Resection Of Gangrenous Bowel Research Articles

A prospective observational study on etiology and management influencing outcome in operatively managed cases of acute intestinal obstruction in adults

Background: Acute intestinal obstruction (IO) is an important cause for acute abdomen in surgery which presents as abdominal pain, vomiting, distension, and constipation depending on the level and extent of obstruction of gastrointestinal tract. Early diagnosis of acute IO with understanding of various etiologies, use of better diagnostic techniques, and skillful operative management and good postoperative care, carries a good outcome. Aims and Objectives: The objective of the study was to find out the prevalence of various etiologies of acute IO and to study the various post-operative morbidity and mortality. Materials and Methods: This was a hospital-based observational study in the Department of General Surgery of Calcutta National Medical College and Hospital among patients with a diagnosis of acute IO during the study period of December 2016-April 2018. Results: Acute IO commonly affects male with a male: female ratio 7:3 and the most common occurrence in the age group of 40–59 years (30%). The most common etiology was obstructed/strangulated hernia (36%), followed by large bowel neoplasm (18%), adhesion (16%), intestinal tuberculosis (12%), and volvulus (10%). The most common surgical procedure performed was the resection of gangrenous bowel and creation of stoma (30%), followed by prosthetic repair of hernia (28%). The mortality rate of the present study was 12%. The morbidity rate was 46%attributing mainly to respiratory complications (30.4%) and surgical site infections (26.08%). Conclusion: This study demonstrates that the pattern of IO differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role.

A CASE OF ACUTE MESENTERIC ISCHEMIA: DIAGNOSTIC DILEMMA AND SURGICAL CHALLENGE

Mesenteric ischemia is an uncommon condition, and we need to have a high index of suspicion to diagnose and manage this condition. Predisposing conditions such as myocardial infarction, portal hypertension, pancreatitis, inflammatory bowel disease, post-operative states, trauma, and hypercoagulable states such as DVT, pregnancy, and neoplasms should always be accounted for before diagnosing this condition. In emergency situations, surgical exploration is warranted. Here, we present a case of 57-year-old male, known case of DVT RT lower limb, on anticoagulants, presented with the complaints of epigastric pain, absolute constipation, and abdominal distention of 3 days duration. He was investigated and managed by exploratory laparotomy with peritoneal lavage and resection of gangrenous bowel with proximal jejunostomy and distal ileostomy.

Concurrent intestinal malrotation and Meckel's diverticulum presenting as acute intestinal obstruction in an adult

Intestinal malrotation is the partial or complete failure of rotation of midgut around the superior mesenteric artery, while Meckel’s diverticulum is the remnant of vitellointestinal duct and concurrence of these congenital abnormalities in an adult is considered a rarity. Till date only 3 cases of concurrent intestinal malrotation and Meckel's diverticulum have been reported. We report a 18 years male who presented with a 3 day history of abdominal pain, bilious vomiting, obstipation and chronic abdominal pain on and off since 3 years of age. During the last episode which occurred 1 year back, he was diagnosed with intestinal malrotation with subacute intestinal obstruction and was treated conservatively. Examination revealed the presence of signs of peritonitis. After resuscitation, CECT abdomen was taken which showed dilated small bowel loops in the subhepatic region associated with malrotation. Emergency laparotomy revealed a Ladd's band below which the gangrenous small bowel loops 150 cm from the duodenojejunal (flexure until 5 cm proximal to the ileocecal junction) were found herniating into the subhepatic region with a Meckel’s diverticulum and a right sided DJ flexure. We proceeded with the band release and resection of gangrenous bowel followed by proximal jejunostomy with distal ileostomy. HPE was consistent with Meckel’s diverticulitis without any ectopic gastric or pancreatic mucosa. Ostomy reversal was done after 8 weeks. Patient had an uneventful postoperative recovery during both the admissions and he is on regular follow-up now.

The efficacy of delayed, repeated reduction enema in management of intussusception

BackgroundManagement of intussusception varies according to the case, time of presentation, cause, and symptoms. In this study, we focus on describing the demographic and sonographic characteristics of children with intussusception with failed initial enema reduction who were managed by delayed repeated enema attempts and identify predictors associated with successful repeated reduction.ResultsThis study was conducted in the period from December 2018 to April 2020 at university hospitals (pediatric surgery unit). This study included 40 patients with intussusceptions; 27 are males, and 13 of them are females. Their ages ranged from 5 months to 3 years old. Patients in this study had failed initial enema reduction attempts under sonographic guidance and had subsequent delayed (≥ 2 h from the initial attempt) repeated enemas made up the study population.Of the 40 patients, 34 patients (85%) were successfully reduced, and 6 patients (15%) failed reduction and required surgical intervention. There were no deaths, perforation, or resection of gangrenous bowel. Two cases showed recurrences, but required no surgical intervention. It is also noted that early presentation (< 12 h), stable, non-complicated, and with little or no bloody diarrhea are predictors of successful DRE.ConclusionDelayed repeated enema in the treatment of intussusception is a viable option in patients with unsuccessful initial enema reduction provided that early presentation, stable vitals, and no signs of perforation or peritonitis are present.

Use of polypropylene mesh in contaminated and dirty strangulated hernias: short-term results.

Synthetic non-absorbable meshes are routinely used in hernia surgery for clean cases but are avoided in the case of clean-contaminated or contaminated hernia or dirty cases to minimize the risk of infection. The present study was conducted to evaluate the outcome of polypropylene mesh in the settings of bowel resection performed for strangulated hernias of the abdominal wall. This prospective observational study was conducted in the Department of Surgery of a teaching hospital in central India between 1st March 2015 and 31st Aug 2017. Adult patients > 18years age, with abdominal wall hernias, presenting with strangulation, and requiring resection and anastomosis for gangrenous bowel were included in the study. Outcomes noted were wound infection, morbidity and mortality, need for the removal of the mesh, and recurrence of the hernia. 30 (22 men and 8 women) patients with strangulated hernias underwent emergency surgery with resection of gangrenous bowel and anastomosis. The 30 cases included 21 inguinal, seven incisional, one femoral and one umbilical hernia. 12 of the 30 cases having gross contamination of the operative wound due to perforated gangrenous bowel were classified as 'dirty'; while the remaining 18 cases with non-perforated gangrenous herniating bowel were classified as 'contaminated'. Wound infection occurred in 8/30 patients (26.67%); but these healed with antibiotics and dressing. Mesh removal was not required in any patient during entire study period. Two recurrences (6.7%; one inguinal and one incisional hernia) were observed. There was no mortality. The use of polypropylene mesh for contaminated and dirty strangulated hernias is effective and safe, with acceptable morbidity and good short-term results.

Childhood intussusception: Impact of delay in presentation in a developing country.

Background:The classical cases of intussusception are readily diagnosed clinically, and despite recent improvements in radiological techniques, the diagnosis of intussusception and success in its nonoperative reduction has been suboptimal, thus making operative management a veritable backup. This study examined the impact of delays in presentation on the rate of bowel resection, length of hospital stay, and appraised the outcome of operative treatment.Patients and Methods:This was a retrospective study of consecutive children admitted and treated surgically for intussusception between January 2002 and December 2011 at the University College Hospital, Ibadan, Nigeria.Results:The mean age at presentation was 13.4 months with a male: female ratio of 1.8:1. Fourteen patients (25.5%) presented within the first 24 h of onset of symptoms with majority (36.4%) presenting between 2 and 3 days of onset of symptoms. The primary surgical intervention was performed on 47 patients (85.5%), and the secondary operative intervention was performed on eight patients (14.5%) who had failed initial nonoperative management of intussusception. Manual reduction of intussusception was performed on 27 patients (49.1%), 26 patients had resection of gangrenous bowel with end-to-end anastomosis while two patients (3.6%) had spontaneous reduction of intussusception which was discovered at laparotomy. The mean duration of hospital stay was 12.1 days (range 3–60 days). The overall mortality was 5.5% (three patients), and three patients (5.5%) had recurrence of intussusception.Conclusion:Although mortality is reducing, a high rate of bowel resection is a consequence of delayed presentation and effort should be made to make an early diagnosis of intussusception and make prompt referral to improve outcome.

Sigmoid Volvulus Causing Intestinal Obstruction in A Child - A Case Report and Review of Literature

Introduction: Sigmoid volvulus is a rare cause of intestinal obstruction in pediatric practice. High index of suspicion is necessary to diagnose the condition. Prompt diagnosis and treatment is mandatory to intervene before colon becomes ischaemic and perforates with dire consequences. Case presentation: We report a case of 11 year old Sri Lankan male child who presented to pediatric surgical unit with features suggestive of intestinal obstruction. X ray abdomen revealed classic omega (coffee bean) sign of sigmoid volvulus. Following resuscitation endoscopic de rotation was attempted, but failed. Subsequently patient underwent laparotomy and Sigmoid volvulus with gangrene and impending perforation was noted. No predisposing cause except long mesentery was identified. Hartmanns procedure with resection of gangrenous bowel was performed at the emergency setting. Patient made an uneventful recovery, and hartmann reversal was performed 8 weeks later. He made a steady recovery and remains free of symptoms to date. Conclusion: Clinicians dealing with pediatric surgical problems should maintain a high degree of suspicion, in order not to miss this important diagnosis, as any delay in instituting treatment has a devastation effect in morbidity as well as mortality. Early diagnosis and prompt treatment confers excellent prognosis.

The "small" wrapping around the "large"!

This is a case report of a 32-year-old female who presented with acute intestinal obstruction. The radiological diagnostic possibilty of midgut volvulus with ileo-sigmoid knotting and obstruction of the proximal sigmoid colon and small bowel was given. The diagnosis was confirmed intra-operatively with associated gangrene of the distal jejunum and proximal ileum. Resection of the gangrenous segments of bowel and the release of ileo-sigmoid knotting was performed. The literature about the ileo-sigmoid knot was reviewed. It may be difficult to diagnose this condition before surgery. This is a surgical emergency that requires urgent resection of gangrenous bowel and untwisting of the volvulus. The aim of this short communication is to increase awareness of the pre-operative computed tomography (CT) diagnosis of this condition.

Ileosigmoid knotting: a case report

Background: Resection of gangrenous/non-viable bowel followed by primary anastomoses is known to be a viable option for treatment of ileosigmoid knotting. We here report a case of ileosigmoid knot and examined the options for treatment. Method: A case report of a patient with ileosigmoid knotting and discussion of relevant literature for surgical treatment. Result: A 26 year old man presented to the accident and emergency unit with two weeks' history of fever and alternating diarrhea and constipation followed by features of intestinal obstruction and later, generalized peritonitis. Plain abdominal X-rays showed dilated loops of bowel and multiple air-fluid levels. The diagnosis of ileosigmoid knotting was missed preoperatively. At exploratory laparotomy, ileosigmoid knot was encountered with non-viable segments of the sigmoid colon and ileum. Resection of the non-viable bowel was carried out with primary anastomoses with good postoperative outcome. Conclusion: Primary anastomoses after resection of gangrenous bowel is a safe surgical treatment option in ileosigmoid knotting. Nigerian Journal of Medicine Vol. 17 (1) 2008 pp. 115-117

An Audit Of Surgery Related Deaths In An Urban Nigerian Teaching Hospital

An audit of surgery related deaths was carried out to determine the most common causes of such death. A total of 338 deaths (205 males and 133 females – 3.3:2) were recorded in the Department of Surgery, University of Benin Teaching Hospital, Nigeria over a five-year period (September 1, 1996 to August 31, 2001). Cancer as an entity accounted for the highest number of deaths (104 or 30.8%); the commonest being those of the colorectum, stomach, pancreas and prostate. Other significant causes of surgery related deaths were burn injury (64 or 13.3%) and intestinal obstruction (22 or 9.5%). Complications from head injury singularly accounted for 33 (9. 8%) of deaths, following road traffic accidents. Most of the deaths from intestinal obstruction were post-operative following laparotomy, resection of gangrenous bowel and anastomosis with neonatal intestinal obstruction accounting for 15 (68%) of the deaths. The other less common causes of death as well as those where diagnosis could not be reached due to lack of postmortem were classified as miscellaneous (47 or 19.8%). Provision of facilities for early detection of cancer as well as enforcing the use of seatbelts and crash-helmets will help in reducing the number of deaths from cancer and road traffic accidents respectively. Trainee surgeons should be exposed to the management of burns while timely intervention especially in neonates will help to reduce the mortality associated with intestinal obstruction. Keywords: Audit, Surgery related deaths, Benin City, Nigeria Annals of Biomedical Science Vol. 2 (1) 2003: pp. 47-53

Congenital mesenteric hernia causing intestinal obstruction in children

A mesenteric hernia is one type of intraperitoneal hernia. There is no hernia sac in this situation but only a mesenteric defect, which is present at birth. Strangulated mesenteric hernia is a rare cause of intestinal obstruction especially in the pediatric population. Between January 1996 and January 2006, four patients with intestinal obstruction were determined to have congenital mesenteric hernia at Chang Gung Children's Hospital. Patients consisted of three boys and one girl, ranging in age from 2 years 5 months to 5 years 4 months. All patients presented with symptoms and signs indicative of intestinal obstruction. On physical examination, all patients appeared to be severely ill. A shock-like state was associated with necrosis of the strangulated bowel in two patients. A palpable abdominal mass was present in one patient with volvulus of small bowel. The plain abdominal radiography and the ultrasound scan also showed dilatation of the small bowel and excluded intussusception. All the patients underwent laparotomy after initial resuscitation. During laparotomy, three patients had incarceration of small bowel through the small mesenteric defect, and another one had volvulus with gangrenous bowel entrapped within a large mesenteric defect. The defects ranged in size are from 2 to 7 centimeters in diameter. Simple reduction of the incarcerated bowel with repair of the defect was performed in two patients, resection of gangrenous bowel and primary anastomosis was required in one patient, and resection with end ileostomy was needed in another one patient. There was no postoperative mortality in our patients. A mesenteric hernia is a rare cause of intestinal obstruction, especially in children. Open exploration is the only way to establish a clear anatomic diagnosis.

Association of midgut malrotation with intussusception

Background: The cause of intussusuception in most infants is unclear. Intestinal malrotation has been postulated as a possible cause in some infants. Waugh,s syndrome is the association of intestinal malrotation with intussusception.Patients/Methods: Of 18 children with intussusception managed in the Paediatric Surgical Unit of our hospital over a 3-year period, eight had abnormality of intestinal rotation and fixation. Their case notes, operation notes and discharge summary sheets have been retrospectively reviewed.Results: There were five boys and three girls. Their ages ranged from 13 days – 12 months (median 10 months). The main clinical features were bilious vomiting, blood stained diarrhoea and abdominal distension. In two infants, the intussusceptions had prolapsed through the anus at presentation. One neonate had ruptured omphalocoele minor containing a caeco-colic intussusception that had perforated at presentation. Two other infants had mid gut volvulus, one as a simultaneous finding with intussusception while the other one 72 hours after operative reduction of intussusception. All had laparotomy. In six infants, the intussusception was ileo-colic while in two it was caeco-colic. There was no lead point in any infant. Four infants had successful operative reduction while four had bowel resection with end-to-end anastomosis. All had Ladd's procedure. One child died of overwhelming sepsis following resection of gangrenous bowel. Conclusion: Intestinal malrotation may be associated with idiopathic intussusception. It is important to look for this association when managing infants with intussusception. Keywords: Waugh's syndrome, intussusception, malrotation, midgut volvulus, Ladd's procedure Nigerian Journal of Surgical Research Vol. 7(1&2) 2005: 159-161

Persistent Hyperinsulinaemic Hypoglycaemia of Infancy in 43 Children: Long-term Clinical and Surgical Follow-up

To describe the clinical, surgical, biochemical, radiological and electrophysiological features of 43 Saudi children with persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI) who have been followed since 1983. Data from 43 patients were retrospectively analysed. PHHI was diagnosed on the basis of high intravenous glucose requirement, high insulin to glucose ratio, negative urinary ketones and normal tandem mass spectrometry. The patients were assessed radiologically by brain magnetic resonance imaging and/or computed tomography and electrophysiologically by brain stem auditory evoked potential, visual evoked response and electroencephalogram. Patients who failed medical therapy received near total pancreatectomy. The patients were severely hypoglycaemic and intolerant to fast. Hypoglycaemic convulsion was the most commonly presenting complaint. Eighteen patients were developmentally delayed and 14 of them had brain atrophy. All patients, except nine, did not respond to medical treatment and underwent surgery. Four pancreatectomized patients developed diabetes and two had malabsorption. One baby had 180 cm resection of gangrenous bowel most likely secondary to octreotide. No common bile duct injury was encountered. One patient was treated medically during childhood and developed diabetes and gained weight during adolescence. PHHI is a relatively common and serious disease among Saudi children. Early intervention is necessary to avoid neurological damage in patients who are severely hypoglycaemic and unresponsive to medical therapy. Surgically and probably medically treated patients are at a high risk of developing diabetes, which could be the natural outcome of this disease. Care and spending time during surgery to visualize the common bile duct help in avoiding its injury.

The management of childhood intussusception in a district hospital.

Fifteen out of 34 infants with intussusception admitted to a district hospital were found to require resection of gangrenous bowel or an anatomical lead point. This resection rate (44 per cent) is considerably higher than those reported from specialist centres which rely on hydrostatic reduction as their primary form of treatment. The difference is probably a reflection of the greater proportion of late cases seen in a district hospital. Complications were virtually confined to those children who had undergone resection and it is concluded that earlier referral to hospital is the single factor most likely to reduce morbidity. Operative management is advocated, although barium enema is a safe valuable adjunct to surgery.

Cryoprecipitate-Induced Mesenteric Venous Thrombosis During L-Asparaginase Therapy for Acute Lymphoblastic Leukaemia

We present a case of fatal mesenteric vein thrombosis (MVT) associated with L-asparaginase (L-asp) therapy and temporally related to cryoprecipitate infusion, in an adult with acute lymphoblastic leukaemia (ALL). Cryoprecipitate was given on two consecutive days to raise a low fibrinogen level of 0.7 g/L, in the presence of severe thrombocytopenia and mucocutaneous bleeding. The thrombotic event presented as sudden abdominal pain a day after the second cryoprecipitate infusion, which raised the fibrinogen to 1.5 g/L. Concurrent levels of antithrombin III (AT III), protein C (PC) and protein S (PS) were very low. The patient died after laparotomy and wide resection of gangrenous bowel. We believe this is the first reported case in the English literature of a patient who developed mesenteric venous thrombosis during L-asp therapy, and once more we advise caution in using conventional blood products, especially cryoprecipitate, and recommend restricting the use of cryoprecipitate and fresh frozen plasma (FFP) to the treatment of serious hemorrhagic manifestations, until new effective and safe therapies are available.

Intestinal obstruction due to ascariasis

Intestinal obstruction due to ascariasis results from heavy worm infestation. This study is a review of 92 patients with intestinal obstruction from Ascaris lumbricoides. Sixty-eight patients without peritonism were treated conservatively with resuscitation, antibiotics and anthelminthics. The remaining 24 patients presented with abdominal signs suggesting strangulation. Plain abdominal radiography was done in all patients. Abdominal ultrasonography was performed in the last 22 patients. There were no deaths in the first group and duration of hospital stay ranged from 4 to 7 days. Five of 24 patients in the second group died during resuscitation. After successful resuscitation, 19 had a laparotomy. Six patients needed resection of gangrenous bowel with primary anastomosis, in 11 an enterotomy was used to remove obstructing worms and in two it was possible to milk obstructing worms into the colon. Seven patients died after operation, giving an overall mortality rate of 12 of 24 patients in the second group. The characteristic sonographic features of 'railway track' sign and 'bull's eye' appearance helped make the diagnosis of ascariasis, and ultrasonographic signs were also typical for strangulation in five patients. Early clinical diagnosis supported by ultrasonography, together with prompt surgery when necessary, might reduce the mortality rate in what is still a potentially dangerous condition.

The ileosigmoid knot

The ileosigmoid knot (ISK) is a rare cause of intestinal obstruction. Unfamiliarity with the condition could have disastrous consequence at surgery. Over the past 20 years, we have encountered seven cases. Analyzing the data gathered from these, and on reviewing the literature, we found it possible to arrive at a preoperative diagnosis in two patients. Four patients were women, two of whom developed the obstruction in the postpartum period. One of the males was found to have an inflamed Meckel's diverticulum included in the knotting. The symptoms and the clinical findings were nonspecific. The characteristic x-ray findings of a double closed loop obstruction, was seen in only three patients. Resection of gangrenous bowel with anastomoses was feasible in four. Unlike in other series, primary anastomosis of the large gut was undertaken. There were two deaths early in the series. Guidelines to the management have been suggested.

Neonatal necrotizing enterocolitis: Experience with 100 consecutive surgical patients

One hundred newborns with neonatal necrotizing enterocolitis (NEC) were treated surgically according to a uniform protocol between July, 1980 and June, 1988. The infants (53 females, 47 males) weighed between 600 and 3,800 g, averaging 1,500 g. Twenty-eight weighed less than or equal to 1,000 g, 38 weighed from 1,001 g to 1,500 g, and 34 weighed more than 1,500 g. Median age at the time of surgery was 14 days. Surgery was performed for pneumoperitoneum in 40, a "positive" paracentesis in 51, and for other reasons in 9 infants. A paracentesis was performed if intestinal gangrene was suspected clinically. Resection of gangrenous bowel with exteriorization was the usual procedure; in only 5 patients was primary closure performed. The hospital survival for the infants was 54% for the group weighing less than or equal to 1,000 g, 74% for the group weighing from 1,001 g to 1,500 g, and 79% for the group weighing more than 1,500 g. Overall hospital survival was 70%; it was 81% for those having a definitive procedure (excluding 14 infants with NEC "totalis"). There were 3 late deaths from causes unrelated to NEC. Significant long-term complications included failure-to-thrive in 23% and stricture formation in 30% of the survivors. Long-term follow-up showed gastrointestinal status to be normal in 74%; only 8% have persistent major gastrointestinal dysfunction. Mental and motor development was considered grossly normal in only 53% of the patients.