maximally inflated with air injection through the needle and the best point of percutaneous entry on the abdominal wall was chosen. An 18-gauge introducer needle was inserted into the lumen of the gastric remnant and a 0.035 wire advanced. The wire track was serially dilated and a gastroscope inserted into the remnant. The gastric wall was now secured to the anterior abdominal wall using full thickness sutures. The gastroscope was removed and a 15mm laproscopy port inserted for duodenoscope access. This novel, one setting minimally invasive approach allows access to remnant stomach and upper GI tract for the purposes of diagnostic and therapeutic endoscopy/ERCP. It allows the use of duodenoscope for difficult cannulation and precise therapeutic ERCP manouvers such as bliary and pancreatic sphioncterotomy. As the gastric wall is secured to anterior abdominal wall with full thickness sutures, one does not run into the risk of dehisence and intra-peritoneal leakage of gastric contents. The use of EUS to access gastric remnant and maximal insufflation alllows for identification of the best point of per cutaneous puncture for gastrostomy tube thus reducing post operative complications and pain. This technique allows the gastrostomy placement and ERCP to be done in the same setting thus reducing health care costs and patient visits.

Reverse PD-a rare cause of acute renal failure in a transplanted patient.

Sir Spontaneous bladder rupture is a known cause of abdominal pain and acute renal failure [1]. Alcoholics and other substance abusers are particularly prone to developing this syndrome [2, 3]. Some patients may present with a history of pelvic surgery, irradiation or a tumor in the lower abdomen [4, 5]. If unrecognized, the mortality of this clinical entity is remarkably high [6]. We report a case of bladder rupture, probably spontaneous, in a young woman who had undergone renal transplantation twice due to congenital cystinosis. Bladder rupture is a pertinent differential diagnosis in transplanted patients with abdominal pain and sudden rise of creatinine. A 29-year-old woman was admitted to our hospital because of acute abdominal pain and anuria. Clinical examination revealed a bloated abdomen with signs of ascites. There was marked suprapubic tenderness. Chemistry on admission showed acute renal failure (creatinine 3.4 mg/dL and blood urea nitrogen 49.6 mg/dL). On ultrasonographic imaging, an obvious postrenal cause could not be found but free fluid was present in the pelvis. A subsequent magnetic resonance imaging (MRI) peritoneography showed large amount of fluid in the peritoneal cavity as well as an irregularity in the bladder wall (see Figure 1). The kidney transplant was unremarkable. We performed a diagnostic ascitic tap and determined creatinine and urea in the intra-abdominal fluid. Both parameters were clearly elevated (creatinine 8.8 mg/dL and urea 69.8 mg/dL). Fig. 1. MRI peritoneography demonstrating irregularity on the bladder dome and large amount of fluid in the peritoneal cavity. Rupture of the bladder wall was deemed the most likely cause. The patient was transferred to the urology department and underwent cystoscopy and micturition cystourethrography. A dehiscence at the left side of the ventral bladder wall with intraperitoneal leakage of contrast medium was demonstrated, in accordance with the MRI images. Median laparotomy was performed and the bladder wall could be repaired. The postoperative course was uneventful. At discharge, the renal function was normal. A definite cause for the bladder rupture could not be established. The patient denied substance abuse or alcoholic binge drinking. After detailed questioning, she reported having carried her 5-year-old nephew the day before admission, which may have caused blunt trauma to the abdomen. Bladder rupture, either spontaneous or traumatic, should be considered in patients with acute renal failure, abdominal pain and ascites. We speculate that her underlying metabolic disease may have predisposed our patient by cystine crystal accumulation in the bladder wall. To the best of our knowledge, this association has not been reported before.

Two Cases of Failed Jejunostomy Tube Changes Using the AMT Capsule Monarch Feeding Tube

Purpose: 1st case: 56-year-old man with gastroparesis secondary to chronic pancreatitis became malnourished, necessitating a direct PEJ tube. At the time of tube change, the original tube was replaced with a MIC feeding tube with a balloon. However, he subsequently had problems with leakage as well as a severe infection at the tube site requiring hospitalization. Therefore, the tube was changed to an AMT Capsule Monarch 18 Fr tube. At the time of the next tube change, due to some patient discomfort and difficulty, a 14 Fr tube was used. Soon afterwards the patient complained of severe abdominal pain. Tube check showed the tube within a jejuna loop with intraperitoneal leakage of contrast. He was taken to surgery where the tract was found to be very weak intraoperatively. He later had a gastric tube with a jejunal extension placed. He has done well with that tube since then. 2nd case: 20-year-old woman with a history of cerebral palsy and gastroparesis had a PEJ tube placed for nutrition. Three months later, the PEJ tube was pulled out and replaced with an AMT Capsule Monarch 18 Fr tube. She later experienced severe rectal bleeding secondary to a rod from a previous back surgery eroding into her colon. She underwent surgery with removal of the hardware. She also underwent a second surgery that admission for lysis of adhesions. Following recovery from these surgeries, she did not tolerate any jejunal feedings. Around that time, it was noted that the existing tube was worn out and it was therefore replaced. Within a few hours, the patient complained of severe abdominal pain. Tube check showed contrast going into the peritoneal cavity. She was treated conservatively with IV antibiotics and no surgical intervention. Her abdominal pain eventually improved and she was discharged. Discussion: We present two cases of perforation happening after a tube change with a jejunal AMT Capsule Monarch tube. Both cases were thought to be due to a weak fibrous tract. In the first case, the tract was likely weakened by the patient's persistent malnutrition. In the second case, the tract was weakened by the patient's recent two major abdominal surgeries. Ideally, jejunal exchange should be done under direct endoscopic visualization. If the replacement tube cannot be seen, then a tube check should be done before discharge from the GI lab. Patients who are malnourished or those who have undergone recent abdominal surgery may have a weakened fibrous tract necessitating great caution when changing a jejunal tube.

Initial Experience with Computed Tomography and Fluoroscopically Guided Placement of Push-Type Gastrostomy Tubes Using a Rupture-Free Balloon Catheter

The purpose of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy placement of push-type gastrostomy tubes using a rupture-free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance. A total of 35 patients (23 men and 12 women; age range 57-93 years [mean 71.7]) underwent percutaneous CT and fluoroscopically guided gastrostomy placement of a push-type gastrostomy tube using an RFB catheter between April 2005 and July 2008. Technical success, procedure duration, and complications were analyzed. Percutaneous radiologic gastrostomy placement was considered technically successful in all patients. The median procedure time was 39±13 (SD) min (range 24-78). The average follow-up time interval was 103 days (range 7-812). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow-up period. The investigators conclude that percutaneous CT and fluoroscopically guided gastrostomy placement with push-type tubes using an RFB catheter is a safe and effective means of gastric feeding when performed by radiologists.

Pseudo-azotaemia due to intraperitoneal urine leakage: a report of two cases.

Ascites, oliguria and increasing serum creatinine levels are often noted in patients with acute kidney injury. However, these presentations are also observed in patients with intraperitoneal urinary leakage. Bladder perforation without obvious trauma is sometimes mistaken for acute kidney injury. We report two cases of bladder perforation resembling acute kidney injury. The first case was a 37-year-old woman with delayed intraperitoneal urinary leakage following total abdominal hysterectomy, and the second was a 70-year-old woman with spontaneous bladder perforation. Although the initial diagnosis in both cases was acute kidney injury, rupture of the urinary bladder was later identified.

Colonic Ischemia and Perforation Associated With Enteral Feeding Through an Ileal Tube

Reported complications of enteral feeding through a jejunostomy include diarrhea, intraperitoneal leaks, bowel obstruction, fistula formation, wound infection, tube occlusion, and other mechanical malfunctions. However, the incidence of these complications is very low, and many physicians prefer to feed their patients by means of a jejunal tube instead of parenteral nutrition. A potentially lethal complication is ischemia of the bowel distal to the site of insertion of the feeding catheter. The described cases of bowel ischemia secondary to enteral nutrition invariably occurred at the level of the jejunum. This report describes an unusual case of perforation of the colon in a patient fed through an erroneously placed feeding catheter in the distal ileum, just proximal to the ileocecal valve. After weeks of continuous and intractable diarrhea and progressive weight loss, the patient developed diffuse colonic ischemia with subsequent free perforation of the left colon and peritonitis. Surgical treatment consisted of placement of a new feeding tube in the proximal jejunum and removal of the old one together with a short segment of small bowel, left hemicolectomy, and end colostomy. The patient tolerated the procedure well, the tube feedings were gradually restarted, and at the 6-month postoperative visit gastrointestinal function was normal. This case illustrates possible complications of an inadvertently placed feeding tube. Not only may it cause unexplained diarrhea and undernutrition, but it may lead to more serious events like colonic ischemia and perforation.

Antegrade deligation of iatrogenic distal ureteric obstruction utilising a high pressure balloon dilatation technique

Background Iatrogenic trauma is the leading cause of ureteric injury with an incidence in abdominal and pelvic surgery varying between 0.4 and 2.5%. Case We report a case of ureteric obstruction caused by a haemostatic clip. There was associated rupture of the ureter proximal to the clip with intra-peritoneal leakage of urine. The patient was unfit for surgery and was managed by a novel procedure of endoluminal balloon deligation. Conclusion Ureteric injuries are rare but potentially serious complications. They require prompt diagnosis and management depends on the patients’ clinical condition, extent of injury and interval from injury to diagnosis. We have successfully demonstrated a new technique to treat ureteric obstruction caused by a haemostatic clip with associated ureteral rupture in a patient unfit for surgery.

Gastrointestinal Complications After Lung Transplantation

Gastrointestinal complications after lung transplantation remain a common yet poorly defined problem. In this study we examine our experience with gastrointestinal complications after lung transplantation. Between August 1990 and June 2005, we retrospectively analyzed 208 patients who had undergone lung transplantation (single, 65% [137 of 212]; double, 34% [72 of 212]; heart-lung, 0.5% [2 of 212]; living related, 0.5% [1 of 212]). Four patients were retransplanted. Gastrointestinal complications were defined as any post-transplant diagnosis related to the gastrointestinal tract. Ninety of 208 (43%) transplant patients developed 113 gastrointestinal complications during follow-up (median 3.5 years [62 days to 10.0 years]). Biliary etiology was the most common (12% [25 of 208]), requiring cholecystectomy in 13 patients. Diarrheal syndromes occurred in 21 patients (10%) with 2 patients requiring laparotomies. Small bowel obstruction and/or gastroparesis were present in 17 (5%) and 12 (6%) patients, respectively. Fourteen patients required surgical lysis of adhesions for small bowel obstruction and 7 patients underwent gastric drainage procedures. Three patients had peptic ulcer disease with 2 patients requiring laparotomy for perforated duodenal ulcer. Ten patients developed gastrointestinal bleeding with 1 requiring a colectomy. Three patients presented with diverticulitis and 2 required colectomy. Three patients required laparotomy due to intraperitoneal leakage of gastric secretions after gastromy tube placement. Eleven (16%) deaths were directly related to gastrointestinal complications. Of those patients who required a laparotomy for indications other than cholelithiasis, 9 (35%) died within 8 weeks. Gastrointestinal complications are common after lung transplantation and are associated with considerable morbidity and mortality. Vigilance is required for early recognition and prompt treatment.