Paracolic Gutter Research Articles

Clostridium difficile appendicitis in an immunocompromised patient: a case report and review of the literature

BackgroundClostridium difficile (C. difficile) is a common cause of infectious colitis in individuals with prior antibiotic or hospital exposure. Extraintestinal manifestations of C. difficile infections, however, are rare. Here we present a case of C. difficile appendicitis in an immunocompromised patient.Case presentationA 53-year-old Caucasian male presented to the emergency room for two days of lower abdominal pain associated with nausea and subjective fevers. He otherwise denied having diarrhea or hematochezia. He did not have any recent hospitalizations, nursing home stays, or antibiotic exposure. His past medical history was notable for stage III tonsillar squamous cell carcinoma for which he was status post tonsillectomy, radiation therapy, and chemotherapy (cisplatin 4 days prior to presentation). He was afebrile with tenderness to palpation in the bilateral lower quadrants, right greater than left. His white blood cell (WBC) count was 15.6 × 103 cells/μL. Computed tomography (CT) of the abdomen and pelvis showed marked edema and inflammation of the cecum and ascending colon as well as an enlarged appendix with surrounding inflammatory changes with a small amount of free fluid in the right paracolic gutter. He was treated non-surgically with antibiotics. He did not clinically improve and on hospital day 3, he developed diarrhea for which C. difficile stool polymerase chain reaction was sent. Repeat CT of the abdomen and pelvis was performed which showed progression to pan-colitis and persistent appendicitis. C. difficile testing later resulted positive, for which oral vancomycin was started. The patient markedly improved with medical management alone and was subsequently discharged on oral vancomycin.ConclusionsOur case highlights the importance of maintaining a high index of suspicion for C. difficile in a patient presenting with both appendicitis and colitis, with prompt diagnosis and treatment being essential.

Pericecal Hernia

Background: Internal hernias involve prolapse of any viscus through normal or abnormal mesenteric or peritoneal aperture and constitute <1% of all cases of hernia. Pericecal hernia is one form of internal hernia rarely reported in the pediatric population. Clinical Description: We describe the case of a 10-year-old boy with underlying tetralogy of Fallot, who presented with third episode of severe abdominal pain, requiring hospital admission with tenderness in the umbilical and right iliac quadrants, voluntary guarding but no organomegaly or abdominal distension, and preserved bowel sounds. Management: Baseline investigations (complete blood count, C-reactive protein, erythrocyte sedimentation rate, blood culture sensitivity, and stool and urine microscopy) and serum amylase and lipase were normal. Ultrasound showed mesenteric lymphadenopathy but no pancreatitis or appendicitis. Computed tomography (CT) demonstrated circumferential wall thickening in distal ileum with clustering of distal ileal loops, posterior and lateral to the cecum, extending into right paracolic gutter, suggestive of pericecal hernia. Child received conservative management and improved. Definitive surgical reduction was deferred due to negative parental consent. Conclusion: To conclude, internal abdominal hernia is rare in children with nonspecific clinical presentation. CT should be considered when underlying etiology of acute abdomen is not found on the basis of history, examination, and baseline investigative workup. Early intervention helps in reducing the morbidity and mortality to great extent.

Malignant peripheral nerve sheath tumor of mesocolon: A rare case

Malignant peripheral nerve sheath tumor (MPNST) is a soft-tissue sarcoma arising from or differentiating toward peripheral nerve sheath cells. It accounts for 5%–10% of soft-tissue sarcomas. The most common sites of origin are proximal portion of upper, lower limbs and trunk. MPNST arising from the nerve plexus of gastrointestinal tract is extremely rare, and only very few cases have been reported in literature. In this report, we are describing a case of MPNST from mesocolon. An 82-year-old male presented to hospital with complaint of pain abdomen and feeling of lump on the left side of lower abdomen for the past 2 months. On contrast-enhanced computed tomography (CECT) of chest and abdomen, there was 15 cm × 10 cm mass palpable in left lumbar region without ascites and multiple random subpleural nodules in bilateral lung. Intraoperatively, there was 15 cm × 10 cm hard irregular mass in left paracolic gutter infiltrating mesentry of descending colon. Left hemicolectomy was performed with end-to-end anastomosis. Histopathological examination revealed malignant peripheral nerve sheath tumor, and on immunohistochemistry, tumor cells were positive for S-100 and negative for C-kit and Smooth Muscle Actin (SMA). The patient was started on tamoxifen in view of old age and lung metastasis. The patient is on follow-up from 2 years with stable disease. In this report, we highlight the possibility of clinical differential diagnosis of MPNST arising from mesocolon should be kept while dealing with mesenchymal tumors of colon. Radical surgery with negative margins is required for achieving palliation, and adjuvant tamoxifen could offer advantage in patient who cannot tolerate chemotherapy.

A Case of an Internal Hernia in the Left Paracolic Gutter Associated with Persistent Descending Mesocolon

A Case of an Internal Hernia in the Left Paracolic Gutter Associated with Persistent Descending Mesocolon

Blunt abdominal injury resulting in a belly full of candy after a motocross accident, a case report

BackgroundBlunt traumatic gastric perforations in children are rare. Delayed diagnosis will lead to abdominal contamination and may result in morbidity and even mortality. We present a case of an adolescent who sustained blunt abdominal injury in a motocross accident and presented with remarkable hyperdense spherical shaped structures on the computed tomography (CT).Case presentationA 15-year-old boy arrived at the emergency room with an acute abdomen after a motocross accident. A CT scan of the abdomen demonstrated free air and hyperdense round structures in the stomach, pelvic cavity and right paracolic gutter. During emergency laparotomy a traumatic gastric perforation was sutured, a splenic rupture was treated with a vicryl mesh and multiple spherical food scraps were removed from the abdomen. After surgery, the boy clarified that he had eaten a whole bag of colorful and spherical shaped candy just before the accident.ConclusionsTraumatic gastric rupture in children is rare but physicians should be aware of this diagnosis in case of blunt abdominal trauma with free air on the CT scan. Gastric contents, in this case candy, can present as hyperdense shaped structures in the abdominal cavity on the CT scan.

Secrets for a Successful Surgical Systematization in the Treatment of Posterior Compartment Endometriosis

Study Objective Demonstrate the secrets of the laparoscopic systematization in the treatment of posterior compartment endometriosis. Design Video demonstrating the systematic technique step by step (Canadian Task Force classification III) Setting: Surgery performed in 30-year-old patient, G0P0, with progressive dysmenorrhea, dyspareunia, menometrorrhagia and infertility. Upon vaginal and rectal touch, palpable thickening of the uterosacral ligaments was noticed with pain on mobilization. The MRI scan showed a low T2 signal lesion over the uterosacral ligaments, resulting in extrinsic damage to the right ureter. Patients or Participants N/A Interventions The nerve sparing laparoscopic excision systematization technique was the following: 1) Carry out the inspection of the cavity without targeting the central disease at first. 2) Mobilization of the sigmoid colon, identifying the line of separation between the mesosigmoid and the parietal peritoneum, above the paracolic gutters. 3) Exposure of the left pararectal fossa, keeping the ureter and mesoureter as the lateral limit and the rectum as the medial limit, dissecting caudally until we surpass lesion. 4) Fixation of the ovaries, exposing the posterior leaflet of the broad ligament. 5) Left ureterolysis begins at level of the promontory, with craniocaudal and lateromedial movements over the ureter, until the proximity with the posterior leaflet of the broad ligament. We then lateralize the ureter to expose the left uterosacral ligament 6) Resection of the left uterosacral ligament, keeping the ureter and hypogastric nerve lateralized - exposing the rectovaginal space. 7) Target the rectovaginal septum from lateral to medial, facilitating the identification of the mesorectum, dissected in a posterior direction. The same steps are performed in the right hemi-pelvis respecting their anatomical differences. Measurements and Main Results: The lesions were excised without complications and with minimal blood loss. Conclusion The surgical systematization proposed is a viable and reproducible technique and may offer greater damage control.

Spontaneous uterine artery erosion from deep infiltrating endometriosis

A 31-year-old woman presented to the clinic with an acute onset of lower abdominal pain after a high-intensity gym activity. The patient had no significant medical or surgical history, and her pregnancy test was negative. Although the patient was initially hemodynamically stable, her vital signs deteriorated, and she had a bedside ultrasound scan that revealed a large free fluid over her paracolic gutters and pouch of Morrison. An emergency laparoscopy revealed 3200 mL of blood in the peritoneal cavity (hemoperitoneum) with an active uterine artery spurting from the left pelvic sidewall (Figure 1; Supplemental Video).

S1771 Right Lower Quadrant Abdominal Pain: Time to Think Beyond Acute Appendicitis

INTRODUCTION: Incidence of primary appendiceal carcinoma is less than 1% amongst all gastrointestinal malignancies. Goblet cell carcinoma (GCC) accounts for less than 14% of all the appendiceal tumor, with an annual incidence rate of 0.05/100,000 per year. We present a case of goblet cell carcinoma who presented with lower abdominal pain. CASE DESCRIPTION/METHODS: 75-year-old lady with a PMH of frequent diverticulitis presented to ED for left lower quadrant (LLQ) abdominal pain that later migrated to right lower quadrant (RLQ). Physical examination revealed tenderness over the RLQ. Lab work revealed leukocytosis. CT abdomen showed inflammatory stranding in the right paracolic gutter and mildly dilated appendix, extensive left colon diverticulosis. Diagnostic laparoscopy revealed sigmoid diverticulitis, purulent fluid in right paracolic gutter and inflamed appendix. Appendectomy was done and biopsy revealed goblet cell carcinoma with TANG B histology. Final staging was pT3pNx with Ki67 of 40%. Immunohistochemical staining was positive for CK-7, synaptophysin and weakly positive for CD-56. CA 125 was high. Further imaging and colonoscopy ruled out metastasis or synchronous disease. Within 3 weeks she relapsed at trocher site. Repeat PET CT showed LLQ nodularity, RLQ fluid collection and activity in the liver indicating possible carcinomatosis. Patient was started on Folfox. DISCUSSION: GCC shares common histological characteristics of both adenocarcinoma and carcinoid tumor with intermediate aggressive behavior. Initial presentation is usually abdominal pain but can present with pelvic mass, abdominal distension, bleeding and genitourinary complications. GCC are usually weakly positive or negative for Chromogranin A and synaptophysin so somatostatin scintigraphy scan is usually not helpful. CEA, CA-125, and Ca19-9 are recommended as the markers for diagnosis and follow up. Surgery is the ultimate treatment, but debate persists between appendectomy vs right hemicolectomy. Right hemicolectomy is recommended for high grade TANG group B and C disease. Since metastatic disease mostly resembles adenocarcinoma 5-FU and leucovorin are usually advised. Prognosis is poor with average survival rate being 4.6 years. Diagnosis and management of GCC is challenging due to unpredictable biological behavior and scarcity of data. Guidelines about extent of surgical resection, role of chemotherapy, follow up protocol and role of aggressive peritoneal management need to be elucidated with prospective trial studies.

S2603 A Case Series: Pseudocirrhosis Presenting as Acute Upper Gastrointestinal Bleeding After FOLFOX Therapy

INTRODUCTION: Pseudocirrhosis refers to morphologic changes seen on imaging in patients with metastatic disease to the liver. We present two cases of upper gastrointestinal bleed in patients with pseudocirrhosis due to metastatic gastrointestinal adenocarcinomas. CASE DESCRIPTION/METHODS: Case 1 A 31 year old female with metastatic adenocarcinoma to the liver, likely cholangiocarcinoma, presented with abdominal pain and vomiting. She completed a course of FOLFOX and was on ivosidenib. She was admitted with concern for sepsis and developed emesis. Imaging revealed progressive metastatic disease with pseudocirrhosis. Placement of a nasogastric tube returned bright red blood and a three point drop in hemoglobin to 4.5 g/dL. Emergent EGD revealed large esophageal varices with a “white nipple sign.” A pediatric bite block precluded banding. The varices were sclerosed with sodium tetradecyl sulfate without complication. Due to poor prognosis she was discharged to hospice. Case 2 A 44 year old male with metastatic colon cancer to the liver, on FOLFOX and panitumumab, presented with hematemesis and melena. He was tachycardiac, tender to abdominal palpation and rectal exam was positive for melena. Laboratory data revealed a hemoglobin of 7.6 g/dL, three points below his baseline. Imaging showed an increased number and size of hepatic lesions and pseudocirrhosis with sequelae of portal venous hypertension. EGD revealed large esophageal varices with red wales. Seven bands were deployed without complication. He was placed on hospice due to lack of chemotherapy options. DISCUSSION: Pseudocirrhosis describes morphologic changes in the liver that mimic cirrhosis, such as diffuse hepatic nodularity, capsular retraction and caudate lobe enlargement, in patients without histopathologic changes of cirrhosis. The diagnosis is made radiologically and is seen in patients with metastatic malignancy to the liver. It is thought that infiltrating tumors lead to fibrosis. Chemotherapy causes decreased tumor burden and scarring leads to capsular retraction. Chemotherapy can induce ischemic injury leading to nodular regenerative hyperplasia. Qayyum et al, report only 9% of patients with pseudocirrhosis have signs of portal hypertension. These patients rarely develop severe manifestations of portal hypertension such as a variceal bleed. Pseudocirrhosis is commonly associated with metastatic breast cancer. Pseudocirrhosis is rarely seen with gastrointestinal malignancy and only two cases were associated with FOLFOX, as in our patients.Image 1.: Case 1's EGD revealed large esophageal varices with a “white nipple sign.”Image 2.: Case 2's EGD revealed large esophageal varices with red wales.Image 3.: CT Image of Case 2 with ascites in the right paracolic gutter and perigastric ascites, splenomegaly, scalloping of the liver margins and metastases. Medial to the spleen is a visible splenorenal shunt.

S1404 Duodenal Perforation After Biliary Stent Placement: How Early Should We Expect It? A Case Report

INTRODUCTION: Endoscopic placement of biliary stents is commonly performed to reestablish bile flow. Stent migration with intestinal perforation is a rare life-threatening complication. We report a case of a biliary stent causing an early duodenal perforation that was diagnosed laparoscopically four days after stent placement. CASE DESCRIPTION/METHODS: A 23-year-old woman presented with two days of worsening RUQ abdominal pain with associated dark urine and pale stool. On physical examination, she appeared ill and uncomfortable with scleral icterus and mild epigastric tenderness. Laboratory evaluation demonstrated a total bilirubin of 4.5 mg/dL, direct bilirubin of 2.8 mg/dL, ALT 354 mg/dL, AST 174 mg/dL, ALP 118 mg/dL , CA 19-9 143U/ml and normal hepatitis serologies. MRCP showed beading of the intrahepatic biliary tree with high grade strictures of the right and left hepatic ducts, suggesting Primary Sclerosing Cholangitis; cholelithiasis, choledocholithiasis with mild dilatation of the CBD and the intrahepatic biliary ducts (Figure 1). ERCP with sphincterotomy and stone extraction as well as brushings from the strictured portions was performed. A 7Fr x 9cm and a 7Fr x 15cm straight plastic stents were placed in the right and left intrahepatic ducts respectively (Figure 2). The evening after the procedure, she developed vomiting and abdominal pain together with elevated lipase and leukocytosis; findings attributable to post-ERCP pancreatitis. The next morning, she developed RLQ pain. She was scheduled to undergo laparoscopic cholecystectomy, so an exploration of the right lower quadrant was also planned. Laparoscopy reveled the biliary stent eroding through the duodenum causing a perforation (Figure 3). There was also significant bilious fluid leakage into the right paracolic gutter associated with inflammation. She underwent repair of the duodenal perforation and had a right hemicolectomy with ileocolic anastomosis. She did well post-op. DISCUSSION: Stent migration is a common complication and measures, such as creation of internal flanges and pigtails, have been taken to mitigate this. Consideration of indication, condition, size and other risk factors is important when assessing what type of stent to use. With the increased use of biliary stents, it is important for physicians to be aware of the many different complications that may arise. Although there are some well-established common complications, an astute physician will consider atypical presentations as cause for concern and further evaluation.Figure 1.: show beading of the intrahepatic biliary tree with high grade strictures of the right and left hepatic ducts.Figure 2.: 7Fr x 9cm straight plastic stent in the right intrahepatic system and a 7Fr x 15cm straight plastic stent in the left intrahepatic system.Figure 3.: Stent eroding through the duodenum.

S3391 Life-Threatening Complication of Chronic Constipation in a Young Patient

INTRODUCTION: Bowel Perforation secondary to stool impaction is a rare entity which has amortality rate of 32-57%. It has Predilection to age 22-85. Risk factors include chronic constipation, NSAIDs, narcotics, antacids, steroids, antidepressants and antipsychotics. Stercoral perforation results from compression of colonic mucosaby a hard fecaloma causing mucosal ischaemia on antimesenteric border withulceration and perforation. CASE DESCRIPTION/METHODS: A 41Year Old Female with PMH of Bipolar disorder, Hypothyroid, HTN, substanceabuse, End Stage Kidney Disease presented with diffuse severe abdominal pain for 2 days. She had bowel enema done one day prior to her presentation. Pain was 10/10 intensity associated with nausea and dizziness. Vitals Pulse rate 115/min, Respiratory rate 22/min, Blood pressure 90/54mmHg, Temperature 98.5F. Her Home medications included Methadone, Quetiapine, Trazodone, Clonazepam, Docusate, Levothyroxine.On examination, abdomen was diffusely tender with signs of peritonitis. Labs WBC: 3.80, AST/ALT 1277/989, Alkaline phosphatase 380, Total bilirubin 2.0. Hepatitis panel negative. Abdominal CT showed chronic obstruction with bowelperforation of redundant sigmoid colon and massively dilated colon with full of stool. Pt was immediately taken to surgery after initial resuscitation and antibiotics. Pt had left Hemicolectomy with primary anastomosis and drain placedin the paracolic gutter. Intraoperatively she was found to have ruptured proximaldescending colon secondary to rock hard stools with generalized fecal peritonitis and pathology report showed colonic transmural Necrosis. She was transferred toICU due to septic shock from Enterococcus faecalis bacteremia started on Zyvox.Patient went into cardiac arrest. Despite aggressive management, unfortunately Pt did not survive. DISCUSSION: Due to widespread use of opioids, antidepressants and antipsychotics earlyrecognition and proper management of constipation is crucial to prevent mortality. Only 10% of individuals are correctly diagnosed and managed properly. Our Pt was taking antipsychotics, antidepressants in addition to Methadone. This resulted in constipation due to disturbances with the migrating myoelectriccomplex causing delay in fecal transit time. Avoiding enema in a Pt like this would be a crucial step as the mucosa is very fragile to cause perforation easily. Frequent monitoring and proper management of constipation could save many young lives.Figure 1Figure 2

Unusual Sites of Necrotic Collections in Acute Necrotizing Pancreatitis: Association with Parenchymal Necrosis and Clinical Outcomes.

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than theretroperitoneum has not been systematically studied. To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes. This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated. A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups. Mesenteric collections are frequent in ANP. The other non-retroperitonealsites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Is the peritoneal lavage cytology coincided with peritoneal metastasis for gastric cancer?

e16533 Background: Gastric cancer (GC) with peritoneal metastasis (PM) is associated with a poor prognosis. The free cancer cells are the prerequisite of peritoneal metastasis. Peritoneal lavage cytology (PLC) is the main measure to identify the free cancer cells, but its positive rate is relatively low. This study aims to investigate the association between the result PLC and peritoneal metastasis for GC. Methods: From November 2017 to December 2019, 33 patients with GC were confirmed with PM through computerized tomography or diagnostic laparoscopy. The inflow and outflow catheters were inserted laparoscopically in all patients for postoperative hyperthermic intraperitoneal chemotherapy. PLC was performed with at least 200 ml of fluid and examined by measures of cytology and immunocytopathology. Ascites was aspirated if detected or 500 milliliter of normal saline infused the Douglas cavity, para-colic gutters and the right and left sub-phrenic cavity and then aspirated. Results: There were 15 males and 18 females and the median age was 56 (24-84) years old. All patients had a cT4a/cT4b and an N-positive tumor. The overall positive PLC (PLC+) rate was 63.6% (21/33). The distribution of Lauren classification was respectively 5 (15.2%) intestinal, 26 (78.8%) diffused and 2 (6.1%) mixed tumor. The diffused cases had a higher rate of PLC+ ( P = 0.004). All 5 intestinal GC had a negative PLC (PLC-). 71.4% (20/28) of patients with a grade G3/G4 had a PLC+, compared, no PLC+ was recorded in 5 grade G1/G2 patients (P = 0.003). The median peritoneal carcinomatosis index (PCI) was 14 (1-39). The PLC+ rate was 94.7% (18/19) in PCI > = 10 group and 21.4% (3/14) in PCI < 10 group ( P < 0.001). The median ascites was 200 (0-7000) ml. The PLC+ rate was 88.2% 15/17) in ascites > = 200 ml group and 37.5% (6/16) in ascites < 10 ml ( P = 0.002). The median follow-up was 13(1-27) months and the overall survival was 75.8%, but no significance was detected between PLC+ group and PLC- group. Conclusions: The present study suggested that the result of PLC was not completely coincided with PM for GC by measures of cytology and immunocytopathology, especially for intestinal and grade G1/G2 tumor.

A185 ABDOMINAL WALL VARICES: A CASE REPORT

Abstract Background Portal hypertension in cirrhosis results in variable and numerous portosystemic collateral circulations. Computed tomography (CT) and Doppler ultrasound (US) can identify these collateral vessels, especially abdominal wall varices, which can be encountered during a bedside paracentesis. Aims Describe a case of traumatic abdominal wall variceal bleed. Methods Case report. Results A 53 year-old Caucasian male presented to the emergency department (ED) with 4-days of abdominal pain and 2-months of increased abdominal girth. His medical history included Child Pugh Class B alcoholic liver cirrhosis diagnosed 1 year ago. No prior history of ascites, esophageal variceal bleed or hepatic encephalopathy. In the ED, his US showed moderate ascites with right portal vein flow reversal. A diagnostic RLQ paracentesis showed yellow ascitic fluid, no spontaneous bacterial peritonitis (SBP), and he was discharged home with diuretics. He returned to the ED the next day for increased abdominal girth with a Hb of 103 g/L. A diagnostic RLQ paracentesis showed orange-red ascitic fluid and no SBP. The following day, a therapeutic US-guided paracentesis was attempted in the RLQ and left-lower quadrant LLQ; however, ascitic fluid aspirate was grossly bloody. The procedure was aborted. Hb was 82 g/L and progressively decreased. CT angiogram was performed and showed a 10.7 x 4.7 x 8.0 cm hyperdense fluid in the right paracolic gutter near the paracentesis site, consistent with intraperitoneal hemorrhage (Figure A). The insertion site was seen as abdominal wall musculature focal thickening around abdominal wall varices and no contrast extravasation was seen. Gastroesophageal, splenic hilar and omental varices were seen. Doppler US showed no sonographic signs of active extravasation. Interventional Radiology performed a US-guided paracentesis and aspirated 3650 mL of hemorrhagic fluid. Color Doppler US showed small varices within the subcutaneous soft tissues (Figure A). The patient later developed hematemesis with an EGD showing a large high-risk esophageal varix actively bleeding that was banded. Given the refractory variceal bleeding, a Minnesota tube was inserted 4 days later and a transjugular intrahepatic portosystemic shunt was inserted the following day. Unfortunately, the patient developed progressive worsening hepatic encephalopy, multi-organ failure and expired 7-days later. Conclusions Adjunct imaging modalities such as color flow Doppler US or CT can be used as a screening tool to identify abdominal wall varices and reduce paracentesis bleeding complications. Funding Agencies None

A Case of Persistent Retroperitoneal Abscess with Large Right Perinephric Collection

Introduction: Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset and nonspecific clinical manifestations. Case Report: 55 years old male, underlying DM, Hypertension, Gouty arthritis. Referred to us for right Hypochondriac pain with persistent fever for past 2 days duration. Abdominal examination showed soft, tender over right side of abdomen, localized guarding. An abdominal CT scan showed right pyonephrosis complicated by a large right perirenal collection.Right Nephrostomy was performed. 1 week later, patient had fever and persistent right sided abdominal pain with increasing septic parameters. CT abdomen performed and showed Right pyonephrosis complicated by a large right perinephric abscess extending into the pelvic and inguinal region. Right Perinephric drainage performed. Patient developed worsening sepsis, repeated CT abdomen revealed residual multiloculated right perinephric collection. Open retroperitoneal drainage was performed, noted retroperitoneal abscsess, caccon right kidney and peritoneal, slough ,unhealthy tissue and necrotic debris over right psoas muscles.1 week after surgery, patient still not improving, repeated CT Abdomen showed features of D2 ischemia with focal retroperitoneal perforation causing large and recurrent right perinephric inflammation with increasing intraabdominal free fluid and enlarging right perinephric collection. Laparotomy done shiwed 1L clear ascites intraperitoneally, no pus collection seen. Cocoon inflammatory mass involving hepatic flexure and duodenum to the retroperitoneum, hepatic flexure appeared normal with no intraluminal mass.Right retroperitoneal exploration done, noted adhesion between hepatic flexure to Gerota's fascia, pus ~30ml at upper part of Gerota's fascia. Repeated CT abdomen showed slightly larger right paracolic gutter collection with similar right perinephric collection. Discussion: Retroperitoneal abscess is very rare. Retroperitoneal abscess may result from a variety of causes, such as pyelonephritis, pancreatitis, retroperitoneal appendicitis, diverticulitis, peptic ulcer disease, perforated cancer, infammatory bowel disease, spinal infection, trauma, and post instrumentation. For our patient ,the exact aetiology of retroperitoneal collection and peri renal collection are still unknown.

Long Term Survival after Cytoreductive Surgery Combined with Perioperative Chemotherapy in Gastric Cancer Patients with Peritoneal Metastasis.

The present study demonstrated prognostic factors for long-term survival in patients after a comprehensive treatment (CHT) for peritoneal metastasis (PM) from gastric cancer (GC). Materials and Methods: Among 419 patients treated with neoadjuvant intraperitoneal/systemic chemotherapy (NIPS), 266 (63.5%) patients received complete resection (CC-0) of the macroscopic tumors. In total, 184 (43.9%) patients were treated with postoperative systemic chemotherapy. Results: All patients treated who received incomplete cytoreduction (CC-1) died of GC within 6 years. In contrast, 10- year survival rates (-YSR) of CC-0 resection were 8.3% with median survival time (MST) of 20.5 months. Post-NIPS peritoneal cancer index (PCI) ≤11, and pre-NIPS PCI ≤13 were the significant favorable prognostic factors. Patients with numbers of involved peritoneal sectors ≤5 survived significant longer than those with ≥6. Both negative pre- and post-NIPS cytology was associated with significant favorable prognosis. Multivariate analyses identified pre-PCI (≤13 vs. ≥14), and cytology after NIPS (negative cytology vs. positive cytology) as independent prognostic factors. Ten year-survivors were found in patients with involvement of the greater omentum (9%), pelvic peritoneum (3%), para-colic gutter (13.9%), upper jejunum (5.6%), lower jejunum (5.5%), spermatic cord (21.9%), rectum (9.5%), ureter (6.3%), ovary (6.7%), and diaphragm (7.0%) at the time of cytoreduction. Twenty-one patients survived longer than 5 years, and 17 patients are still alive without recurrence. Conclusions: GC-PM should be removed aggressively, in patients with PCI after NIPS ≤11, PCI before NIPS ≤13, mall bowel PCI ≤2, and complete cytoreduction should be performed for metastasis in ≤5 peritoneal sectors.

Microscopic diseases remain in initial disseminated sites after neoadjuvant chemotherapy for stage III/IV ovarian, tubal, and primary peritoneal cancer.

ObjectiveThis study aimed to evaluate the presence of pathological residual tumor (pRT) in each initial disseminated site after neoadjuvant chemotherapy (NACT) to assess the appropriate surgical margins during interval debulking surgery (IDS) for a favorable prognosis.MethodsThis prospective descriptive study included patients with stage IIIC–IV epithelial ovarian, fallopian tubal, and peritoneal cancer. One hundred eleven patients underwent diagnostic exploratory laparotomy, and their initial intra-abdominal dissemination statuses were recorded. Any tumor >1 cm in diameter found during the exploratory laparotomy was resected during IDS even if it was macroscopically invisible after NACT. The pRT rate after NACT and negative predictive value (NPV; probability that sites with macroscopically invisible tumors have no pRT) during IDS were assessed in each disseminated site.ResultsA median of 5 NACT cycles were performed. Sites with a high incidence of pRT and low NPV included the rectosigmoid colon (71.4%, 38.6%), transverse mesentery (70.3%, 50.0%), greater omentum (68.3%, 51.7%), right diaphragm (61.9%, 48.1%), paracolic gutters (61.1%, 50.0%), and vesicouterine pouch (56.6%, 50.0%). Organs/tissues with a high incidence of pRT featured a low NPV. The median progression-free survival and overall survival in this cohort were 27.7 and 71.9 months, respectively.ConclusionEven if a disseminated site >1 cm in diameter before NACT is invisible during IDS, microscopic disease remains present within it. The appropriate surgical margins for IDS with a favorable prognosis could be secured by resecting a lesion of >1 cm before NACT even if it is invisible during IDS.

A Very Unusual Pattern of Intraperitoneal and Extraperitoneal Heterotropic Splenic Tissue-Mimicking Metastases Identified on 68Ga-DOTA-NOC Positron Emission Tomography/Computed Tomography and 99mTc Heat-denatured Erythrocyte Study.

The dissemination and autotransplantation of viable splenic tissue in different anatomic compartments of the body can present a diagnostic dilemma, especially when metastatic disease is suspected. We report a case of a 30-year-old male with well-differentiated gastric neuroendocrine tumor (Grade II) treated with surgery. Follow-up 68Ga-DOTA-NOC demonstrated a suspicious peritoneal soft-tissue nodule in the right paracolic gutter with increased tracer uptake. In view of splenectomy 10 years ago, the patient underwent 99mTc heat-denatured erythrocyte study which showed a very unusual pattern of multiple tracer-avid foci of splenic tissue in both intraperitoneal and extraperitoneal distributions. The integration of the patient's history and complementary nuclear imaging results led to the correct diagnosis of splenosis.

A Simple Technique for the Placement of Seprafilm, a Sodium Hyaluronate or Carboxymethylcellulose Absorbable Barrier, during Laparoscopic Myomectomy

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter

BackgroundParacecal hernias, also known as pericecal hernias, are an exceptionally rare type of internal hernia. We report a unique case of paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter.Case presentationAn 86-year-old female was admitted to our hospital with vomiting and abdominal pain. Laboratory findings showed a slightly elevated C-reactive protein level. Computed tomography scan showed dilated loops of the small intestine in the right paracolic gutter with medial displacement of the cecum and ascending colon. Internal hernia around the cecum due to postoperative adhesion after appendectomy was suspected, and she underwent emergency laparotomy. Intraoperative findings revealed the adhesion between the omentum and right paracolic gutter forming a cavity with the small intestine incarcerated. No abnormal adhesion in the ileocecal region was seen. We transected the omental adhesion from the orifice to the far end of the cavity near the hepatic flexure of the colon to release strangulation and to prevent recurrence. The patient was discharged on postoperative day 14 without complications.ConclusionsParacecal hernias have a type of membranous adhesion of the omentum to the right paracolic gutter. Surgeons should be aware of this paracecal hernia type, when they encounter the internal hernia.