Re-look Laparotomy Research Articles

WP5.9 - Emergency laparotomies in the elderly: a patient perspective

Abstract Aims Emergency laparotomy is known to convey worse morbidity and mortality for elderly patients. Despite a growing elderly population, there is a limited understanding of the patient experience in emergency laparotomy. This study aims to assess patient satisfaction following emergency laparotomy. Methods Patients were identified from the National Emergency Laparotomy Audit (NELA) database, who were aged 80 and above, and underwent surgery between: January 2020 and August 2023 at Torbay Hospital. Of the patients who survived to discharge, a telephone-based interview was undertaken in January 2024. Exclusion criteria included: confusion, severe illness and relook laparotomy. Data were collected on functional status and satisfaction with the procedure. Patients were also asked what they wished they known prior to the operation. Post-operative outcomes were assessed in a separate study. Results 132 cases were undertaken in this period. 72 cases met inclusion criteria. We achieved a 61% response rate. 59% of respondents were living independently post operatively and 61% had no functional decline. 93% of respondents were happy to have had the operation and if given the opportunity again would still have had the procedure. Patients were overall very happy with the information offered prior to the procedure, 7% felt they had no alternative option. One patient was not satisfied with the follow up received. Conclusions Although emergency laparotomy in the elderly is high risk, our data demonstrate excellent patient satisfaction. This study provides a better understanding of what is important to patients; this should be considered in the consent process and communication.

Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service.

Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs. Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses. Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p<0.01) and patients requiring LSC were significantly older (p<0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p<0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p<0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p<0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p<0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n=8, 15%) (p<0.001). There were two readmissions within 30days, one mortality, and no BDIs occurred in the LSC cohort. LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

Rare Emergency Case of Bowel Ischaemia as a Result of Diabetic Ketoacidosis Complication: A Case Report and Literature Review of an Unusual Entity

Introduction and Importance: Diabetic ketoacidosis (DKA) is a life-threatening situation that if inadequately managed, is related to high fatality risk. It is associated with mesenteric ischaemia that necessitates early detection and intervention to enhance the prognosis for mesenteric ischaemia. Case Presentation: A 58-year-old male patient presented to our hospital with severe generalized abdominal pain, vomiting, and polyurea. On admission, he was newly diagnosed with diabetes mellitus type II (DM II) which is complicated by DKA. Days later, his abdominal pain worsened, and bowel obstruction was confirmed by both X-ray and ultrasonography of the abdomen. Due to the deterioration in the patient’s clinical condition, an emergent diagnostic laparoscopy was decided which was followed by an open laparotomy with bowel resection of the detected dilated and ischaemic bowel loops. The resected specimens, including small bowel and peritoneal wall mass, were sent for histopathological studies. Three re-look laparotomies were also performed, and the postoperative period was uneventful. Clinical Discussion: Intestinal ischaemia is a rare complication of DKA. Bowel ischaemia can be either occlusive or nonocclusive mesenteric types. It is clinically manifested by abdominal symptoms in diabetic patients. Evaluation is mainly by abdominal computed tomography (CT) and the main treatment approach is laparoscopy and/or laparotomy in combination with resection of the affected bowel loops. Conclusion: In our case report, we document an additional unusual case of intestinal ischaemia and necrosis as a DKA consequence, in a recently diagnosed DM II patient, as one of the few non-occlusive mesenteric ischaemia causes.

HPB P30 The role of interventional radiology in managing post-pancreatectomy hemorrhage at a major hepatobiliary centre in the UK

Abstract Background Pancreatoduodenectomy (PD) is a common surgery performed by hepatobiliary surgeons. Mortality is 5% and morbidity is 30-40%. An important cause is post-pancreatectomy hemorrhage (PPH). As per the International Study Group for Pancreatic Surgery (ISGPS), grade C PPH represents most cases of hemorrhage post-PD and always requires intervention. They tend to be arterial in origin and CT angiogram of the celiac axis and superior mesenteric artery is recommended. Historically, the treatment for PPH was a re-look laparotomy. With the development of interventional radiology (IR) techniques, morbidity and mortality has improved. Transcatheter arterial embolization is a well-established treatment for bleeding. Methods Southampton General Hospital is a tertiary centre for hepatobiliary surgery and interventional radiology. All patients who underwent PD between 2019 and 2023 were checked for complications. Patients who developed PPH were selected and their PACs was checked for what investigation they underwent. The findings of the angiogram and intervention done were recorded. Morbidity and mortality data was also collected including whether patients returned to theatre. Results Seven male patients aged 57 to 75 had type C PPH. Symptom onset including melaena and haematemesis was between 24 hours to 38 days. The time to CT from the request was between one to six hours. One patient was bleeding from the gastroduodenal artery stump. The other six patients had no obvious bleeding point identified. Of the seven patients, five had bleeding points identified on angiograms done by IR and underwent embolization. One patient returned-to-theatre for a re-look laparotomy. Two of seven patients died within one year of PPH. One had repeated PPH and had embolization multiple times. Conclusions Harnoss et al., (2014) reported that the rate of PPH post PD was 5.9%. The use of angiography with embolization is being adopted worldwide for arterial bleeding in hemodynamically stable patients due to its minimal invasiveness. Even if embolization fails, angiography can help identify the bleeding point and guide surgical management. The reported immediate mortality rate from PPH is 30% and at our centre it was 0% in our small sample size.

The impact of colon injuries on the outcome of gunshot wounds to the abdomen

PurposeFactors predicting morbidity and mortality in patients with colon-related gunshot injuries and the management of these injuries are not always straightforward. This aimed to assess the impact of abdominal gunshot wounds with colonic injuries on patients’ overall outcomes.MethodsThis cross-sectional prospective observational study compared patients with colon injuries and without colon injuries. Data was collected from admission, theatre and postoperative care. Patients were recruited between 1 January 2020 and 20 October 2021.ResultsOf 132 patients with abdominal gunshot injuries, 71 (54.0%) had colon injuries. The colon injury group had a higher incidence of laparotomy wound sepsis (p<0.0001), bullet exit wound infection (p<0.0001), tract necrotizing fasciitis (p<0.0001), relook laparotomies (p<0.0001) and a longer hospital stay (p<0.0001). Septicaemia (p=0.002) or anastomotic leak (p=0.041) was associated with a penetrating abdominal trauma index (PATI) ≥25. Most patients who developed tract necrotizing fasciitis did not have their tract debrided/ lavaged (p=0.004). The type of colon repair did not influence the length of hospital stay (p=0.688) or the development of a colon-related complication (p=0.578). Between 18 and 25 years (p<0.0001) and >2 organs injured (p=0.018) were associated with colon-related complications. Patients between 18 and 25 years were 4.748 times more likely to develop a colon-related complication (p=0.046).ConclusionGunshot wounds to the abdomen with associated colonic injuries had a worse outcome with an increased risk of developing wound infections. There is no difference in the operative management of colonic injury. Patients between the ages of 18 and 25 years or >2 organs injured are more likely to develop a complication.

FTP2.13 Outcomes of emergency and elective colorectal resections in a busy DGH

Abstract Aims Evaluate outcomes of emergency and elective colorectal resections in a busy DGH. Methods Single-centre retrospective study of emergency and elective colorectal resections between December 2021-November 2022.Each patient’s hospital records were reviewed, and data were collected on patient demographics, type of operation performed in the emergency or elective setting, ASA, post-operative complications encountered based on Clavien-Dindo classification, mortality rates, and length of hospital stay. Results A total of 201 cases were performed (132 elective,69 emergency), 57 cases were open,136 laparoscopically and 8 were converted. Median age was 70(range 20 – 92) years old, 114males:87females. The median length of hospital stay was 8(range 3–105) days. ASA grade of most (57.2%) patients were ASA 3. Missing data were unavailable in 20.4% of cases. Pre-operative VTE compliance rates were prophylactic clexane (92.5%) and TEDS (91.5%) respectively. The elective operations performed include right hemicolectomy (46.2%), extended right hemicolectomy (4.5%), anterior resection (23.5%), ultra-low anterior resection (6.1%), left hemicolectomy (2.3%), APER (7.6%), Subtotal colectomy (2.3%), Total colectomy (2.3%), Panproctocolectomy (2.3%), Proctocolectomy (1.5%) and Hartmanns (1.5%). Four patients returned to theatre for pouch resection (1 case), laparotomy + stoma formation (2 cases) and closure of burst abdomen (1 case). Our elective mortality rate was 1.5%. The emergency operations performed include right hemicolectomy (43.5%), extended right hemicolectomy (2.9%), anterior resection (5.8%), subtotal colectomy (8.7%) and total colectomy (2.9%). Four patients returned to theatre for relook laparotomy and refashioning of stoma with a 5.8% mortality rate. Conclusions This snapshot audit demonstrates low morbidity and mortality rates in our centre, despite our patient cohort having co-morbidities of ASA III.

Indocyanin Green Fluorescence Evaluation of Colonic Perfusion During Elective Open Abdominal Aortic Aneurysm Repair.

Colonic ischaemia is a rare but devastating complication of open aortic aneurysm repair and is associated with high morbidity and a mortality of up to 50%. The aim of this study was to determine the safety and effectiveness of using indocyanin green florescence (ICG) to interrogate colonic perfusion intra-operatively. Prospective observational study. All elective open abdominal aneurysm repairs over a 6month period underwent colonic perfusion interrogation with ICG according to a pre-defined protocol. Patient demographics and imaging findings were recorded prior to surgery. ICG was given just prior to laparotomy closure. Time to florescence was measured from the start of IV administration to surgeon defined maximal florescence of the sigmoid colon. Ten patients fulfilled the inclusion criteria. All patients were male with an average age of 69.7years. Inferior mesenteric artery reimplantation was performed in 5 patients. Median colonic fluorescence time was 58s. No complications related to ICG were identified. A single patient had clinical concern of colonic ischaemia and delayed perfusion (>3min) on ICG; colorectal opinion advised not for immediate resection. At relook laparotomy, ischaemic colon at the area of demarcation was noted and a Hartmann's procedure was performed. No other patients had delayed perfusion and no further episodes of colonic ischaemia were noted. IMA reimplantation did not show statistical difference in colonic ICG time (P = .81, 95% CI -1.98 to 2.45). There was no statistical difference between operating times between the cohort and all repairs performed 6 months before the data collection (P = .59, 95% CI -.73 to 1.24). In this pilot study ICG appears to be a safe and useful adjunct in objective assessment of colonic perfusion during open AAA repair. Further research is required to fully determine its role in this cohort of patients.

Single Center Retrospective Review of Post-laparotomy CT Abdomen and Pelvis Findings and Trends.

To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time. Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in management were also recorded. In total 1,047 patients underwent exploratory laparotomy initially at our institution between 1/2006-2/2019. Of those, only 96 had a diagnostic CT of the abdomen and pelvis within 24 h after initial surgery, first occurring in 2010. Among these 96, there were 71 blunt and 25 penetrating injuries. Most common injuries recognized during exploratory laparotomy were bowel/mesentery (55), spleen (34), and liver (26). Regarding CT findings, all patients (96/96, 100%) had residual pneumoperitoneum, 84/96 (87.5%) had residual hemoperitoneum, 36/96 (37.5%) noted post-surgical changes or additional injuries to the spleen, 36/96 (37.5%) to the bowel/mesentery, and 32/96 (33.3%) to the liver, and 34/96 (35.4%) were noted to have pelvic fractures. After CT, 31/96 (32.3%) went back to the OR for relook laparotomy and additional surgical intervention and 7/96 (7.3%) went to IR for embolization. Most common procedures during relaparotomy involved the bowel (8) and solid organs (6). CT examination within 24 h post damage control laparotomy was exceedingly rare at our institution prior to 2012 but has steadily increased. Frequency now averages 20.5% yearly. Damage control laparotomy is an uncommon clinical scenario; however, knowledge of frequent injuries and common post-operative changes will aid in radiologist detection of additional injuries helping shape next step management and provide adequate therapy.

Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen

PurposeOne of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction.MethodsTwenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT).ResultsThe mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia.ConclusionVertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.

P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention

Abstract Background Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure. Methods Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021. Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L). Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care. Results A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone. Conclusions Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.

EP.FRI.337 Active management of the open abdomen in non-trauma catastrophes, including use of negative pressure wound therapy, is associated with high primary fascial closure rates

Abstract Aims Deliberate use of the open abdomen (OA) following emergency laparotomy (EL) may be life-saving in the non-trauma abdominal catastrophe (NTAC) and damage control surgery (DCS) can reduce the risk of abdominal compartment syndrome in compromised patients. Controversy exists over optimum management of the abdominal wall. An audit was undertaken of negative pressure wound therapy (NPWT) in OA patients. Methods All patients who underwent OA management of NTAC from 1st Jan 2019 to 31st Dec 2020 were identified. Data on patient demographics, indication for OA and clinical outcomes were analysed. Results Eighteen patients (median age 65.5 years; M:F9 each) underwent OA following EL. The indications were: bowel ischaemia (8), intra-abdominal sepsis (5), grossly distended bowel (3) and intra-abdominal haemorrhage (2). In all cases, ABTHERATM dressings (KCI/Acelity) were used. Mean ICU stay was 7.4 days (range 1-15) and mean hospital stay 33 days (range 2-61). Four patients died, 3 within 24 hours of initial EL. Relook laparotomy was performed within 48 hours in the remaining 15 patients; 3 patients required 2 relooks and 1 patient had three. Primary fascial closure (PFC) was achieved within five days in 13/14 (93%) survivors. Eight patients had SSIs with 2 intra-abdominal collections and all were treated conservatively. One patient developed an enterocutaneous fistula. Conclusions The use of commercially-available NPWT dressings in OA management is associated with high PFC rates within one week of initial EL. This practice is consistent with World Society of Emergency Surgery guidance recommending planned re-look laparotomy within 48 hours.

707 Principles of Damage Control Surgery in Trauma and Beyond: Experience at A Tertiary Centre

Abstract Damage control surgery (DCS) is an abbreviated laparotomy used as a temporising measure in critically unwell patients who have limited physiological reserves to tolerate complex definitive surgeries. The aim of DCS is to address life-threatening haemorrhage and manage abdominal contamination. Following an abbreviated laparotomy, patients are continuously resuscitated in intensive care unit until physiological stability can be maintained for definitive surgeries. The role of DCS in the trauma setting is well-described; however, its principles can also be applied in General Surgery for a variety of indications such as mesenteric ischaemia, uncontrolled haemorrhage, and secondary peritonitis. Judicious selection of the non-trauma patient who will benefit from this strategy is paramount. We present two cases of a polytrauma patient (Patient A), and non-trauma patient with abdominal septic shock (Patient B) who underwent DCS at our tertiary centre. Patient A is a 49-year-old male involved in a road traffic accident who sustained multiple injuries including liver laceration, splenic laceration, and colonic injury. Intra-abdominal packing and repair of serosal tears were performed, with a re-look laparotomy 48 hours later -- no further bleeding or visceral injuries were identified. Patient B is a 51-year-old gentleman who re-presented in septic shock due to infected retroperitoneal collection following a bleeding duodenal ulcer, initially managed radiologically. A T tube was inserted into the duodenum with two abdominal drains at initial DCS. After thorough washout, a feeding jejunostomy was sited at the re-look laparotomy. 30-days mortality is 0% and both patients are under follow-up.

479 Penetrating Chest Trauma Causing A Superior Mesenteric Artery-Inferior Vena Cava Fistula and Pancreatic Injury: A Case Report

Abstract Penetrating traumatic injuries can present a challenging scenario due to the potential for multisystem involvement requiring swift collaboration between surgical specialities. We present the case of a 66-year-old female who was stabbed in the right posterior chest. CT revealed a diaphragmatic injury, liver laceration involving segments 6/7 with active bleeding, and a posterior superior mesenteric artery (SMA) to anterior inferior vena cava (IVC) fistula. Due to the proximity of the SMA injury to a replaced right hepatic artery origin, the fistulous connection with the suprarenal IVC, and suspected pancreatic and duodenal injuries, a hybrid rather than a purely endovascular approach was taken. A large compliant occlusion balloon was placed percutaneously in the hepatic IVC. Subsequent trauma laparotomy and right medial visceral rotation identified SMA and SMV injuries, which were repaired with temporary supracoeliac aortic clamping. Further kocherisation of the duodenum revealed a 10 cm longitudinal IVC laceration causing sudden large volume venous haemorrhage. This was repaired after control was gained with supracoeliac aortic clamping, infrarenal IVC vessel loop and balloon inflation. An abdominal VAC dressing was applied. Before transfer to ICU, however, 1L of blood was noted in the VAC cannister and a relook laparotomy demonstrated more than 1L of intrabdominal fresh blood. Bleeding vessels around the uncinate process were ligated. After 48 hours, a relook laparotomy revealed no significant bleeding, and the abdomen was closed. A post-operative MRCP demonstrated pancreatic divisum and likely laceration of the aberrant ventral duct. A subsequent peripancreatic collection was managed conservatively.

830 A Case of Colo-Colonic Intussusception Secondary to A Large Lipoma in An Adult

Abstract Colonic lipomas are benign tumours, most commonly in the right colon or caecum, usually detected incidentally at colonoscopy and are often asymptomatic not requiring treatment. Lipomas leading to intussusception have previously been described in case reports, but it remains a rare occurrence, no specific incidence data has been documented. We present the case of a patient with a 7cm colonic lipoma that developed an intussusception. This patient suffered non-specific pulling pain along the right and upper abdomen for many years. A distal ascending colonic lipoma was identified, on repeated imaging and colonoscopy and biopsied. It was concluded that the abdominal pain was due to gallstones, diverticulitis and adhesions from previous pelvic surgery. In early December 2020, the patient was reviewed and listed for elective cholecystectomy. Later the same month, the patient was admitted with severe abdominal pain, watery and bloody diarrhoea. CT scan showed the colonic lipoma had acted as the lead point for an intussusception, with the lipoma and surrounding colon having intussuscepted into the transverse colon. Patient had an open right hemicolectomy and anastomosis for colo-colic intussusception secondary to the lipoma. Subsequently, the patient developed anastomotic breakdown requiring relook laparotomy with resection of ileo-colic anastomosis and end ileostomy formation. Adults presenting with intussusception is rare and associated with nonspecific signs and symptoms. Variability in clinical presentation highlights the need for a low index of suspicion in people with known colonic masses. In addition, early surgical intervention should be considered in masses &amp;gt;4cm as previously suggested in the literature.

639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation

Abstract Background Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE. Case Summary A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely. Conclusions RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.

Sustaining viability in a pre-gangrenous bowel with midgut volvulus

Midgut volvulus is a condition peculiar to neonates having acute abdomen. The condition is anticipated in any neonate having bilious vomitus and inability to pass stools. This being a surgical emergency does not sanction any time-consuming radiological procedures, thus, history and the clinical picture are sufficient to warrant surgical exploration. A sick neonate in the 2nd week of life presented with all signs and symptoms of midgut volvulus for which he was explored. Exploration gave the outlook of a necrotic midgut along its entire length. No haste was made in resection as it had a fatal prognosis for survival, instead, watchful waiting opted after necessary measures were taken to allow for the resumption of perfusion. Not only the baby survived to undergo a relook laparotomy showing marked improvement but also showed improvement in lab values and started passing stool and tolerating orally after a wait of three weeks post 1st laparotomy. Midgut volvulus leading to seemingly necrotic intestine should be given due consideration by relook surgery. The alternative would be total resection followed by short bowel syndrome, need for an intestinal transplant while being on TPN. This approach gives an immense advantage by giving the gut a fair chance to restore its perfusion by gut rest after de-twisting.

Fulminant Clostridium Difficile colitis after ileostomy reversal: Case Report and Review of Literature

Introduction: Clostridium Difficile infection (CDI) following restoration of intestinal continuity is uncommon and may progress to fulminant colitis. Fulminant CDI is associated with significant morbidity and mortality. In an unwell patient without clear evidence of an anastomotic leak, surgeons should be aware of the possibility of CDI and institute appropriate management. Presentation of Case: We report the case of a 71- year-old man, who presented for an elective loop ileostomy reversal after an ultra-low anterior resection for a low rectal cancer eight months prior. The patient deteriorated clinically on post-operative day (POD) 4 and by POD 5 was in septic shock with multi-organ failure. A relook laparotomy confirmed no anastomotic leak and a flexible sigmoidoscopy revealed typical appearance of pseudomembranous colitis. The patient continued to deteriorate in the intensive care unit despite oral and rectal Vancomycin. An abdominal computed tomography (CT)1 on POD 9 demonstrated severe pancolitis and enteritis necessitating surgical intervention. He underwent an emergency subtotal colectomy with an end ileostomy after failing medical management. Discussion: Many factors have been shown to increase the incidence of Clostridium difficile colonization in the colon including recent hospitalization, antibiotic use, and length of defunctioning beyond six months. The presence of risk factors associated with an increase in CDI such as proton pump inhibitor use, steroid use or immunosuppression and advanced age may allow surgeons to predict high risk patients. Conclusion: Although rare, fulminant CDI following reversal of ileostomy is a potentially fatal condition. Surgeons should be aware of the risk factors predisposing patients to CDI particularly in a patient with an acute abdomen without clear evidence of an anastomotic leak.

Large Lactobezoars Causing Postoperative Small Bowel Obstruction in a Neonate- A Case Report and Review of Literature

Lactobezoars causing small bowel obstruction in the postoperative period has been rarely reported. Here, a term baby with severe intrauterine growth restriction was admitted in neonatal unit for low birth weight care. Baby was started on mother’s milk and gradually upgraded to full feeds. He developed Necrotising Enterocolitis (NEC) requiring surgery. Subsequently, amino acid based formula was warranted because of Short Bowel Syndrome (SBS). After reaching full feeds, baby demonstrated signs of small bowel obstruction requiring relook laparotomy. Large lactobezoars were found throughout the small bowel which were kneaded out. Postoperative period was also complicated by Enterocutaneous Fistula (ECF) which was conservatively managed. Child was discharged on full feeds after he showed consistent weight gain.

Skin-only closure as a temporary abdominal closure technique in a rural setting - exploring role and safety profile

Background Acute laparotomy for trauma or sepsis often prevents definitive closure due to need for relook laparotomy or to prevent abdominal compartment syndrome. Skin-only closure is widely used in our setting. In this study, we review the safety and effectiveness of this technique. Methods Patients presenting with intra-abdominal pathology undergoing acute laparotomy and then subsequent skinonly closure using 2-0 prolene were included in the study and followed postoperatively for a three-month period for adverse events stratified by Clavien-Dindo grading, and rate of definitive closure. Results During the study period, twenty-five patients underwent emergent laparotomy and skin-only closure. The median age of patients undergoing skin-only closure was 27 years (standard deviation 9.1). Six patients presented with major trauma and 19 presented with sepsis. Twenty-one patients underwent subsequent fascial closure. One patient was unable to undergo fascial closure and was managed as a planned ventral hernia. Fourteen patients developed a postoperative complication. There were no deaths and no readmissions to intensive care. Three further patients developed a ventral hernia. Conclusion Skin-only closure, in carefully selected patients, is a feasible alternative to other temporary abdominal closure techniques in a resource-constrained setting.

Beware the band adhesion: an unexpected cause of double obstruction following intraperitoneal kidney transplantation.

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.