Multiple Bowel Resections Research Articles

Abdominal and neuroimaging quiz case

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(255) Why oral opioids may not be effective

There are pain patients who report that oral opioids are ineffective. The effective use of oral opioids depends upon a complex metabolic system in the gastrointestinal track. Some of the factors necessary to adequately digest and transport oral opioids into the serum include gastric emptying, intestinal flora, cytochrome P450 enzymes, mucosal opioid receptors, and intestinal motility which is controlled by the autonomic nervous system that emanates in the brain and spinal cord. The objective of this study was to determine some of the possible pathologic causes of poor oral opioid effectiveness. Ninety-five (95) adults who were referred for medical management of their intractable pain were screened by written inquiry as to whether oral opioids provided adequate pain relief. A clinical evaluation including history, physical examination, cytochrome P450 enzyme testing, and hydromorphone injection challenge was done to determine possible causes of poor oral opioid effectiveness. Twenty (20; 21.1%) of the 95 patients screened reported oral ineffectiveness of two or more oral opioids. Remarkably 46 possible, pathologic causes were identified which could cause interference with oral opioid metabolism. The most common possible causes were multiple cytochrome P450 enzyme defects, multiple bowel resections, other abdominal or pelvic surgeries, traumatic brain or neck injury, and spine disease or surgery. There is a group of intractable pain patients who have multiple, genetic or other pathologic conditions which interfere with oral opioid metabolism Pain patients who report poor oral opioid effectiveness should be evaluated for the presence of underlying pathologic conditions which may interfere with oral opioid metabolism.

Urolithiasis and crohn's disease.

Objective:To present an updated description of the relation between Crohn's disease (CD) and Urolithiasis.Patients and Methods:A literature search for English-language original and review articles was conducted in Medline, Embase, and Cochrane databases in the month of December 2014 for papers either published or e-published up to that date, addressing the association between CD and urolithiasis as its consequence. All articles published in English language were selected for screening based on the following search terms: “CD,” “renal calculus,” “IBD,” and “urolithiasis.” We restricted the publication dates to the last 15 years (2000–2014).Results:In total, 901 patients were included in this review of which 95 were identified as having CD and urolithiasis simultaneously, for a total of 10.5%. Average age was 45.07 years old, irrespective of gender. 28.6% of patients received some kind of medical intervention without any kind of surgical technique involved, 50% of patients were submitted to a surgical treatment, and the remaining 21.4% were submitted to a combination of surgical and medical treatment. Urolithiasis and pyelonephritis incidence ranged from 4% to 23% with a risk 10–100 times greater than the risk for general population or for patients with UC, being frequent in patients with ileostomy and multiple bowel resections. We found that urolithiasis occurred in 95 patients from a total of 901 patients with CD (10.5%); 61.81% in men and 38.19% in women. Stone disease seems to present approximately 4–7 years after the diagnosis of bowel disease and CaOx seems to be the main culprit.Conclusions:CD is a chronic, granulomatous bowel disease, with urolithiasis as the most common extraintestinal manifestation (EIM), particularly frequent in patients submitted to bowel surgery. This complication needs to be recognized and addressed appropriately, especially in patients with unexplained renal dysfunction, abdominal pain, or recurrent urinary tract infection. We believe this study to be an updated valuable review as most data related to this kind of EIM refers to articles published before 2000, most of them before 1990. These patients need to be followed up with a specific prevention plan to eliminate or mitigate the risk factors for stone disease, aiming at preventing its formation and its complications, preserving renal function, reducing morbidity, and ultimately improving their quality of life.

Successful Haploidentical Hematopoietic Stem Cell Transplant for GATA2 Deficiency

▪Background: GATA2 deficiency results in a clinical syndrome known variably as: MonoMAC for the lack of monocytes and atypical mycobacterial infections (MAC); DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger’s syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Reconstitution of the deficient cell compartments in GATA2 deficiency with allogeneic hematopoietic stem cell transplant (HSCT) results in reversal of the infection susceptibility and represents the only curative therapy for both the myeloid disease and the virally driven malignancies seen in this disorder. However, only about one-half of patients that require HSCT will have an HLA-matched related or unrelated donor. Moreover, the use of umbilical cord blood has been reported to be suboptimal in this cohort of patients in whom infection susceptibility underlies much of the need for a transplant.Methods: We performed haploidentical, related donor HSCT with high dose post-transplant cyclophosphamide (PT/CY) in 3 patients with GATA2 deficiency in whom a suitable HLA matched donor was not available. All three patients had a first degree relative (sibling) who shared at least 1 HLA-haplotype. The first patient, a 21 year-old Chinese woman presented with Hydroa Vacciniforme like T-cell lymphoma involving her lung, bowel (resulting in multiple small bowel resections and ileostomy), and skin (with large ulcerative lesions); multiple thrombotic cerebral events; and macrophage activation syndrome requiring etoposide and high dose prednisone in the intensive care unit (ICU). The second patient, a 20 year-old Hispanic female, presented with myelodysplasia (MDS), profound neutropenia, an invasive fungal sinusits due to Fusarium sp., and recurrent bacteremias. The third patient, a 45 year-old woman, presented with Emberger’s Syndrome, multiple episodes of bacterial and fungal sepsis and hypocellular MDS. All three patients received cyclophosphamide 14.5mg/kg on day’s -6 and-5; fludarabine 30mg/m2 on day’s -6 through -2; 200cGy of total body irradiation (TBI) on day -1. Patients 2 and 3 also received busulfan 3.2 mg/kg on day’s -4 and -3 because of MDS. All 3 patients received high dose PT/CY 50mg/kg on day’s +3 and +4, and mycophenolate mofetil and tacrolimus starting on day +5.Results: All 3 patients engrafted at a mean of 18 days and all are alive at a median follow-up of 9 months (range, 5 to 13 months). All three patients achieved 100% donor myeloid and lymphoid chimerim by day +100 post-transplant. The first patient had complete resolution of her T-cell lymphoma and macrophage activation syndrome, the second patient has had complete reversal of her hematopoietic and infectious phenotype, and the third patient has had resolution of her infectious complications that required continuous IV Daptomycin for 5 years prior to transplant. In addition, all three patients had complete reconstitution of the monocyte, NK cell, and B-lymphocyte compartments that were severely deficient prior to transplant. The main toxicity was mucositis, which required intravenous narcotics in all three patients. Lastly, the first patient developed late grade I liver graft-versus-host disease (GVHD) that was responsive to cyclosporine, the second patient developed grade I acute GVHD of skin that was responsive to topical steroids, and the third patient had no evidence of acute or chronic GVHD.Conclusions: Haploidentical, related donor HSCT represents a safe and effective viable alternative for patients with GATA2 deficiency who lack an HLA-matched donor, including patients such as our first patient who was in the ICU at the time of transplant. DisclosuresNo relevant conflicts of interest to declare.

The Case Files

The Case Files

Ovarian Torsion in an Adolescent Female With Long-Standing Cystic Fibrosis

Background: Cystic fibrosis (CF), which was once considered a fatal childhood illness, is now manageable with advances in treatment. Progressive damage to the lung and intestinal systems are caused by the cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation. The most commonly known gynecologic complications of cystic fibrosis involve infertility, namely amenorrhea, ovarian dysfunction and chronic anovulation. The majority of these endocrine disorders affect reproductive-aged females. Recent research suggests CFTR is expressed in the fallopian tubes, cervix and endometrium. Females with cystic fibrosis have been noted to have multicystic ovaries, much like those observed in Polycystic Ovarian Syndrome (PCOS). Reproductive tract effects of the CFTR mutation are believed to be present as early as the initiation of puberty, providing a mechanism for ovarian cyst formation. This case will demonstrate the importance of recognizing ovarian pathology as a cause for acute onset abdominal pain in the adolescent female CF patient. Case: A 14-year-old female presented to the hospital with acute lower abdominal pain, nausea and vomiting. Her medical history was significant for pancreatic insufficiency, cirrhosis, chronic constipation, multiple previous small bowel resections and an active pseudomonas aeruginosa and staph aureus pulmonary infection. An extensive work up failed to show a primary gastrointestinal cause of the pain. A pelvic ultrasound showed an 8.5cm cystic lesion in the left adnexa with normal vascular flow to the ovary. A pelvic magnetic resonance study showed a 9.6cm thick walled cystic lesion suggestive of a dermoid cyst with intermittent ovarian torsion. Gynecology was consulted and urgent exploratory surgery revealed a necrotic left ovary and adherent tube. The ovarian pathology was significant for a mature teratoma. Comments: Abdominal pain in patients with cystic fibrosis presents a diagnostic challenge because primary gastrointestinal conditions are so prevalent. This case report highlights the importance of considering ovarian pathology as a potential cause of acute or persistent abdominal pain in adolescent females patients with cystic fibrosis. Timely diagnosis could lead to preservation of ovarian tissue in a population that faces a high prevalence of infertility as they reach their reproductive years. Further scientific investigation into the association of the CFTR gene mutation and ovarian pathology is warranted to guide clinical practice for pediatric gynecologists who care for adolescent female CF patients.

Polyp Clearance via Operative and Endoscopic Polypectomy in Patients With Peutz-Jeghers Syndrome After Multiple Small Bowel Resections.

Peutz-Jeghers syndrome is an autosomal dominant inherited disease that manifests as a combination of mucocutaneous pigmentation and gastrointestinal hamartomatous polyps that usually cause intussusception and intestinal hemorrhage. We report the case of a 40-year-old male patient who was diagnosed 20 years ago and had previously undergone 3 intestinal resection surgeries. This time, with the use of combined operative and endoscopic polypectomy, more than 100 polyps were removed. This technique is useful for providing a "clean" small intestine that allows the patient a long interval between laparotomies and reduces the complications associated with multiple laparotomies and resections.

State of the art of surgery in advanced epithelial ovarian cancer

State of the art of surgery in advanced epithelial ovarian cancer

Strongyloides stercoralisInfection in a Non-Endemic Area

Patient: 75-year-old Caucasian male. Chief Complaint: Frequent diarrhea. History of Present Illness: The patient had a history of Crohn’s disease, initially diagnosed in 1976 with a positive test for toxigenic Clostridium difficile ( C. difficile ) in August 2011, successfully treated with methronidazole (500 mg PO bid ×10 d). There was a concern that diarrhea may be a result of C. difficile recurrence. Past Medical History: The patient had an extensive medical history, including eosinophilia (8%, normal 0%–7%) in October 2011, gastroesophageal reflux disease, anemia secondary to Crohn’s disease, coronary artery disease, hypertension, osteoarthritis, and Type II diabetes mellitus. Additionally, the patient has severe Crohn’s disease which involves the terminal ileum and colon, and has undergone multiple small bowel resections as well as a colectomy. Medications included immunomodulatory therapy with balsalazide (Colazal), azathioprine (Imuran), infliximab (Remicade), ranitidine, and prednisone for both Crohn’s disease and osteoarthritis. Previous biopsies of the small intestine and colon (before the current presentation) indicated changes consistent with Crohn’s disease. Travel History: The patient was originally from Louisiana, and briefly lived in Las Vegas, NV. For approximately 40 years, he has lived in western Iowa. The patient did not have a history of foreign travel nor had he recently traveled outside of Iowa or Nebraska. He drives a bus for a local business. Principle Laboratory Findings: Loose brown stool was collected in December 2011 and submitted for laboratory testing for toxigenic C. difficile and cultured for enteric pathogens. An ova and parasites exam was not ordered at that time. Salmonella, Shigella , and Campylobacter species, as well as Shiga toxin producing- Escherichia coli , were not detected; the toxigenic C. difficile assay was negative. A laboratory technologist noted the presence of small trails of displaced bacteria on the blood agar plate from the original stool culture (Image 1). From …

Balloon-Assisted Enteroscopy: A Window to Small Bowel Polypectomies in Peutz–Jeghers Syndrome

Peutz–Jeghers syndrome is an autosomal dominant inherited polyposis disorder where diffuse characteristic gastrointestinal polyps, mainly involving the small bowel, coexist with mucocutaneous pigmentation. Until the advent of balloon-assisted enteroscopy, intraoperative enteroscopy and surgical treatment were the sole treatment options for patients with Peutz–Jeghers syndrome. Balloon-assisted enteroscopy, allowing direct visualization of the small bowel and therapeutic maneuvres, paved the way for nonsurgical small bowel therapy. In the context of patients diagnosed with Peutz–Jeghers syndrome, balloon-assisted enteroscopy with polypectomy allows prevention of polyp-related complications such as intussusception/obstruction or bleeding and reduces the need for future operative polypectomies and either elective or emergent laparotomies, thus avoiding the risk of multiple enterotomies or small bowel resections leading to short bowel syndrome. Furthermore, clearance of small bowel polyps could potentially decrease malignancy risk, although low, by removal of precursor lesions.Here different small bowel polypectomy techniques are described in a patient affected by Peutz–Jeghers syndrome presenting with multiple jejunal polyps detected at prior videocapsule endoscopy surveillance. This article is part of an expert video encyclopedia.

Multiple large bowel resections: Potential risk factor for anastomotic leak

ObjectivesIdentify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL. MethodsAll cases of AL after LBR for OC between 01/01/1994 and 05/20/2011 were identified and matched 1:2 with controls for age (±5years), sub-stage (IIIA/IIIB; IIIC; IV), and date of surgery (±4years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL. Results42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95% CI 1.13–6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL patients had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95% CI 1.18–3.57, P=0.011). ConclusionsMultiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).

Pulmonary Mucormycosis in a Patient with Crohn Disease on Immunosuppressive Medications including Infliximab

Case presentation A 68-year-old man presented to hospital with a two-day history of increasing shortness of breath, left-sided pleuritic chest pain and chills. His medical history was significant for longstanding Crohn disease (>55 years) requiring multiple bowel resections in the 1970s in addition to high-dose corticosteroid therapy. For the past five years, he had been maintained on infliximab with only low-dose steroids for iatrogenic adrenal insufficiency. Additional medical problems included short gut syndrome, hypothyroidism and bronchiectasis; there was no history of diabetes. He experienced two hospital admissions in the preceding six months for pneumonia, one of which was due to Pneumocystis jirovecii confirmed by open lung biopsy. His medications on this admission included budesonide 6 mg orally three times daily, azathioprine 100 mg orally twice daily, infliximab 600 mg intravenously every four weeks, levothyroxine 25 µg orally daily, atovaquone 1500 mg orally daily, and salbutamol and ipratropium inhalers as needed. His most recent dose of infliximab was one month before admission. A physical examination revealed signs of consolidation in the left lung. His complete blood count included a white blood cell

Macrolipasemia due to Crohnʼs Disease

Purpose: In a patient presenting with epigastric pain, emesis, and elevation of lipase, a diagnosis of pancreatitis may seem inevitable. But in spite of its specificity, the elevation of lipase in the context of a normal amylase value merits further investigation into other potential etiologies. A 56-year-old female with a history of longstanding severe Crohn's disease requiring multiple small bowel resections was initially seen in 2010; remission was maintained with certolizumab pegol. However, a few months later she started to experience epigastric and periumbilical pain, so cerrtolizumab pegol was boosted and split, deferring dual therapy with a thiopuine due to prior infections. Despite initial improvement, she was admitted two months later for emesis and severe periumbilical pain; lipase was elevated at 7000 U/L with a normal amylase. She did not consume alcohol, have a history of gallbladder disease, or take any known pancreatotoxins. Ultrasound and MRI demonstrated a normal pancreas; CT suggested a slightly plump pancreas, but IgG4 was negative. Serum trypsin, urinary lipase, fecal elastase, and serum amylase were all negative or normal. Colonoscopy revealed inflammation at the ileocolonic anastomosis causing significant narrowing. Based on this investigation, it was determined that the patient had macrolipasemia due to Crohn's disease. Isolated macrolipasemia is a rare finding that has been observed in celiac disease, cryptogenic liver cirrhosis, non-Hodgkin's lymphoma, and Crohn's disease. Although significantly more uncommon than hyperamylasemia, a solitary increase in lipase values in patients without pancreatitis has been reported in the literature; there has been only one such documented case of macrolipasemia and Crohn's disease. Laboratory measurements of lipase account for all forms of the enzyme regardless of composition. Macroenzyemes are formed by either self polymerization or the creation of a complex consisting of the physiologic enzyme and immunoglobulin; there have been reports of such complexes in association with autoimmune phenomena. The increased molecular mass of these macroenzymes does not allow for physiologic filtration and removal of the enzyme via the kidney, thereby accounting for the accumulation of the enzyme in serum levels and lack of presence in the urine. Currently, no evidence has been found to suggest that macroenzymes play a compelling role in the cause of disease, nor do they require treatment. Therefore, in a patient with repeated episodes of abdominal pain and isolated elevation of lipase, consider alternatives to the diagnosis of pancreatitis, particularly when another known abdominal disease exists.

Thoracic Aorta to Popliteal Artery Bypass for Bilateral Lower-Extremity Critical Limb Ischemia

Thoracic aortic to infrainguinal arterial bypasses are rare in the literature, even more so when the outflow is the popliteal artery bilaterally. The case of a patient presenting with critical limb ischemia, chronic infrarenal aortic occlusion, and recurrent thrombosis of a unilateral axillobifemoral graft managed with thoracoretroperitoneal bitransobturator bipopliteal bypass is presented. The patient's vascular history was significant for multiple previous groin procedures for thrombectomy of her axillobifemoral graft, aortomesenteric bypass, redo aortomesenteric bypass for graft thrombosis, and multiple bowel resection procedures for acute mesenteric ischemia. The thoracic aorta and popliteal arteries were selected as sites for proximal and distal anastomoses, respectively, given anticipated difficulty in exposing the supraceliac aorta and femoral arteries. The technique of this operative approach is discussed.

The Case of a Disappearing Knife

Purpose: A 32 year old female with a history of psychiatric illness and compulsive foreign body ingestion presented after swallowing a butter knife 10 hours earlier. The patient had 57 upper endoscopies, six exploratory laporatomies and multiple small bowel resections in the past six years, all related to ingested foreign bodies. At presentation, she complained of chest and neck pain, odynophagia and inability to rotate her neck. She was afebrile, normotensive, but tachycardic. She was in no acute distress. Examination of her oropharynx revealed no gross lesions or signs of trauma, no crepitus and no palpable mass in the neck. Her abdominal exam showed some recent surgical scars but was otherwise normal. A radiograph revealed a knife in the hypopharynx and esophagus, terminating below the level the carina. Her laboratory tests showed no leukocytosis. An upper endoscopy with endotracheal intubation was performed in the operating room. No foreign body was found in her esophagus. No esophageal perforation or signs of trauma were noted. The stomach and duodenum were also normal. A lateral x-ray was repeated and showed the knife to be posterior to her esophagus. Surgery was consulted. An exploratory neck surgery was performed emergently and the knife removed from the posterior mediastinum. Postoperative endoscopy excluded injury to the esophagus No free air or pneumothorax was seen on abdominal or chest radiographs. Barium swallow performed two days later showed no evidence of contrast extravasation. The patient progressed well in the postoperative period and was discharged after a short hospital course. Foreign body impaction in the esophagus is a very common clinical problem faced by endoscopists. However, only rarely do foreign bodies penetrate the wall of the upper aerodigestive tract and even more rarely do they migrate into the soft tissue, neck or mediastinum. If perforation occurs it is facilitated by strong contraction of the hypopharyngeal and cricopharyngeal muscles which explains the higher rate of penetration through the hypopharynx and cervical esophagus. Certain findings on endoscopy may suggest the site of penetration such as esophageal ulceration, edema and laceration. However, in many cases of migratory foreign bodies, such as this one, no definitive site of perforation in the hypopharynx is found. The greatest danger with foreign body perforation is the risk of infection. The foreign body can introduce bacteria and if left untreated, carries a high mortality rate. Therefore, if no foreign body is identified on initial endoscopy, the patient should have a CT scan and/or immediate neck exploration for removal.

Avaliação e seguimento de pacientes adultos com síndrome do intestino curto pelo exame contrastado de trânsito intestinal

A síndrome do intestino curto é definida pela incapacidade da superfície do intestino delgado em manter as condições adequadas de absorção de nutrientes, ocasionando deficiências nutricionais. Em adultos, as principais causas de síndrome do intestino curto são as ressecções cirúrgicas amplas ou múltiplas, secundárias a infarto mesentérico, doença de Crohn e enterite actínica. Além de avaliar o tempo de trânsito até o intestino grosso, o exame contrastado de trânsito intestinal pode ser utilizado na medição da extensão do intestino remanescente e no acompanhamento dos fenômenos de adaptação estrutural das alças delgadas e colônicas. Em pacientes com síndrome do intestino curto, a adaptação estrutural do intestino delgado consiste na hiperplasia das vilosidades e das pregas mucosas, que se tornam mais numerosas, profundas e de maior diâmetro, assim como a dilatação do segmento remanescente. Esses achados morfológicos são mais pronunciados e bem estabelecidos nas alças ileais, evidenciando sua maior capacidade adaptativa. O conhecimento dos achados por imagem das características morfológicas e adaptativas do intestino delgado é de grande importância na abordagem multidisciplinar da síndrome do intestino curto.

A Case of Pulmonary Carcinoid Tumor in a Patient on Adalimumab for Crohnʼs Disease

Purpose: We report a unique case of pulmonary carcinoid tumor associated with adalimumab therapy for Crohn's disease. Methods: Adalimumab is a fully human monoclonal antibody against tumor necrosis factor alpha (TNFα). TNFα is a protein synthesized by activated macrophages and T cells. It is approved for the treatment of Crohn's disease and its' safety is established by clinical trials. However serious side effects can occur. Patients on TNFα inhibitors are at risk for injection reactions, serious infections and can develop malignancy. There is an FDA warning regarding risk of B-cell lymphomas and other tumors. Results: 63 year old female with fisutlizing, structuring Crohn's colitis and ileitis diagnosed at age 18, required multiple bowel resections and ileocolonic anastomosis. Presented with recurrent peri-anal fistulas and was started on adalimumab 10-11 months ago. Recently had developed a peri-rectal fistula and abscess requiring drainage. Previous smoker. No family history of Inflammatory Bowel Disease (IBD) or colorectal cancer. Physical exam notable for a non-tender, non-distended abdomen and rectal exam revealing non-tender peri-anal excoriations and a draining sinus fistula tract. Abdominal CT done for follow up of perirectal abcess had incidental finding of pulmonary nodules. This was a new finding; a chest CT then showed a 2cm RUL lung mass and multiple bibasilar sub-centimeter pulmonary nodules. Prior chest x-rays upon close inspection did not reveal the mass. Bronchoscopy with bronchiolar lavage and transbronchial biopsy was inconclusive. Whole body PET scan was remarkable for the right upper lung bronchial nodular density with low level FDG activity. Surgery performed a thoracotomy and wedge resection for diagnosis and cure. Pathology review confirmed a typical carcinoid tumor with pathologic stage of pT1a pN0. Adalimumab was stopped and she was placed on antibiotics for her fistulas along with prednisone taper. Patient later underwent an uncomplicated right lung wedge resection with curative intent and has since been doing well. She denies rectal pain or discharge and has 1-2 formed bowel movements daily. Post operatively she was placed on methotrexate for Crohn's maintenance therapy. Conclusion: Studies have demonstrated the clinical association of biologic therapy and Non-hodgekin's lymphomas. The action of TNFα antagonists has been shown in laboratory models to possibly potentiate tumor growth. Pulmonary carcinoid is a slow growing neuroendocrine tumor, but in this case appears to have developed in conjunction with adalimumab therapy. To our knowledge this is the first case of primary pulmonary carcinoid to be associated with adalimumab.

Incarcerated massive incisional hernia: extensive necrosis of the colon in a very obese patient. Surgical treatment and vacuum-assisted closure therapy: a case report

We discuss a diabetic obese patient with an extensive necrosis of the ascending and transverse colon plus segmental necrosis of the small bowel incarcerated in a massive median incisional hernia below the umbilicus. After a blood test and an abdominal CT scan (without contrast dial), the patient underwent an urgent operation. We performed an extended right hemicolectomy, multiple segmental small bowel resections and a terminal ileostomy. The defect of the abdominal wall was treated with vacuum-assisted closure (VAC) therapy with good results.

Active Crohn Disease and Hypercalcemia Treated With Infliximab: Case Report and Literature Review

To report a case of 1,25-dihydroxyvitamin D-mediated hypercalcemia caused by active Crohn disease that improved with infliximab therapy. We present the clinical and laboratory findings and describe the clinical course of a patient who had hypercalcemia during Crohn disease exacerbations. The literature is reviewed regarding 1,25-dihydroxyvitamin D production in Crohn disease, and the 3 cases of hypercalcemia in individuals with Crohn disease reported in the literature are described. A 50-year-old man with long-standing Crohn disease treated with multiple bowel resections presented for take-down ileostomy. He was hypercalcemic and had suppressed parathyroid hormone and parathyroid hormone-related peptide levels. Histopathology of the resected ileostomy site and adjacent small bowel indicated active Crohn disease. Hypercalcemia promptly resolved after a few days of treatment with intravenous glucocorticoids. One month later, hypercalcemia recurred in the presence of an inappropriately high 1,25-dihydroxyvitamin D level and increased urinary calcium and serum angiotensin-converting enzyme levels. The serum and urinary calcium levels became normal with infliximab therapy. Three previous reports of hypercalcemia caused by active Crohn disease describe effective treatment with glucocorticoids. This is the first report of successful response to infliximab in this setting. Hypercalcemia mediated by 1,25-dihydroxyvitamin D in the setting of Crohn disease may respond to glucocorticoid-sparing immunomodulators.

Survival impact of multiple bowel resections in patients undergoing primary cytoreductive surgery for advanced ovarian cancer: A case–control study

Objective. To evaluate clinicopathological factors and survival outcome of patients with advanced epithelial ovarian carcinoma undergoing multiple bowel resections to achieve optimal (≤ 1 cm) cytoreduction. Methods. A case–control study was performed identifying patients undergoing optimal primary cytoreductive surgery with ≥ 2 bowel resections between 10/1997 and 2/2006. The two control groups consisted of (1) patients undergoing optimal cytoreduction with ≤ 1 bowel resections matched [1:2] for age and stage and (2) patients left with suboptimal disease. Cox proportional hazards model were used to evaluate the effects of demographic and surgico-pathologic factors on survival outcome. Results. A total of 34 patients underwent ≥ 2 bowel resections. Sixty-eight patients underwent ≤ 1 bowel resections. All patients had optimal cytoreduction and 40/102 patients (39.2%) underwent complete cytoreduction. Patients undergoing multiple bowel resections experienced a higher EBL (700 v 500 mL, p = 0.01) and longer LOS (10 v 7 days, p = 0.01) compared to patients with ≤ 1 bowel resections. Multivariate analysis revealed the amount of residual disease to be a statistically significant and radiation therapy to the right pelvic sidewall and cul-de-sac independent predictor of overall survival. The median overall survival time for patients undergoing ≥ 2 bowel resections was 28.3 months, which was comparable to patients undergoing ≤ 1 bowel resections, (37.8 months, p = 0.09) but statistically significantly superior to patients left with suboptimal residual disease (12 months, p = 0.02). Conclusions. Although primary surgery that includes ≥ 2 bowel resections is associated with longer LOS and a higher EBL, such extensive procedures are warranted if they will contribute to an overall optimal residual disease state.