Segmental Intestinal Resection Research Articles

Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis

Objective(s)To investigate Mesenteric vascular and nerve Sparing Surgery (MSS) as surgical laparoscopic technique to perform segmental intestinal resection for deep infiltrating endometriosis (DIE). Study DesignProspective cohort study between January 2013 and December 2016. Consecutive patients with suspected intestinal DIE underwent clinical and imaging evaluation to confirm intestinal involvement. Indications for radical surgery and surgical technique (intestinal resection versus shaving) were consistent with Abrão algorithm. Surgeons aimed to perform MSS in all the consecutive patients that required intestinal resection. MSS consists in mesenteric artery, branching arteries, and surrounding nerve fibers preservation by dissecting mesentery adherent to the intestinal wall. Data about history, preoperative and post-operative evaluation, surgery and complications were recorded. Symptoms were evaluated before and 30–60 days after surgery with numeric rating scale for pain. Constipation was evaluated with the Constipation Assessment Scale (CAS). Patients with diagnosis of irritable bowel syndrome, inflammatory bowel diseases, diverticulitis, and previous segmental intestinal resection were excluded. ResultsSixty-two out of 75 (82.7%) consecutive women with intestinal endometriosis underwent laparoscopic segmental intestinal resection performed with MSS. Major complications that required repeated operation occurred in 4 cases (6.5%). Anastomotic leakage occurred in only 1 case (1.6%). Dysmenorrhea (p < .001; r = -0.86), dyspareunia (p < .001; r = -0.80), dyschezia (p < .001; r = -0.86) and dysuria (p < .001; r = -0.56) were significantly improved after surgery. After an average of 33.1 months from surgery, severe constipation was reported only by two patients (3.6%) (CAS: 13–16). The median time from surgery to intestinal function recovery (flatus or stool passage) was one day. Logistic regression analysis showed constipation related to the distance from anal verge and time since surgery. Conclusion(s)MSS in laparoscopic intestinal resection for DIE may be reproducible, safe and effective. MSS could be combined with pelvic nerve-sparing surgery as an effective approach to improve intestinal symptoms after radical surgery for DIE that requires segmental intestinal resection.

Enteric Duplication Cysts in Children: A Single‐Institution Series with Forty Patients in Twenty‐Six Years

The purpose of the study was to evaluate our experience with enteric duplication cysts in 40 children during the past 26years, while assessing the variability of their presentations and to propose an algorithm for surgical management. We retrospectively analysed sex, age, clinical presentations, duplication site, surgical treatment, presence of ectopic tissue, complications, associated anomalies, and prognosis of 40 patients with gastrointestinal tract duplications who were surgically treated in our clinic. Overall, there was a predominance of boys (28 males, 70%; 12 females, 30%). The presenting symptom was vomiting in 23 patients, rectal bleeding in 11 patients, abdominal mass in 10 patients, abdominal pain in 9 patients, constipation in 6 patients, cough in 2 patients, and respiratory distress in 2 patients. In 30 patients, a complete excision of the cyst with additional segmental intestinal resection and anastomosis was performed. Cystectomy was performed in seven patients, while complete excision of the cyst with additional wedge resection was performed in two. A Wrenn procedure (mucosectomy) was performed in one patient. Due to the variability in the site of enteric duplications, a wide range of presenting symptoms can exist, which is challenging for diagnosis. In children with a diagnosis of acute abdomen, enteric duplication cysts should be considered, and these children should be further investigated for additional skeletal, urogenital, and gastrointestinal system pathologies. Surgical treatment depends on the site and type of the cyst.

Jejunoileal diverticulosis, a rare cause of ileal perforation - Case report.

IntroductionJejunoileal diverticulosis (JID) is a rare condition associated with nonspecific symptoms, consisting of acquired false diverticula. It frequently co-exists with colonic diverticulosis. Diagnosis is usually made incidentally or after complications. These include hemorrhage, obstruction and diverticulitis, with or without perforation.Presentation of case81-year-old man presented with a painful abdominal mass in the right lower quadrant (RLQ), diffuse abdominal discomfort and fever. Abdominal examination confirmed a well-defined mass in the RLQ without rebound tenderness. Laboratory analysis revealed elevated inflammatory markers and CT scan showed a cavitated lesion with an air-fluid level in the RLQ, without evidence of intraperitoneal free air or fluid. Admitted for conservative treatment, failure to improve led to laparotomy on the 6th day of hospitalization, with identification of jejunoileal diverticulosis complicated with diverticulitis and walled-off perforation. We performed segmental enterectomy.DiscussionThe incidence of JID is estimated at 0.2–7% and it is usually diagnosed in the sixth/seventh decade of life. From a diagnostic perspective, JID is a challenging disorder, without reliable diagnostic tests. Diverticulitis is the most common complication. Perforation generally causes only localized peritonitis, as involved diverticula are often walled off by the surrounding mesentery. In selected cases, medical therapy may suffice. For all other patients prompt laparotomy with segmental intestinal resection is the treatment of choice.ConclusionJID remains under diagnosed. When it presents as an acute complication it may require immediate surgical intervention. In an elderly person, especially with known gastrointestinal diverticulosis, one must have a high index of suspicion for perforation.

A case of retrograde jejuno-duodenal intussusception caused by jejunal lipoma: a case report and review of literature

Adult intussusception is a rare entity, comprising 5% of all cases of intussusception. The presentation of adult intussusception commonly varies, ranging from chronic abdominal pain to acute presentation mimicking symptoms of bowel obstruction. This report describes a case of retrograde jejuno-duodenal intussusception in a 48-year old healthy male with a history of several episodes of diffuse abdominal pain and an acute episode of melena of 3 days duration. Examination revealed a soft, nondistended abdomen with palpable mass at upper abdomen associated with tenderness on palpation. Computed tomography scan findings revealed a 10cm length of jejuno-duodenal intussusception likely secondary to a jejunal lipoma. Exploratory laparotomy revealed resolved intussusception secondary to a lipoma which was treated with segmental intestinal resection. In this case report, we describe a rare case of retrograde jejuno-duodenal intussusception caused by a jejunal lipoma and performed a literature review on retrograde intussusception.

Gut wall replacing type of gastrointestinal stromal tumor presenting as a perforation of the ileal diverticulum

Gastrointestinal stromal tumors (GISTs) usually form a well-circumscribed mass. Very rarely, however, sporadic GISTs show gut-wall replacing growth, similar to the diffuse hyperplasia of interstitial cells of Cajal (ICC) observed in patients with neurofibromatosis type 1 (NF1) and hereditary GIST. Here we describe a patient with ileal perforation caused by this unusual type of GIST. An 82-year-old man was admitted to the emergency department with sudden abdominal pain. Following a provisional diagnosis of perforation of Meckel's diverticulum, he underwent segmental resection of the small intestine. Macroscopic examination revealed a diverticulum-like structure 2.5cm in size near the site of mesenteric attachment of the ileum. Histological examination showed diffuse and nodular proliferation of spindle cells positive for c-KIT and CD34 that had replaced the muscularis propria of the small intestine. Mutational analyses of the lesions revealed monoclonality of proliferating cells with a somatic mutation in c-kit exon 11 (p.Leu576Pro). Gut-wall replacing type of GIST should be recognized as a specific type of GIST causing diverticulum-like structures of the gastrointestinal tract.

Laparoendoscopic reduction of sigmoidorectal intussusception

We present the case of a 29-year-old woman who was admitted to Beaumont Hospital, Dublin with a 12-hour history of left iliac fossa pain, tenesmus, hematochezia, and sudden prolapse of tissue per rectum. On examination, she was tender in her left iliac fossa with guarding. On digital rectal examination there was a hard, smooth mass and an adjacent soft, fleshy mass palpable in the lower third of the rectum. A computed tomography (CT) scan demonstrated a sigmoid intussusception with an associated polyp (Fig. 1a). A laparoscopy and on-table colonoscopy were carried out. At laparoscopy, the sigmoid was found to be intussuscepted into the rectum (Fig. 1b). Using continued traction with atraumatic bowel graspers, the intussusception was reduced (Video S1). Following reduction, colonoscopy was carried out and the polyp identified (Fig. 2a). Using a hot snare, a polypectomy was carried out (Fig. 2b). A 35-mm polyp with clear margins was retrieved (Fig. 2c,d). Postoperatively, the patient started an oral diet on day 2 and passed flatus on day 3. Following a prolonged period of observation to assess for delayed ischemic insult to the colon during which time a normal colonoscopy was carried out, she was discharged well to home on day 9. At latest follow up she is well, with no complications. Adult intussusception is a rare clinical entity, representing 1% of adult intestinal obstruction. Traditional surgical teaching advocates resection of the involved intestinal segment, with only 3.6% of cases attempted laparoscopically. While prior reports of sigmoidorectal intussusception have used segmental colectomy as the definitive surgical management, the current case demonstrates that with accurate preoperative imaging the affected colonic segment may be reduced laparoscopically and the etiological polyp resected colonoscopically. With judicious patient selection and considered operative technique, not all instances of colonic intussusception require segmental intestinal resection and intestinal conservation can be achieved.

Total Extraperitoneal (TEP) Hernioplasty With Intestinal Resection Assisted by Laparoscopy for a Strangulated Richter Femoral Hernia

We describe the first clinical case of a total extraperitoneal hernioplasty combined with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia. The patient was a 94-year-old woman admitted to the emergency room with signs and symptoms of acute small bowel obstruction. Diagnosis of a strangulated left Richter femoral hernia was only possible during the initial exploratory laparoscopy. The extraperitoneal approach for mesh positioning was performed gaining access through an infraumbilical 12 mm trocar incision, and assistance of two 5 mm laparoscopic ports at the hipogastrium and right flank. Laparoscopy was resumed and segmental intestinal resection with primary anastomosis was performed. The patient recovered without complications and was discharged home at the fourth postoperative day. The total extraperitoneal approach for acute hernia repair was successful in our particular case. However, factors such as laparoscopic surgical experience, careful patient selection, and correct preoperative diagnosis must be considered before studies in the emergency setting.

Palpation of preoperatively inserted indwelling angiocatheter facilitates intraoperative localization of obscure gastrointestinal bleeding of small intestinal origin

Summary Background Palpation of the indwelling angiographic catheter inserted before operation to localize obscure gastrointestinal bleeding of small intestinal origin during laparotomy has rarely been reported in the literature. Purpose The purpose of the study is to investigate the role of palpable indwelling angiocatheter inserted before operation in localizing obscure gastrointestinal bleeding of small intestinal origin during laparotomy. Methods Between January 2003 and December 2010, seven patients who had a clinical impression of obscure gastrointestinal bleeding of small intestinal origin and angiographic extravasation from the mesenteric artery had an angiocatheter inserted into the distal mesenteric branch. During laparotomy the catheter was palpated to guide subsequent resection of the intestine. The clinical outcomes of these patients were retrospectively reviewed. Results During laparotomy the retained catheter failed to be palpated in one patient. Six patients underwent segmental resection of intestine under guidance of the palpated catheter. All six patients had positive identification of small bowel bleeding. The yield rate of intraoperative localization was 86% (6 out of 7). Two of the six patients ceased bleeding after operation, but died of underlying disease progression. Four of the six patients had an uneventful postoperative clinical course without recurrent bleeding after a median follow-up period of 25 months. Conclusion Palpation of the indwelling angiographic catheter selectively left before operation is effective for precisely locating obscure gastrointestinal bleeding of small intestinal origin during laparotomy.

Adult intussusceptions caused by a lipoma in the jejunum: report of a case and review of the literature

Intussusceptions in adults is rare. Gastrointestinal lipomas are rare benign tumors and intussusceptions due to a gastrointestinal lipoma constitutes an infrequent clinical entity. Lipoma may develop as a benign tumor in all organs and rarely in large or small intestine. The present report describes a case of jejunojejunal intussusceptions in an adult with a history of colicky upper abdominal pain. Ileo-ileal invagination was diagnosed by computed tomography scan. Exploratory laparotomy revealed jejunojejunal intussusceptions secondary to a lipoma which was successfully treated with segmental intestinal resection. A review of the literature is also performed regarding this rare association revealing the diagnostic and therapeutic debates that exist. (french)L’invagination chez les adultes est rare. Les lipomes gastro-intestinaux sont de rares tumeurs bénignes et l’invagination intestinale due à un lipome gastro-intestinal constitue une entité clinique trés rare. Le lipome peut se développer comme une tumeur bénigne dans tous les organes et rarement dans l’intestin grêle ou le colon. Le présent rapport décrit un cas d’invagination jéjunojéjunale chez un adulte avec une histoire de douleurs abdominales. Iléo-iléale invagination a été diagnostiquée par tomodensitométrie. Une laparotomie exploratrice a révélé l’existence d’une invagination jéjunojéjunale secondaire à un lipome qui a été traitée avec succès par une résection intestinale segmentaire. Une revue de la littérature est également effectuée au sujet de cette association rare révélant les débats diagnostiques et thérapeutiques qui existent.

Bowel obstruction with intestinal lipomatosis

A 59-year-old woman presented to our hospital after 2 days of progressive abdominal pain, nausea and vomiting. The physical examination showed a distended abdomen, hypoactive bowel sounds, and diffuse abdominal tenderness. The laboratory tests revealed white-cell count of 6450 per cubic millimetre with 78% neutrophils. A contrast enhanced computed tomographic scan of the abdomen revealed lipomatosis of small bowel and causing bowel obstruction (Fig. 1). An explorative laparotomy discovered lipomatosis of small intestine and mesentery (Fig. 2A), which were causing intestinal obstruction. Segmental resection of tumour-involved intestine was performed. The pathological diagnosis was confirmed with lipomatous polyposis of ileum. Under microscopy sections, the specimen showed small intestinal tissue with multiple submucosal lipomatous nodules and composed of abnormal collections of mature adipose tissue (Panel 2B). The patient started oral intake with water at postoperative day 7 and regular diet at postoperative day 9. Postoperative wound infection was presented. After wound change dressing, the patient was discharged in good health 1 month later.

Die Bedeutung der De- / Vaskularisation des Harnleiters bei der Rekonstruktion nach Verletzungen

Serious errors may occur in the reconstruction of injured ureters if the degree of -devascularisation is not taken in account. The problems involved in ureter reconstruction after traumatic reconstruction are presented by means of two case -studies reviewed by the Expert Committee for Re-viewing Errors in Medical Treatment of the Ärztekammer Nordrhein. In a 55-year-old man there was a persistent drainage disorder of the left kidney following implantation of a Y-prosthesis with "lateralisation of the ureter". Following renewed splint-ing of the ureter and percutaneous nephrostomy, operative ureterolysis with partial resection of the ureter and end-to-end anastomosis resulted in anastomostic necrosis with a ureter-skin fistula. Fol-lowing a renewed nephrostomy, the left kidney had to be removed because of considerable loss in function. In a 66-year-old woman with right-sided salpingo-oophorectomy and right-sided -colonectomy there was extensive devascularisation of the right ureter with complete -severance in the lower third. An emergency uretero-uretero anastomosis led to scar-induced stenosis of the anastomosed segment of the ureter. Following unsuccessful attemps at splinting, the ureter was reimplanted using the psoas hitch procedure. Because of a fistula to the small intestine, relaparotomy with segmental resection of the small intestine and opening of an abscess -because of wound infection were necessary. A satisfactory final result was obtained after about nine months. When reconstructing damaged -ureters, numerous factors must be taken into account, e. g., the type, extent and location of the -damage to the ureter(s), the time of detection, the duration and severity of the sequelae for the kidney(s), the patient's concomitant condition and the suitability of the reconstruction procedure. Further-more, the degree of de- / vascularisation is of decisive impor-tance.

Surgical treatment of rectovaginal endometriosis with rectal involvement

Rectovaginal endometriosis (RVE) is one of the most serious and incapacitating forms of presentation of this disease. Traditionally, medical treatment has not been considered effective for the majority of patients, being surgery the only reasonable and therapeutic choice in these cases. This exposes patients to a potentially serious morbidity, thus a careful evaluation should be done by a surgical board considering the impact of the disease as well as the quality of life of the patients. The main surgical techniques used are the shaving of the rectal wall affected by the endometriosic implants, the discoid excision of the front rectal wall, and the segmental intestinal resection, and there is no consensus concerning which is the most effective and suitable between them. The bibliography published in the last 10 years relating to the surgical treatment of RVE is being reviewed with the intention of updating the knowledge base about the topic and looking for common ground between different studies, allowing us to come closer to reaching a consensus about treatment for this pathology.

Marginal Zone B-cell Lymphoma of MALT in Small Intestine Associated with Amyloidosis: A Rare Association

A 62-yr-old man presented with a 5-yr history of intermittent abdominal distention and pain. These symptoms persisted for several months and subsided without treatment. A diagnosis of suspected small bowel lymphoma was made based on plain radiograph and computerized tomogram findings, and he was referred to our institution for further evaluation. Segmental resection of the small intestine was performed and the diagnosis of marginal zone B-cell lymphoma associated with amyloidosis was made. This is the first case of marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) in the small intestine associated with amyloidosis in Korea.

Jejunal Perforation Caused by Primary Jejunal Diffuse Large B Cell Lymphoma

Small bowel malignancy accounts for approximately 2% of gastrointestinal malignancies. In particular, malignant lymphoma of the small intestine is so rare that it accounts for less than 1% of gastrointestinal malignancies. Initial symptoms are non-specific and diagnosis may be delayed until the patient presents with complications such as intestinal obstruction, hemorrhage, or perforation. A 79-year-old man visited the emergency room with lower abdominal pain. Segmental resection of the small intestine was done and surgery revealed a 9.5×6 cm sized mass with jejunal perforation at 20 cm inferior to the ligament of Treitz. The mass was diagnosed as diffuse large B cell lymphoma. We experienced a case of diffuse large B cell lymphoma which was diagnosed after emergent surgery for jejunal perforation, and report it with a review of literature. (Korean J Helicobacter Up Gastrointest Res 2011; 11:205-208)

Duodenal obstruction - an unusual presentation of Strongyloides stercoralis enteritis: a case report

BackgroundIntestinal obstruction is a poorly recognized and probably underreported complication of strongyloidiasis. We present herein an unusual case, of complete duodenal obstruction caused by S. stercoralis.MethodsA systematic review of the literature examining the clinical course, diagnostic methods, and outcome of this rare complication of strongyloidiasis was performed.ResultsA 42-year-old woman presented with a 5-month history of abdominal pain, vomit, and weight loss. An abdominal CT scan showed an obstruction of the third part of the duodenum. Segmental intestinal resection was carried out and histopathology examination revealed heavy Strongyloides stercoralis infestation. Duodenal obstruction is a rare complication of S. stercoralis infection, with only 8 cases described in the literature since 1970. Most of the patients are males, middle-aged, and the diagnosis was made by duodenal aspirate/biopsy, or analysis of surgical specimen.ConclusionsDuodenal obstruction is an unusual, but potential fatal, complication of S. stercoralis infection. The large spectrum of clinical manifestation and lack of classic clinical syndrome make the final diagnosis of strongyloidiasis extremely difficult. A high index of suspicion, mainly in patients from endemic areas, is needed for correct and early diagnosis of this uncommon presentation of Strogyloides stercoralis enteritis.

Gastro-Intestinal Bezoars: Thirty-Five Years Experience

Background and aims: Because of their rarity and late diagnosis, gastro-intestinal bezoars can be treated after the occurrence of some complications such as acute intestinal obstruction, strangulation, decubitus ulceration and bleeding. In this study, reasons for bezoar formation, measures to be taken and treatment modalities were investigated. Patients and methods: The files of the patients who were found to have gastro-intestinal bezoars and who were treated at Istanbul University, Cerrahpasa Medical Faculty General Surgery Department and Emergency Unit between the years 1970 and 2005 were analysed.Results: Thirteen (30%) of the 44 patients in the study were women, 31 (70%) were men: the mean age was 55.5 ± 19.6 (range 22–96) years. Enzymatic dissolution (3 patients) and endoscopic fragmentation (four patients) were unsuccessful. Laparoscopic gastrotomy (n = 2), gastrotomy(n = 16), gastric resection (n = 3), enterotomy (n = 12), segmental intestinal resection (n = 3), gastroduodenotomy (n = 1), and gastrotomy + enterotomy (n = 3) were performed. In two patients, bezoars were fragmented and milked to caecum. There were no major postoperative complications, except abdominal wound infection in 4 patients and one patient who had a recurrent intestinal bezoar five years after the operation. One of the patients died because of heart failure on the 7th postoperative day. Mean hospital stay was 9.5 ± 3.6 days. Conclusion: Even though rarely seen in digestive tract diseases, the probability of BZ formation should always be remembered. After the removal of BZs by conservative methods or surgery, precautions should be taken against recurrence and possible underlying psychiatric disorders should be treated.

Gastrointestinal stromal tumor causing small bowelintussusception in a patient with Crohn’s disease

We report a case of jejunoileal intussusception in a 42-year-old patient with Crohn's disease caused by a gastrointestinal stromal tumor. The patient complained of vague diffuse abdominal pain for a period of 4 mo. Intussusception was suspected at computer tomography and magnetic resonance imaging scans. Segmental resection of the small intestine was performed. Pathological examination of the surgical specimen revealed a gastrointestinal stromal tumor as well as aphthous ulcerations and areas of inflammation, which were characteristic of Crohn's disease. This is the first report of small bowel intussusception due to a gastrointestinal stromal tumor coexisting with Crohn's disease.

Lethal Intestinal Perforation After Foreign Body Ingestion in a Superobese Patient

Accidental ingestion of foreign bodies is common in the general population. Most foreign bodies pass through the entire digestive tract without incidents. However, in some cases, the ingested foreign body can cause complications such as acute abdomen due to intestinal perforation and even death. Bowel perforation may not be more common in the massively obese than in the normal-weight population but may be more problematic. We describe a super-obese female (body mass index, 52.3 kg/m2) who underwent emergency surgery for small-bowel perforation caused by an ingested foreign body (fish bone); the patient died despite segmental intestinal resection and intensive care.

Incarcerated Umbilical Hernia in a Super-super-obese Patient

Abdominal wall hernias are more prevalent in the morbidly obese. Incarceration of external hernias is a relatively common process in adults and is associated to a high rate of complications and mortality. We present the case of a morbidly super-super-obese patient (body mass index, 80 kg/m(2)) who underwent emergency surgery for an incarcerated umbilical hernia; the patient died despite segmental intestinal resection, hernia repair using mesh, and intensive care.

Les diverticules de Meckel chez l’enfant : à propos de 11 cas

We report 11 cases of Meckel's diverticulum in children admitted to the department of Paediatrics Surgery of Lomé (Togo). None of the cases was identified before surgery. A systematic search during appendectomy identified 3 cases. It was fortuitously discovered four times, and due to complications in four cases. There was one complication related death. Segmental intestinal resection was the only technique used.