Need For Bowel Resection Research Articles

Interval debulking surgery following neo-adjuvant chemotherapy for stage IVB ovarian cancer using neutral argon plasma (PlasmaJet™)

ObjectiveWe present a novel surgical approach to ovarian cancer debulking using neutral argon plasma (PlasmaJet™). Case historyA 48 year-old woman diagnosed with FIGO stage IVB grade 3 serous epithelial ovarian carcinoma received three cycles of neoadjuvant chemotherapy with carboplatin and paclitaxel. Operative techniqueDissection and radical debulking surgery were performed using PlasmaJet™ as previously described [1,2]. This included diaphragmatic and abdominal peritoneal stripping, supra-colic omentectomy, tumour ablation on the small and large intestines and mesentery, pelvic and para-aortic lymphadenectomy. ResultsThe only post-operative complication was a superficial wound breakdown, which healed by secondary intention. She remains well two years after surgery, with no sign of recurrence. ConclusionIn this case, PlasmaJet™ facilitated diaphragmatic peritoneal stripping as well as dissection of tissue close to bowel and major vessels. Further study is required to assess whether this device can reduce the need for bowel resection while achieving complete cytoreduction.

Abdominal Pain and Mass

A28-year-oldman presentedwith severalmonths of constant, burning upper abdominal pain centered on the epigastrium. The pain was associated with morning nausea and was worsened by food and alcohol. He was given trials of proton pump inhibitors and dicyclominewithno relief. Hehadnoprior chronicmedical conditions.His family historywaspositive for a brother with kidney stones. He was a former smoker but denied current drug or alcohol use. Review of systems was positive for dry throat, gastroesophageal reflux, and frequent headaches. Physical examinationwasnotable for a faintly palpablemidabdominalmass slightly to the left andabove the umbilicuswith localizeddiscomfort topalpation.Ultrasonographyof theabdomenshowed a hypoechoic, hypervascular, solidmass left of themidline (Figure, A). A subsequent computed tomography scan of the abdomen and pelvis demonstrated a left adrenal myelolipoma and a 4.4 × 3.7-cm hypervascular soft tissue mass just left of the midline within the mesentery in close approximationwith the small bowel, centered at the level of the L3-L4 intervertebral disc (Figure, B). A laparotomy was performed and a round, wellcircumscribed soft tissuemass located approximately 90 cm distal to the ligament of Treitz at the base of themesentery was removed intact without the need for bowel resection (Figure, C). Pathologic photomicrograph of the specimen is shown (Figure, D). A B

260 Colonic Inflammation Induces Neurogenesis via Transdifferentiation of Enteric Glial Cells

G A A b st ra ct s with CD who underwent CTe/MRe at a single institution between 2010 to 2012 and who were reported to have strictures. Patient demographics, disease history, enterographic characteristics and clinical course of each patient following the enterography was reviewed. The length of follow-up was defined as the interval between the CTe/MRe to the event of interest (surgery) or last follow-up if the patient remained surgery-free. A time-to-event Kaplan-Meier analysis was performed to identify clinical and enterography characteristics associated with the need of bowel resection or stricturoplasty at the stricture site (primary outcome). Results: A total of 82 patients were included in the study (mean age, 34 ± 13 years; females, 46%; White, 67%; prior surgery, 46.3%; current smoker, 11.1%). Majority of the patients (74.3%) had one stricture seen on CTe/MRe. Median Lemann score was 4.5 (IQR; 2.1-9.1). Overall, 30 (36.6%) had surgical resection or stricturoplasty in a median follow-up interval of 222 days (IQR; 51-349 days). Time-to-event analysis showed that 4S scores was able to stratify patients and predict the need for surgery with only 10% of patients with no major predictors undergoing surgery as compared to 75% of patients with 3 or more major predictors (see Table 1 and Figure 1). There was no significant correlation between Lemann score and 4S. Conclusions: The findings of this study validate the use of onetime enterography-based 4S for differentiating high-risk strictures from low-risk strictures and prognosticating the need for future surgery. The predictors included in 4S can help guide optimal decision-making with respect to medical versus surgical options at the point-of-care. Table 1

259 Determination of Intestinal Permeability in Patients With Active and Inactive Ulcerative Colitis

G A A b st ra ct s with CD who underwent CTe/MRe at a single institution between 2010 to 2012 and who were reported to have strictures. Patient demographics, disease history, enterographic characteristics and clinical course of each patient following the enterography was reviewed. The length of follow-up was defined as the interval between the CTe/MRe to the event of interest (surgery) or last follow-up if the patient remained surgery-free. A time-to-event Kaplan-Meier analysis was performed to identify clinical and enterography characteristics associated with the need of bowel resection or stricturoplasty at the stricture site (primary outcome). Results: A total of 82 patients were included in the study (mean age, 34 ± 13 years; females, 46%; White, 67%; prior surgery, 46.3%; current smoker, 11.1%). Majority of the patients (74.3%) had one stricture seen on CTe/MRe. Median Lemann score was 4.5 (IQR; 2.1-9.1). Overall, 30 (36.6%) had surgical resection or stricturoplasty in a median follow-up interval of 222 days (IQR; 51-349 days). Time-to-event analysis showed that 4S scores was able to stratify patients and predict the need for surgery with only 10% of patients with no major predictors undergoing surgery as compared to 75% of patients with 3 or more major predictors (see Table 1 and Figure 1). There was no significant correlation between Lemann score and 4S. Conclusions: The findings of this study validate the use of onetime enterography-based 4S for differentiating high-risk strictures from low-risk strictures and prognosticating the need for future surgery. The predictors included in 4S can help guide optimal decision-making with respect to medical versus surgical options at the point-of-care. Table 1

Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage

Noncompressible abdominal bleeding is a significant cause of preventable death on the battlefield and in the civilian trauma environment, with no effective therapies available at point of injury. We previously described the development of a percutaneously administered, self-expanding, poly(urea)urethane foam that improved survival in a lethal Grade V hepatic and portal vein injury model in swine. In this study, we hypothesized that survival with foam treatment is dose dependent. A high-grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncompressible hemorrhage. After injury, the animals were divided into five groups. The control group (n = 12) was treated only with fluid resuscitation, and four polymer groups received different dose volumes (Group 1, n = 6, 64 mL; Group 2, n = 6, 85 mL; Group 3, n = 18, 100 mL; and Group 4, n = 10, 120 mL) in addition to fluids. Ten minutes after injury, the foam was percutaneously administered, and animals were monitored for 3 hours. Survival with hepatoportal injury was highest in Group 4 (90%) and decreased in a dose-dependent fashion (Group 3, 72%; Group 2, 33%; Group 1, 17%). All polymer groups survived significantly longer than the controls (8.3%). Hemorrhage rate was reduced in all groups but lowest in Group 4 versus the control group (0.34 [0.052] vs. 3.0 [1.3] mL/kg/min, p < 0.001). Increasing foam dose volume was associated with increased peak intra-abdominal pressure (88.2 [38.9] in Group 4 vs. 9.5 [3.2] in the controls, p < 0.0001) and increased incidence of focal bowel injuries. The self-expanding foam significantly improves survival in a dose-dependent fashion in an otherwise lethal injury. Higher doses are associated with better survival but resulted in the need for bowel resection.

Comparison of open and endovascular treatment of acute mesenteric ischemia

Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding the rates of bowel resection following endovascular vs open repair of AMI. Using the National Inpatient Sample database, admissions from 2005 through 2009 were identified according to International Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities were also examined. Outcome measures included mortality, length of stay, the need for bowel resection (45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization. Statistical analysis was conducted by χ(2) tests and Wilcoxon rank-sum comparisons. Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025). Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.

Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation

Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital. We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes. Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality. Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

English

Inguinal hernia is the most common hernia seen in females. Only independent risk factors for inguinal hernia in females are positive family history and obstipation. Here we present a case of 60yr old female with irreducible inguinal hernia. On examination an intra-vaginal foreign body was found which was causing patient to strain during micturition leading to chronic increase in intra-abdominal pressure. A herniorrhaphy was done and foreign body was removed intra- operatively. INTRODUCTION : Inguinal hernia in females is relatively uncommon as compared to males but inguinal hernia is the most common hernia in females. The incidence of inguinal hernia in females is <5%. Inguinal hernias are nine times more common in men than in women. (1) The incidence of indirect hernia relates to the congenital weakness at the internal abdominal ring. The sac is formed by the unobliterated portion of the prenatal peritoneal invagination of the canal of nuck that runs along and partly covers the round ligament. Virtually nothing is known about risk factors for inguinal hernia in females. High sports activity is protective in inguinal hernia. Smoking, appendicectomy, abdominal operations and multiple deliveries are not associated with inguinal hernia in females. (2) Inguinal hernia has been reported to be more prevalent in people with low socio-economic status. (3) Inguinal hernias have an approximate incidence of incarceration of 10% and a portion of these may become strangulated. (4) In a study, bowel resection rate in patients with obstructed or strangulated hernias was 15.9%. The need for bowel resection closely correlated with the time interval between the onset of acute symptoms and subsequent operation. (5) Immediate operation should be done in all patients who are ill with incarcerated or obstructed hernia, without attempting reduction.

An audit of paediatric intussusception radiological reduction at the Bloemfontein Academic Hospital Complex, Free State, South Africa

Background. Intussusception remains the most common cause of bowel obstruction in infants and toddlers and can result in considerable morbidity and mortality if not properly treated. The aim of this study was to determine the success rate of air intussesception reduction (AIR), and to identify factors predicting an unsuccessful procedure, among paediatric patients diagnosed with idiopathic intussusception at the Bloemfontein Academic Hospital Complex, Free State, South Africa. Methods. This retrospective analytic cohort study assessed data from the records of all paediatric patients with the diagnosis of idiopathic intussusception discharged from the Department of Paediatric Surgery between 1 January 2003 and 30 September 2011. Results. Thirty-five children with intussusception were identified. AIR enemas were performed in 18 children (51.4%), with successful reduction in 2 (11.1%). Seventeen children (48.6%) were primarily treated surgically without attempting radiological reduction. Successful AIR was more likely if the duration of symptoms was <48 hours. Sixteen patients in whom AIR was attempted eventually required surgical intervention, either due to perforation during AIR or irreducibility. Approximately 94% of children required bowel resection at surgery. In 37.5% of cases AIR was complicated by perforation, making surgical treatment mandatory. Nine patients (56.3%) had unsuccessful AIR without perforation, but needed bowel resection at surgery. One patient (6.3 %) required manual reduction only, without the need for bowel resection at surgery. No deaths were recorded during the period covered by this audit. Conclusions. Our institution’s radiological reduction outcomes were not comparable to international standards. The only statistically significant predictor of poor outcome of AIR was time delay before attempted reduction.

Serum Procalcitonin for Predicting the Failure of Conservative Management and the Need for Bowel Resection in Patients with Small Bowel Obstruction

Ischemia and necrosis are complications of small bowel obstruction (SBO) and require rapid surgical treatment. At present, there are no sufficiently accurate preoperative biomarkers of ischemia or necrosis. The objective of the current study was to evaluate the value of serum procalcitonin levels for predicting conservative management failure and the presence of intraoperatively observed bowel ischemia (reversible or not) in patients with SBO. One hundred and sixty-six participants of 242 in a randomized controlled trial focusing on the management of SBO (Acute Bowel Obstruction Diagnostic study [ABOD], NCT00389116) had available data on procalcitonin and were included in the study. The primary study objective was to determine whether serum procalcitonin could identify patients in whom conservative management (CM) failed (the surgical management [SM] group) and the subset of SM patients with intraoperatively observed ischemia (reversible or not). For the analysis, the patients were divided into subgroups according to the success or failure of CM and (for surgically managed patients) the presence or absence of intraoperative ischemia (reversible or not). Procalcitonin levels were higher in the SM group (n = 35) than in the CM group (n = 131) (0.53 vs 0.14 ng/mL; p = 0.031) and higher in the group managed surgically with ischemia (n = 12) than patients managed surgically without intraoperative ischemia (n = 23) (1.16 vs 0.21 ng/mL, respectively; p < 0.001). A multiple logistic regression showed that procalcitonin is a risk factor for CM failure (odds ratio = 3.5; 95% CI, 1.4-8.5; p = 0.006) and for ischemia (reversible or not) (odds ratio = 46.9; 95% CI, 4.0-547.3; p < 0.001). Procalcitonin can help predict CM failure and occurrence of bowel ischemia (reversible or not) in SBO patients, but additional studies are needed.

Obturator hernia: the relationship between anatomical classification and the Howship–Romberg sign

The obturator hernia sac may follow the anterior or posterior branch of the obturator nerve, and thus, it can be classified anatomically. The relationship between the symptoms and the anatomical classification of obturator hernia has not yet been clearly described in the literature. Multidetector-row computed tomography (MDCT) examinations of 35 consecutive cases of new-onset obturator hernia admitted from March 2005 to April 2012 were reviewed retrospectively. Obturator hernia was classified anatomically using MDCT. Patient characteristics and clinical presentations were compared among the anatomical classifications. Fifteen cases were classified as type I (anterior branch type) and 20 cases as type II (posterior branch type). There were no significant differences regarding time from onset of symptoms to diagnosis, presence of small bowel obstruction, and need for bowel resection. The Howship-Romberg sign was seen in 6 cases (30 %) of type II and 10 cases (67 %) of type I (p = 0.044). The Howship-Romberg sign was present significantly more often with the anterior than the posterior branch type of obturator hernia.

Conservative Management for an Entero-Adnexal Fistula at Initial Presentation of Advanced Ovarian Carcinoma

Gastrointestinal fistulae can occur in ovarian cancer patients, usually in the setting of advanced relapsed disease. Treatment typically involves immediate surgery.Here, we describe a case of an abscess resulting from an intestinal fistula as the first manifestation of advanced epithelial ovarian cancer, and we review the current literature on this subject. The patient was successfully treated with a combination of chemotherapy, antibiotics, and delayed surgery. Optimal debulking was achieved without a need for bowel resection.This report is the first of conservative management of a fistula in an ovarian cancer patient in the chemotherapy-naïve setting.

Abdominal Cocoon Syndrome (Idiopathic Sclerosing Encapsulating Peritonitis): How Easy Is Its Diagnosis Preoperatively? A Case Report

The abdominal cocoon syndrome (or idiopathic encapsulating peritonitis) is a rare cause of intestinal obstruction. It has been reported predominantly in adolescent girls living in tropical/subtropical region in which diagnosis is only made at laparotomy in most cases. The cause and pathogenesis of the condition have not been elucidated. Prolonged administration of practalol, meconium peritonitis, and tuberculous infection of the female genital tract have been incriminated as possible causes. The author reports a case of a female patient with recurrent intestinal obstruction treated for years but failed to settle down on conservative treatment during her last hospital admission and had to undergo surgery. Preoperative diagnosis of this syndrome as the cause of her intestinal obstruction was not made until at laparotomy, when a thick fibrotic peritoneal wrapping of the bowel in a concertina-like fashion with some adhesions was found. Excision of this membrane and adhesiolysis were carried out without any need for bowel resection, and this led to relief of the obstruction and patient's complete recovery. Awareness of this benign condition in the differential diagnosis of intestinal obstruction will result in early diagnosis and correct management and prevent unnecessary bowel resections and bad outcomes.

Intra-abdominal and Pelvic Abscess in Crohnʼs Disease: A Single Center Experience

Intra-abdominal and pelvic abscesses occur in 10-30% of patients with Crohn's disease (CD) at some time in the course of the illness. We aimed to characterize patients with abdominal or pelvic abscesses complicating CD. Retrospective single center study, including 21 patients admitted in our Hospital between January 2007 and December 2011 with abdominal or pelvic abscess complicating CD. Statistics were performed with SPSS v.17.0 Twenty one patients included, 52% male, with median age 29±8,4 years. The average hospital stay was 30±15 days. 24% of our patients were treated only with antibiotics, in 14% surgical and/or percutaneous drainage was performed and 62% were submitted to surgical bowel resection. The abscess size or location failed to anticipate the need for bowel resection. However all patients who had fistula or a history of abdominal surgery related to CD, underwent surgical drainage or bowel resection. Of those submitted to surgical intervention, one began biological therapy after discharge compared with 5 patients treated conservatively (antibiotics with or without drainage), this difference being statistically significant. The median follow-up after hospital discharge was 32 months, with recurrence of abscess in 2 patients, one treated conservatively and other with bowel resection. In patients with abdominal or pelvic abscess complicating CD, the need for surgical intervention is related to the presence of fistula and previous abdominal surgery related to CD. Treatment with antibiotics alone did not show to increase the rate of recurrence. Patients treated conservatively were later more often treated with biological therapy compared with those treated surgically, and this difference was statistically significant. The biological therapy has proved to be safe in penetrating CD, with low recurrence rate.

Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting.

BackgroundInguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature.MethodsA descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0.ResultsA total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P = 0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini’s repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P = 0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P < 0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P < 0.001).ConclusionInguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem.

OC02.01: Ebstein's anomaly of the tricuspid valve in the fetus: a multicentre experience

and the current standard of care is represented by the maximal surgical effort aimed at leaving no residual disease. Bowel resection is common intervention in experienced hands for achievement of optimal debulking. We analysed ability of transvaginal ultrasound to predict need of rectosigmoid resection. Methods: Retrospective study comparing transvaginal ultrasound findings and histopatology and preoperative findings in advanced ovarian cancer patients (stages IIC-IV) surgically debulked at our department in years 2009–2011. Results: In total, 214 patients were included into this study, in 88 of them, rectosigmoid resection was needed to achieve complete debulking and involvement of bowel serosa or wall was confirmed by histology. In 82 of them ultrasound predicted need of bowel resection. In addition, ultrasound indicated bowel involvement in 92 patients, however, in 10 of them the bowel was not affected (as assessed by surgeon). This gives the sensitivity for transvaginal ultrasound prediction of rectosigmoid resection 93.2% and specificity 92.1% (PPV 89.1% and NPV 95.1%). Conclusions: Transvaginal ultrasound has high accuracy in prediction of rectosigmoid resection and thus allows for planning appropriate surgical team and conditions. This work was supported by the Internal Grant Agency, Ministry of Health of the Czech republic, project No. NT13070.

Laparoscopic adhesiolysis: consensus conference guidelines

Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

Fish Bone Perforation Mimicking Acute Appendicitis

Fish bone ingestion is relatively common, however, resultant perforation of the small bowel is fortunately rare. We present a case of a 48-year-old gentleman who attended our emergency department complaining of severe, unrelenting right lower abdominal pain for the preceding five hours. CT scanning suggested a perforated appendix however at operation the appendix was normal. Several loops of small bowel walling off an inter-loop abscess and a fishbone were discovered in the washout fluid. A diagnosis of small bowel fish bone perforation was made intra-operatively and the patient subsequently made a full recovery without the need for bowel resection. We present this as a rare case of small bowel perforation by a fish bone where the site of perforation was unidentifiable but was treated successfully without the need for bowel resection. doi:10.4021/jmc151w

An Unusual Cause of Postprandial Abdominal Pain

Purpose: Paraduodenal hernias are rare congenital malformations and are the most common form of internal hernias. They result from an error in intestinal rotation and fixation that leads to entrapment of the small bowel between the mesocolon and posterior abdominal wall. Methods: We present a 50-year-old man who was referred to Howard University Hospital for colorectal cancer screening and postprandial abdominal pain with reflux symptoms of 1 month duration. Results: Bidirectional endoscopy was performed. Esophagogastroduodenoscopy (EGD) was non-diagnostic. However, colonoscopy revealed extrinsic mass compression in the ascending colon just distal to the cecum. CT scan of the abdomen was recommended for evaluation of the protruding mass and mesenteric Doppler ultrasonography was recommended for the postprandial abdominal pain to exclude mesenteric angina. Patient presented a few days later with worsening abdominal pain. The CT of the abdomen showed conversions of mesenteric vascular branches resembling a ‘whirl sign' which can be seen with obstruction with mass effect in the left upper quadrant. Diagnostic laparoscopy revealed a large defect in the mesentery with a paraduodenal hernia filled with multiple bowel loops. The hernia was reduced without a need for bowel resection. The area of defect was closed up using sutures. The patient recovered uneventfully. Conclusion: Paraduodenal hernia is an unusual cause of intestinal obstructions. Its presentation is ambiguous and variable; making it difficult to establish a correct early diagnosis. Surgical management offers definitive therapy. Gastroenterologists and other clinicians should be more familiar with paraduodenal hernia in order to make an early diagnosis and early surgical intervention to minimize morbidity and mortality.

Abdominal cocoon syndrome as a rare cause of mechanical bowel obstruction: report of two cases

An abdominal cocoon is an extremely rare condition, and has been reported mainly in young adolescent women as a cause of small bowel obstruction. In these patients, the small bowel is encased in a fibrous sac called an abdominal cocoon. We hereby present two cases who were diagnosed only by laparotomy and their correlation with the literature. They both received early intervention, thus preventing the need for bowel resection. The pathology of both membranes showed inflammation.