Limited Bowel Resection Research Articles

Perforated jejunal diverticulum as an unsual cause of acute abdomen: A case report.

Introduction and importanceJejunal divertica is a rare entity with an often clinically silent course. However, it may be associated to life-threatening complications such as perforation. Therefore it should be considered in every case of acute abdomen.Case presentationA 60-year-old female presented with a generalized abdominal pain associated with vomiting evolving for 24 h. Physical examination found an irreducible and tender hernia in the umbilical region with abdominal guarding. Laboratory test results showed a biological inflammatory syndrome. The primary diagnosis of strangulated umbilical hernia was suspected and the patient underwent an emergency laparotomy. Intra-operative examination revealed mutiple jejunal diverticula, with a perforation in one diverticulum leading to generalized peritonitis. A bowel resection and peritoneal lavage were performed with good outcome.Clinical discussionJejunal diverticula is a challenging condition with various non-specific clinical presentations. Jejunal perforation is its most feared complication. Deceitful abdominal examination among elderly patients and lack of specific signs may lead to diagnostic delay responsible for high mortality rate and poor prognosis. Adjunctive imaging modalities may be needed to help establish a prompt diagnosis and dictate management strategy. Treatment of perforated jejunal diverticulum is based on limited bowel resection associated to primary anastomosis.ConclusionJejunal diverticulitis should be kept in mind as a differential diagnosis in every case of acute abdomen. High index of clinical suspicion and eventual further radiological examinations are required to avoid misdaignosis and save patients' lives.

Utility of adjuvant whole abdominal radiation therapy in ovarian clear cell cancer (OCCC): a pragmatic cohort study of women with classic immuno-phenotypic signature

BackgroundTo evaluate the initial experience and clinical utility of first-line adjuvant intensity-modulated whole abdominal radiation therapy (WART) in women with ovarian clear cell cancer (OCCC) referred to an academic center.MethodsProgression-free and overall survival was analyzed in a pragmatic observational cohort study of histologically pure OCCC patients over-expressing HNF-1ß treated between 2013 and end-December 2018. An in-house intensity-modulated WART program was developed from a published pre-clinical model. Radiation dose-volume data was curated to American Association of Physics in Medicine (AAPM) Task Group 263 recommendations. A dedicated database prospectively recorded presenting characteristics and outcomes in a standardized fashion.ResultsFive women with FIGO (2018) stage IA to IIIA2 OCCC were treated with first-line WART. Median age was 58 years (range 47–68 years). At diagnosis CA-125 was elevated in 4 cases (median 56 kU/L: range 18.4–370 kU/L) before primary de-bulking surgery. Severe premorbid endometriosis was documented in 3 patients. At a median follow-up of 77 months (range 16–83 mo.), all patients remain alive and progression-free on clinical, biochemical (CA-125), and 18Fluoro-deoxyglucose (FDG) PET/CT re-evaluation. Late radiation toxicity was significant (G3) in 1 case who required a limited bowel resection and chronic nutritional support at 9 months post-WART; 2 further patients had asymptomatic (G2) osteoporotic fragility fractures of axial skeleton at 12 months post-radiation treated with anti-resorptive agents (denosumab).ConclusionsThe clinical utility of intensity-modulated WART in OCCC over-expressing HNF-1β was suggested in this small observational cohort study. The hypothesis that HNF-1β is a portent of platinum-resistance and an important predictive biomarker in OCCC needs further confirmation. Curating multi-institutional cohort studies utilizing WART by means of “Big Data” may improve OCCC care standards in the future.

A clinicopathologic study of intussusception in Nepalese adults

Introduction: Intussusception is rate in adults and is usually secondary to a definable pathology. This study was designed to review adult intussusception, including presentation, diagnosis, and pathology.
 Methods: A retrospective study of 18 cases of intussusception in individuals older than 18 years of age visiting the department of surgery of Civil Service Hospital from 2010 to 2018 was done.
 Results: There were 18 cases of adult intussusception. The mean age was 49.2 years (range 19-84 years). Abdominal pain and vomiting were the commonest symptoms. The median duration of presentation was 5 days (range 20 hours to 10 months). Three patients (16.6%) presented with generalized peritonitis. There were eight ileocolic, seven ileoileal, and three colocolic intussusceptions. Two patients (11.1%) settled spontaneously. Twelve out of the 18 patients (66.6%) had leading lesions. Benign pathologies were seen in seven cases (38.8%) and malignant in five patients (27.7%). All malignancies were in the large bowl
 Conclusions: Adult intussusception is a rare entity, nearly one-third of their causes are malignant. Surgery is the best recommended treatment, with or without a primary reduction of the intussusception; the latter can result in more limited bowel resection.

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report.

Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported. To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it. A literature search for 'duodenal lipoma' was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery. Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery. Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour.

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study

During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75±9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. The technical success rate was 97.6%. Failures were device migration (n=1), navigation failure (n=2), and release outside the target zone (n=1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111±51mL and the radiation dose was 127,777±89,528mGy/cm(2). The total fluoroscopy time was 854±538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n=41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Inflammatory myofibroblastic tumor masquerading as perforated appendicitis

Inflammatory myofibroblastic tumor (IMT) is a rare and histologically benign tumor that most commonly presents in pediatric patients. Abdominal IMTs often present with non-specific symptoms, and therefore they can masquerade as other more common abdominal conditions. This report describes two cases of IMT presenting as perforated appendicitis. Both cases are of young children who presented with over 48 hours of abdominal pain and who had peritonitis on examination. Pre-operative ultrasounds for both patients revealed complex free fluid. Laparoscopic evaluation demonstrated hemoperitoneum, and further exploration revealed mesenteric avulsion with abnormally thickened mesentery. Pathology confirmed IMT arising from the small bowel mesentery in both cases. Both children underwent limited bowel resection and were discharged in stable condition on a course of non-steroidal anti-inflammatory drugs (NSAIDs). Given the association of avulsed bowel to trauma, non-accidental trauma was suspected in both cases and demonstrated in one. Both patients showed complete resolution of tumor on follow-up MRI. The diagnosis of IMT must always be considered when an intra-abdominal mass is encountered as its treatment differs greatly from other neoplasms.

A Case of Adult Intussusception

Introduction: A 38-year-old Indian man with B-cell adult lymphocytic leukemia on chemotherapy was admitted with diarrhea, nausea, vomiting, and worsening abdominal pain. On presentation, a CT of his abdomen and pelvis found a mild colonic and small bowel distention. The patient was managed with IV fluid hydration and pain medication, and his symptoms improved. Three days later, the patient developed severe colicky abdominal pain. On abdominal exam, he had peri-umbilical tenderness with guarding. The patient was neutropenic and thrombocytopenic throughout his hospital stay, with a WBC of 500/μL and platelets of 16000/μL. Given his acute change in symptoms, another CT scan was performed, which showed small bowel intussusception. Surgery evaluated the patient, and given his neutropenia and thrombocytopenia, opted for conservative management. Five days later, the patient had a repeat CT scan that showed resolution of the intussusception and the patient was eventually discharged home and continued on his chemotherapy regimen. Intestinal invagination or intussusception is the leading cause of intestinal obstruction in children. Intussusception in adults accounts for only 5% of intussuception cases. Intussusception can present as acute, intermittent, cramping, and abdominal pain with nausea and vomiting; however, vague abdominal symptoms is a common presentation. While in children, 95% of cases are idiopathic, about 90% of causes of intussusception in adults are due to a distinct pathologic abnormality. In the small bowel, this consists of benign neoplasms, inflammatory lesions, and adhesions. Malignant lesions are found in only 30% of cases of intussusception in the small intestine, in contrast to 60% in colonic intussusception. Abdominal x-rays often show signs of intestinal obstruction, and can give information regarding the site of obstruction. CT has been reported to be the most useful diagnostic tool for the diagnosis of intussusception, with an accuracy of 58-100% with a finding of a homogenous mass that is target or sausage-shaped. The optimal management of adult intussusception is controversial, particularly in the small bowel. While resection of colonic intussusception is generally advocated due to the high percentage of associated malignancies, small bowel intussusception is less commonly due to malignancy, and thus intraoperative manual reduction with careful palpation of the intestinal wall might allow for limited bowel resection. Intussusception in adults is rare, and can present with non-specific abdominal complaints. Gastroenterologists should be aware of this rare condition for abdominal pain and the current treatment methods.

Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Laparoscopic port site Richter's hernia – An important lesson learnt

IntroductionWe report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity. Case reportA 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm3, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter's hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery. ConclusionMost port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.

Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis—a proof of concept

Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.), and second look to restore intestinal continuity was developed. This algorithm allowed for three surgical procedures: primary anastomosis +/- VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III) RESULTS: All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n = 6). Nine patients in group II (n = 15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n = 7), the rate of anastomosis in surviving patients was 70%. Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.

Mesenteric rheumatoid nodules masquerading as an intra-abdominal malignancy: a case report and review of the literature

BackgroundRheumatoid nodules are the most common extra-articular findings in patients with rheumatoid arthritis. They occur most commonly at pressure points such as the extensor surfaces of the forearms, fingers, and occiput, but have also been reported to occur in unusual locations including the central nervous system, pericardium, pleura, and sclera. We present the unusual case of rheumatoid nodules in the small bowel mesentery masquerading as an intra-abdominal malignancy.Case presentationA 65-year-old-male with a known history of longstanding erosive, nodular, seropositive rheumatoid arthritis was incidentally found to have a mesenteric mass on computed tomography (CT) exam of the abdomen. This mass had not been present on prior imaging studies and was worrisome for a malignancy. Attempts at noninvasive biopsy were nondiagnostic but consistent with a "spindle" cell neoplasm. Laparotomy revealed extensive thickening and fibrosis of the small bowel mesentery along with large, firm nodules throughout the mesentery. A limited bowel resection including a large, partially obstructing, nodule was performed. Pathology was consistent with an unusual presentation of rheumatoid nodules in the mesentery of the small bowel.ConclusionRheumatoid nodules should be considered in the differential diagnosis of a patient who presents with an intra-abdominal mass and a history of rheumatoid arthritis. Currently, no tests or imaging modality can discriminate with sufficient accuracy to rule out a malignancy in this difficult diagnostic delimma. Hopefully, this case will serve as impetus for further study and biomarker discovery to allow for improved diagnostic power.

Pharmacologic Management of Mesenteric Occlusive Disease

Mesenteric vascular disease has been diagnosed increasingly over the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population, an increasing number of critically ill patients and a greater clinical recognition of the condition. Although surgical revascularization and resection has long been the standard of treatment, medical management can also play an important adjunctive role. Early diagnosis before irreversible bowel damage, which may occur within 6-8 hours after the insult, is necessary to improve survival and reduce morbidity. Even in the presence of irreversible bowel ischemia, perioperative medical treatment may reduce disease progression, enabling more limited bowel resection. This article outlines the appropriate pharmacologic management of ischemic disorders of the intestine, with an emphasis on the pharmacologic treatments presently being used in clinical practice and those being studied in the laboratory.

Thrombolysis via an Operatively Placed Mesenteric Catheter for Portal and Superior Mesenteric Vein Thrombosis: Report of a Case

Mesenteric venous thrombosis (MVT) is a catastrophic form of mesenteric vascular occlusion. In the absence of peritoneal signs, anticoagulation therapy should be started immediately. For selected patients, thrombolysis through the superior mesenteric artery (SMA), jugular vein, or portal vein via a transhepatic route might be successful; however, exploratory laparotomy is mandatory when peritoneal signs develop. We report a case of acute MVT associated with protein C and S deficiency, treated successfully by limited bowel resection and simultaneous thrombolytic infusion, given via an operatively placed mesenteric vein catheter.

Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study

The preoperative diagnosis of adult intussusceptions (AIs) remains difficult, and the assessment of the radiological methods has been evaluated very little in the literature. The aim of this study was to evaluate the interest of the different imaging modalities for the preoperative diagnosis of AI and describe causes of AI. Consecutive patients of 15 years and older with the postoperative diagnosis of intussusception from 1979 to 2004 were reviewed retrospectively for this multicentric study. Data concerning clinical considerations, morphological examinations, surgical procedure, histological conclusions, mortality rate and recurrence were analysed. Forty-four patients with documented intussusception were included. The mean age was 51 years (15-93 years). The preoperative diagnosis of intussusception was made in 52% of the cases. The sensitivities of the different radiological methods were abdominal ultrasounds (35%), upper gastrointestinal barium study (33%), abdominal computed tomography (CT) (58%) and barium enema (73%). An organic lesion was identified in 95% of the cases. There was 29 enteric and 15 colonic (including appendicular) intussusceptions. Thirty-seven percent of the enteric lesions were malignant, and a bit less than 50% of them were metastatic melanomas. The benign enteric lesions were Meckel's diverticulum and Peutz-Jeghers syndrome in half of the cases. Fifty-eight percent of the pure colonic lesions (excluding appendix) were malignant, and 85% of them were primary adenocarcinomas. The benign colonic lesions were lipomas in 80% of the cases. All patients, except one, had a surgical treatment, and 13 of them had a complete reduction of the intussusception before resection. The mortality rate was 16% and recurrence occurred in three patients; two of them had a Peutz-Jeghers syndrome. Intussusception rarely occurs in adults, but nearly half of their causes are malignant. The CT scan is a helpful examination for enteric intussusceptions whether barium enema seems to be the most performing method for colonic lesions. Surgery is the recommended treatment, with or without a primary reduction of the intussusception. During the surgical procedure, this reduction can lead to a more limited bowel resection.

Primary jejunoileal tumors: A review of 45 cases

We reviewed 45 patients who underwent surgery for primary jejunoileal tumors over a 15-year period. There were 16 benign and 29 malignant tumors, which included 13 lymphomas, 7 adenocarcinomas, 7 carcinoid tumors, and 2 leiomyosarcomas. Eighteen patients, 13 of whom had benign tumors, presented with intestinal bleeding and 5 tumors were found incidentally at laparotomy. Benign lesions were more frequently sited in the jejunum while malignant lesions were more common in the ileum (p less than 0.001). Lesions presenting with hemorrhage were more likely to be benign than malignant (p less than 0.001) and were more commonly sited in the jejunum than in the ileum (p less than 0.05). Visceral perforation (31%), intestinal obstruction (21%), and an abdominal mass (17%) were other presenting features in patients with malignant tumors. In spite of a wide variety of investigations, the correct diagnosis was reached preoperatively in only 31% of patients. Surgical management included either limited bowel resection or segmental resection with regional lymphadenectomy. Operative mortality was 13% and morbidity was 36%. Actuarial 5-year survival for all malignant tumors was 24%, being 64% at 5 years for carcinoid tumors, 20% at 30 months for adenocarcinomas, and 10% at 42 months for lymphomas. These results reemphasize the need for a high index of suspicion and early laparotomy in patients with obscure intestinal symptoms if the prognosis of small bowel tumors is to improve.

Irradiation injury to the gastro-intestinal tract: clinical features, management and pathogenesis.

SUMMARYCure of cancer by radiotherapy may be achieved only at the expense of some damage to healthy tissue. In so far as the abdomen is concerned, the bowel is particularly vulnerable. In the treatment of abdominal cancer, it may be justifiable, on occasions, to risk limited bowel necrosis to produce adequate tumour destruction if there is a reasonable chance of a net gain in health status. In the present communication the signs, symptoms and pathology of irradiation injury to the stomach and bowel are illustrated by the description of three patients, treated for carcinoma of the cervix uteri, seminoma of the testis and malignant teratoma of the testis respectively. In all three cases the primary tumour had been removed, and irradiation was given for proven or suspected recurrence of the cancer. The irradiation caused both direct irradiation injury to the intestinal epithelium and injury to blood vessels with depletion of blood supply ; the latter process probably produced the greater damage. A variety of lesions occurred in the bowel, including ulceration, hæmorrhage, perforation, fibrosis, obstruction and malabsorption. Limited bowel resection became necessary in all three cases. Two patients have survived, with impaired health but without clinical evidence of recurrence ; the one treated for carcinoma of the cervix is surviving after two years, and the one treated for seminoma of the testis is surviving after three years. Improved methods of irradiation are discussed.