Small Bowel Loops Research Articles

Case Report: Bilateral Spigelian Hernia With Meckel’s diverticulum

Spigelian hernia is an uncommon form of ventral hernia, with an incidence ranging from 0.1% to 2%. This case report describes a 72-year-old female who presented with an obstructed right Spigelian hernia, a left Spigelian hernia, and an uncomplicated Meckel’s diverticulum, along with the management approach. The patient had experienced intermittent tenderness in the right iliac fossa for the last two months, which had worsened to severe pain over the previous two days, accompanied by a palpable mass in the right lower quadrant. An urgent CT scan of the abdomen and pelvis revealed an obstructed right Spigelian hernia containing dilated proximal small bowel, and a left uncomplicated spigelian hernia. The patient experienced worsening abdominal pain and vomiting. Emergency laparotomy was performed, revealing a right Spigelian hernia with viable small bowel loops, a non-complicated Meckel’s diverticulum located 20 cm from the ileocecal valve, and a small left Spigelian hernia. The right Spigelian hernia was repaired using intraperitoneal sublay mesh, while the left hernia was treated with primary repair. No bowel resection was performed at the site of the Meckel’s diverticulum, as it was non-inflamed, to prevent contamination of the mesh with bowel flora. Bilateral Spigelian hernias accompanied by Meckel’s diverticulum present a challenging clinical scenario. Although rare, this condition should be considered in the differential diagnosis of acute abdominal pain due to the potential for serious complications.

Venous intestinal ischemia of fungal origin as a cause of intestinal obstruction in immunocompromised patients: case report and literature review

BackgroundMucormycosis is a highly lethal opportunistic fungal disease caused by ubiquitous molds of the order Mucorales, with Rhizopus, Lichtheimia and Mucor being the most common genera. This rare disease primarily affects immunocompromised patients, with presentations ranging from rhino-orbito-cerebral infections to disseminated mucormycosis with angioinvasion, leading to thrombosis and tissue infarction. Gastrointestinal mucormycosis is the least common clinical presentation and is believed to be secondary to spore ingestion. It can involve multiple components of the gastrointestinal tract, such as the stomach, liver, ileum, and colon, with nonspecific manifestations, including pain, nausea, vomiting, and abdominal distension. The initial clinical presentation may even manifest as gastrointestinal bleeding due to gastric ulceration or intestinal perforation.Case presentationHere we present the case of a 48-year-old male patient with a 9-year history of human immunodeficiency virus (HIV) infection who was hospitalized in the context of febrile neutropenia and whose acute respiratory infection was documented; therefore, antibiotic treatment was initiated. However, due to persistent febrile peaks and peripheral blood showing documentation of multilineage cytopenias, a bone marrow biopsy was performed, compatible with presenting features of marrow myelodysplasia. During hospitalization, the patient presented left flank abdominal pain, and an abdominal computed tomography (CT) scan revealed signs of intussusception of a small bowel loop at the distal jejunum level, leading to intestinal obstruction with ischemic progression, requiring ileectomy (60 cm). Histopathological analysis of the resected intestine revealed severe transmural ischemic changes associated with venous thrombosis due to fungal structures, with histochemical studies demonstrating the presence of zygomycete (Mucor) fungal structures, leading to the initiation of treatment with amphotericin B. However, despite treatment, the patient experienced progressive clinical deterioration with persistent fever and ventilatory failure, with follow-up tests showing absolute neutropenia and blood cultures positive for yeast, leading to death 52 days after admission.ConclusionsThe diagnosis of intestinal mucormycosis may be delayed due to the lack of specificity of the signs and symptoms. Pathologists as well as histopathological studies are essential for timely treatment.

Spontaneous Transvaginal Small Bowel Evisceration After Laparoscopic Hysterectomy

Vaginal cuff dehiscence can be a rare complication of total hysterectomy, with an estimated prevalence of 0.032% to 1.25% and a high mortality rate of 6 to 10%. Dehiscence is also reported in cases following total laparoscopic hysterectomy, with a prevalence of 0.87%. This case report details the emergency management of a 59-year-old female who complained of abdominal and pelvic pain and the feeling of a foreign body in her vagina. The patient reported a history of laparoscopic total hysterectomy 6 months prior to presenting at the Emergency Department. A clinical examination revealed small bowel loops protruding through the vagina. The patient underwent exploratory laparotomy through a Pfannenstiel incision, and the terminal ileum was found prolapsing through the vaginal cuff. The bowel loops were identified as viable and the vagina was sutured. The patient had an unremarked post operative course. This case report showcases that in patients with transvaginal evisceration, immediate surgical management is crucial in order to avoid serious life threatening complications, and both surgeons and gynecologists should remain vigilant regarding this pathology.

Type 1a Duodenojejunal Tubular Duplication Cyst with Complex Rotational Anomaly Masquerading as Chronic Anemia

ABSTRACT Enteric duplication cysts and reversed intestinal rotation (RIR) are rare congenital anomalies, with their coexistence being exceptionally uncommon. We report a 4-year-old girl who presented with chronic anemia and intermittent abdominal symptoms since infancy. Detailed workup for medical causes of anemia was inconclusive. Computed tomography of the abdomen revealed intestinal malrotation with a grossly dilated small bowel loop. Intraoperative findings revealed a long duodenojejunal tubular duplication with a separate mesentery (Type 1a) and RIR. The patient underwent a Ladd’s procedure, resection of the duplication cyst, and end-to-end anastomosis. This case underscores the anatomical rarity, varied clinical presentation, and challenges in making an accurate and timely diagnosis in such a case.

A Case Report of Left Paraduodenal Hernia in a young boy

Internal hernia is a relatively uncommon condition and is a rare type of intestinal obstruction. Paraduodenal hernia (PDH) is the most frequent type of congenital hernia, especially on the left side. Although acute intestinal obstruction due to internal hernias is rare, it can be fatal if it is not identified and treated right away. The clinical diagnosis of paraduodenal hernia is difficult due to its rarity and variable symptoms. Here, we present the case of a 14-year-old boy who had been experiencing intermittent abdominal pain for a week duration. The pain had been worse during the previous two days, and the boy also experienced nausea and repeated vomiting episodes. He was otherwise healthy and had no history of previous abdominal operations. A left paraduodenal hernia was diagnosed based on the findings of a computed tomography scan, which showed a dilated small bowel loop occupying the left hypochondrial region anterior to the pararenal region. Due to the complicated nature of the disease, the patient had an exploratory laparotomy, during which herniated jejunal loops were reduced and hernial sac wide opened to prevent a recurrence. The patient tolerated the procedure, and recovery was uneventful. This case sheds light on the importance of considering the diagnosis of left paraduodenal hernia in patients with abdominal pain, particularly among those who have not undergone abdominal surgery previously. Early detection and treatment can prevent life-threatening complications such as intestinal perforation and peritonitis.

Role of computed tomography enteroclysis in the evaluation of small bowel diseases

Background: Examining small bowel loops within the peritoneal cavity poses significant challenges because of their length and overlapping nature. Aims and Objectives: This study aimed to evaluate the utility of computed tomography enteroclysis (CTE) in diagnosing small intestinal diseases and to understand its clinical application. Materials and Methods: The study was conducted from November 2019 to October 2021 in 30 patients undergoing CTE treatment. The day before treatment, bowel preparation included a low-residue diet, lots of fluids, an overnight fast of 8–12 h, and laxatives. A 16-slice Aquilion Lightning computed tomography (CT) scanner was used in general hospitals, and a 128-slice GE Healthcare helical CT scanner was used in multispecialty hospitals. Results: Among the 30 patients, 20 (66.7%) were male, and 10 (33.3%) were female, predominantly aged between 30 and 60 years old. Positive findings were noted in 23 patients (76.7%), including intestinal tuberculosis, inflammatory bowel disease, small bowel obstruction, and neoplastic lesions. Various small intestinal pathologies, such as non-specific edema, intussusception, and ischemic bowel disease, were also identified. Conclusion: This raises the standard of current small bowel imaging by delivering suitable intestinal distension using the enteral volume challenge principle and helps identify and characterize small-bowel problems.

Giant intra-abdominal desmoid-type fibromatosis infiltrating into the pancreas

Abstract: Intra-abdominal desmoid-type fibromatosis is a proliferative fibroblastic lesion that constitutes 8% of all desmoid tumors and 0.03% of all neoplasm. It is histologically benign with a local aggressive nature and recurs even after excision. It can occur sporadically and or associated with familial adenomatous polyposis mutation. The present case is a 25-year-old female admitted with a chief complaint of abdominal mass gradually increasing in size in the last 6 months. Ultrasound of the whole abdomen initially suggested it to be a uterine/ovarian mass, which is further detailed by the contrast-enhanced computerized tomography (CT) scan. The CT scan showed a large heterodense intraperitoneal mass lesion measuring 34 cm × 25 cm × 16 cm with foci of calcification and necrosis. The mass extended superomedially. It displaced and compressed the stomach wall. It was abutting the peritoneum and was associated with diffuse peritoneal thickening anterolaterally. Posteriorly it was abutting small bowel loops and inferiorly extending into the pelvis and compressing the urinary bladder wall. Posterosuperiorly seems to abut the left kidney and spleen. Desmoid tumor and gastrointestinal stromal tumor (GIST) remained as differentials radiologically and then the patient underwent laparotomy. Histology and immunohistochemistry confirmed it to be fibromatosis. It is, therefore, justified to describe the tumor by considering its rarity, difficulties in diagnosis, and therapeutic ambit.

Real-time quantification of laser speckle contrast imaging during intestinal laparoscopic surgery: successful demonstration in a porcine intestinal ischemia model

BackgroundAnastomotic leakage (AL) is a dreaded complication following colorectal cancer surgery, impacting patient outcome and leads to increasing healthcare consumption as well as economic burden. Bowel perfusion is a significant modifiable factor for anastomotic healing and thus crucial for reducing AL.AimsThe study aimed to calculate a cut-off value for quantified laser speckle perfusion units (LSPUs) in order to differentiate between ischemic and well-perfused tissue and to assess inter-observer reliability.MethodsLSCI was performed using a porcine ischemic small bowel loop model with the PerfusiX-Imaging® system. An ischemic area, a well-perfused area, and watershed areas, were selected based on the LSCI colormap. Subsequently, local capillary lactate (LCL) levels were measured. A logarithmic curve estimation tested the correlation between LSPU and LCL levels. A cut-off value for LSPU and lactate was calculated, based on anatomically ischemic and well-perfused tissue. Inter-observer variability analysis was performed with 10 observers.ResultsDirectly after ligation of the mesenteric arteries, differences in LSPU values between ischemic and well-perfused tissue were significant (p < 0.001) and increased significantly throughout all following measurements. LCL levels were significantly different (p < 0.001) at both 60 and 120 min. Logarithmic curve estimation showed an R2 value of 0.56 between LSPU and LCL values. A LSPU cut-off value was determined at 69, with a sensitivity of 0.94 and specificity of 0.87. A LCL cut-off value of 3.8 mmol/L was found, with a sensitivity and specificity of 0.97 and 1.0, respectively. There was no difference in assessment between experienced and unexperienced observers. Cohen’s Kappa values were moderate to good (0.52–0.66).ConclusionReal-time quantification of LSPUs may be a feasible intraoperative method to assess tissue perfusion and a cut-off value could be determined with high sensitivity and specificity. Inter-observer variability was moderate to good, irrespective of prior experience with the technique.

Tubercular abdominal cocoon: a rare cause of subacute small bowel obstruction

BackgroundEncapsulating peritoneal sclerosis (EPS) or abdominal cocoon is a very rare cause of subacute intestinal obstruction. We hereby report an elderly male presenting with recent-onset subacute intestinal obstruction with characteristic imaging findings of this entity in a background of abdominal tuberculosis on computed tomography (CT) scan that enabled timely diagnosis and appropriate clinical management. The report aims to highlight the typical radiological findings of this rare entity that may otherwise go undetected on imaging investigations, thereby causing a delay in diagnosis with adverse clinical outcomes.Case presentationA 57-year-old male patient presented to the hospital with complaints of diffuse abdominal pain with obstipation and recurrent episodes of vomiting since last three days. Clinical evaluation also revealed an ill-defined lump in right lower abdomen. An urgent contrast-enhanced CT scan after oral contrast administration was performed that revealed dilated, clumped up small bowel loops in a ‘whorl-like’ pattern in right iliac fossa region. These obstructed loops were encased by a thick peritoneal membrane giving a ‘cocoon-like’ appearance. Also appreciated were scattered punctate calcific foci in jejunal walls and adjacent peritoneum along with mild ascites. On the basis of typical imaging findings, provisional diagnosis of tubercular cocoon abdomen was given that was later confirmed by laboratory investigations and diagnostic laparoscopy.ConclusionEncapsulating peritoneal sclerosis or cocoon abdomen is an extremely rare cause of subacute intestinal obstruction. Further, cocoon abdomen in a background of abdominal tuberculosis is even rarer. However, this case report highlights the characteristic imaging findings for broader audience that enabled prompt diagnosis and appropriate clinical management in this case, achieving optimal clinical outcome.

A Case of an Adult Complicated Left Diaphragmatic Hernia: Case Report and Literature Review

Introduction: Diaphragmatic hernia by definition is the protrusion of abdominal structures into the thoracic cavity. Classified as either congenital or acquired, adult diaphragmatic hernia without a history of trauma is rare, and iatrogenic diaphragmatic hernia is rarer. The array of symptoms may be acute or latent and will depend on the herniated organ, which certainly makes this pathology a challenge at the level of diagnosis and subsequent management. Case Report: Here we present the case of a 73-year-old male patient who presented one year post left nephrectomy complicated by splenectomy (post splenic injury), with two weeks history of diffuse abdominal pain, non-bilious vomiting, and shortness of breath. Workup done revealed a left diaphragmatic hernia containing necrotic-perforated small bowel loops. A laparotomy with intestinal resection, loop ileostomy along with a primary repair of the diaphragmatic defect were performed. Conclusion: Although a great portion of acquired diaphragmatic hernias remain asymptomatic, they may be presenting with severe symptomatology and aggravating complications. At the level of clinical manifestation, suspicion of diaphragmatic hernia ascends the ladder of differential diagnosis in a patient with combined respiratory and gastrointestinal symptoms and hence is essential to avoid delayed treatment and superimposing lethal complications. Definitive treatment of diaphragmatic hernia is surgical repair given the high morbidity and mortality associated with such injury.

LOSS OF DRAINAGE VACUUM AFTER MINIMAL INVASIVE SUBLAY OPERATION – EARLY INDICATOR FOR AN INTERPARIETAL HERNIA WITH SMALL BOWEL OBSTRUCTION – A CASE REPORT

Abstract Background Newer repair techniques for abdominal wall hernias, such as the enchanced-view totally extraperitoneal technique or the mini- or less-open sublay operation are increasingly being used. With these new techniques special complications might occur. Case Report We present an 81-year-old patient with a recurrent ventral incisional hernia after IPOM repair. The preoperative abdominal CT scan showed the hernia defect, measuring 3 × 3 cm. A repair was performed in MILOS technique, the IPOM mesh was removed. The posterior the rectus sheath was closed under slight tension. A Mesh 15 × 15 cm without fixation and a 14 french Redon drainage were inserted. Over the next 4 postoperative days the drainage had a repeatedly loos of vacuum, until the patient developed clinical symptoms of a ileus. A CT scan showed a bowel dysfunction without a clear sign for incarceration. At this point, the suction drainage was without vacuum a total of seven times. A diagnostic laparoscopy was performed and a small bowel loop was found trapped between the implanted mesh and the posterior rectus sheath, as an interparietal retro-rectus hernia (iRRH). The intestinal loop could be removed, no necrosis or ischemia was found. The fascial defect was covered using vicryl mesh patch. Conclusion The role of vacuum drainage remains to be considered. Suction of remaining intraabdominal gas might occur due to fascia dehiscence and CT diagnostics can mislead surgeons decisions. Tension free fascial closure remains of capital importance. Mesh fixation, use of special stitching techniques, transversus-abdominis-release or preoperative application of botulinum toxin should be kept mind.

OPERATING ON A GIANT (BELOW KNEE) INGUINO-SCROTAL HERNIA AND RECOMMENDATIONS FOR REPAIR

Abstract Background and Aim To increase knowledge and understanding about giant inguino-scrotal hernias and share our experience with the European Hernia Society. Method A 52-year-old gentleman presented with a symptomatic giant inguino-scrotal hernia which reached the ankle level, with a buried penis. A CT scan showed the sac to contain the right hemicolon, omentum, multiple loops of small bowel, sigmoid colon and the right ureter. The patient was taken through a complex hernia multidisciplinary team (MDT) meeting. A period of prehabiliation was undertaken to optimise the patient for operation. The scrotal skin was cared for to eradicate pressure areas and fungal infection. Pre-operative botox was used for restoration of abdominal domain. Results A successful operation was carried out by two experienced hernia surgeons. The surgical approach was inguino-scrotal, with dissection of sac contents and a midline laparotomy to aid reduction of contents with restoration of anatomy into the peritoneal cavity. The large defect was repaired with biological mesh. The patient recovered well post-operatively and was discharged on day 13. The patient continues to do well 20 months post-operatively without recurrence. Conclusion In order to carry out this operation we recommended a multidisciplinary approach with careful and meticulous work up. Discussion in an MDT environment should be standard where all approaches can be considered e.g. pre-operative botox. The operation should be carried out by an experienced hernia surgeon and another consultant.

A RARE CASE OF TRANSMESOCOLIC HERNIATION OF SMALL BOWELTHROUGH A CONGENITAL DEFECT PRESENTING AS A CLOSED BOWEL OBSTRUCTION - A CASE REPORT AND LITERATURE REVIEW OF REPAIRS OF INTERNAL HERNIAS

Transmesocolic hernia is an uncommon type of Internal hernia with incidence ranging from approximately 5–10% of all Internal Hernias. To the best of our knowledge, this is the first reported case of a transmesocolic hernia in adults without any surgical history or trauma. Small bowel loops were found herniating into the supracolic compartment through a congenital defect in transverse mesocolon presenting clinically as Small Bowel obstruction. A 20-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency Exploratory Laprotomy was performedand bowel loops with discolouration seen enclosed in hernial sac in supracolic compartment which were milked out of defect and observed to have obtained vascularity almost immediately. The postoperative period was uneventful. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as Bowel gangrene, peritonitis and sepsis.

One-step approach by enterolithotomy as surgical treatment of biliary ileus associated with bridle: case report and literature review

Gallstone ileus is a rare cause of intestinal obstruction, more common in adults and in the context of late complications due to gallbladder stones. The pathophysiology describes long-term inflammatory processes of the gallbladder, with biliodigestive fistula development and passage of the gallstone into the intestine, impacting the terminal ileum in most cases. It manifests with data of intestinal obstruction in patients with a chronic history of gallbladder lithiasis. The ideal imaging study is a computed tomography (CT) scan of the abdomen to identify pneumobilia, intestinal obstruction and the lithiasis impacting on the bowel. The surgical approach depends on the context of each patient through laparoscopy or laparotomy in order to perform enterotomy and extraction of the stone or by performing also the management of the fistula and cholecystectomy at the same surgical time. Management must be individualized for each patient. We present the case of a patient in her tenth decade of life with a history of recurrent biliary colic without management, who was admitted to the general surgery department with data of probable intestinal occlusion. Imaging studies were performed, with radiographic evidence of distension of the small bowel loops and tomography with findings suggestive of biliary ileus. Due to the clinical context and comorbidities of the patient, laparotomy with enterotomy and extraction of the stone was performed.

Encapsulating Peritoneal Sclerosis in a hemodialysis patient: a case report

Background: Encapsulating peritoneal sclerosis is a rare manifestation nowadays. Case report: This was a case report of a young female with ESKD on hemodialysis for more than 6 months with a previous history of continuous ambulatory peritoneal dialysis (CAPD) and recurrent peritonitis which currently presented with painful abdominal distension. The CT scan of the abdomen showed a clumping of small bowel loops at the left side encased into a thin fibrocartilaginous membrane. Initially, she was treated for intrabdominal sepsis however after recurrent admission, IV Methylprednisolone was started followed by high dose steroids and tamoxifen as a treatment for EPS. Surprisingly she improved and had a good clinical response. She had readmitted again after a few months with abdominal pain due to an abrupt stop in steroid but improved again after the steroid was started. Conclusion: Abdominal pain in a patient with history of CAPD peritonitis needs to raise suspicion of EPS even though is rare Radiological Imaging is helpful in making early diagnosis. The most important thing is steroid as a mainstay of the treatment of EPS besides tamoxifen with a minimal one-year duration or lifelong as surgical intervention is very risky.

Imaging Gigantic Small Bowel Gastrointestinal Stromal Tumours Through Different Radiological Lenses: A Case Report

Gastrointestinal stromal tumours (GIST) account for 1–3% of all the gastrointestinal (GI) neoplasms. It is the most common mesenchymal tumour in the Gl tract. The majority of GISTs are KIT gene positive; however, it is necessary to diagnose them pre-operatively. Here, the authors report the case of a 65-year-old male who presented with pain and a lump in the umbilical region for the last 2 years. On abdominal ultrasound, there was a heterogeneously hypoechoic mass in the umbilical region, with lobulated margins and central necrotic areas. On small bowel series, the core of the mass showed faint contrast opacification. Contrast-enhanced CT of the abdomen showed a heterogeneously enhancing, lobulated exophytic lesion arising from the small bowel loops, the central core of the lesion demonstrating an air-contrast level. Under ultrasound guidance, the lesion was biopsied. Histopathological findings were suggestive of a spindle cell tumour. The sample was c-KIT positive. Hence, the diagnosis of GIST was confirmed. The patient was given imatinib after resection of the mass. Usually, a GIST of larger size has higher malignant and metastatic potential; however, this article shows a gigantic small bowel GIST with cavitation and heterogeneity in different imaging modality, and still has no metastasis on imaging or high mitotic activity, and nuclear atypia on histopathology. A radiologist should also know the imaging pattern on conventional imaging and ultrasound, apart from usual cross-sectional imaging.

AN UNUSUAL CAUSE OF ACUTE SMALL BOWEL OBSTRUCTION

Up to 20% of admissions with severe acute abdomen are due to intestinal obstruction, a common surgical emergency. Paraduodenal hernia is a rare entity of congenital internal hernia which is an unusual cause of small bowel obstruction. This case report describes the case of a 29-year-old woman with acute pain abdomen and vomiting without other significant past history. Radiological investigations revealed mechanical bowel obstruction and gangrenous bowel loops was evident on surgical exploration. Non-viable small bowel loop was resected and peritoneal defect was sutured. Left paraduodenal hernia is a rare cause of acute abdomen and high index of suspicion is required for early diagnosis and management.

Unique laparoscopic emergency management of traumatic obstructed abdominal wall hernia: A case report and review of literature

Abstract Traumatic abdominal wall hernia (TAWH) is a rare clinical occurrence, with only limited cases published since 1906. This type of hernia is primarily caused by low- or high-energy blunt force trauma, resulting in damage to abdominal wall musculature while the skin is intact. The diagnosis and management of TAWH poses a lot of challenges and complexities. Herein, we present a case of a 32-year-old male Saudi patient who sustained significant abdominal trauma as a driver involved in a front collision while wearing a seat belt. Upon arrival at the trauma center, the patient was hemodynamically stable and exhibited clinical signs of left flank bulge, seat belt sign, and abdominal bruising. First, a focused assessment with sonography for trauma (FAST) was performed, which revealed minimal free fluid in the abdomen. Subsequent contrast-enhanced IV computed tomography (CT) scan confirmed a 3.6-cm left lateral abdominal wall defect with herniation of short segments of the large and small bowel loops and adjacent subcutaneous fluid. Following initial observation, the patient developed signs of bowel obstruction. A repeat CT scan showed interval progression of the hernia, partial small bowel obstruction, and other concerning findings. An emergency laparoscopic exploration revealed a large defect at the left lumber region containing omentum and long segments of the small bowel with mild distension. The bowel and omentum were reduced. The surgical repair included herniorrhaphy and mesh placement. The patient recovered well and was discharged on the third postoperative day. This case underscores the importance of thorough evaluation and timely intervention in TAWHs. Rapid surgical management, aided by advanced imaging techniques, can lead to favorable outcomes even in complex cases involving bowel herniation and associated complications.

A130 RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN

Abstract Background A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, an extended left hemicolectomy with end-colostomy formation, and a flap to close the abdomen. He subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula. Aims In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed high-risk. He was placed on total parenteral nutrition and referred for endoscopic management. Methods Under fluoroscopic guidance, we injected methylene blue &amp; contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast (Fig 1A). Retrograde ileoscopy was performed with an Olympus pediatric colonoscope via the patient’s colostomy. 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis (Fig 1B), extending to the previously filled loop of small bowel. Given the length and characterof the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible. Results We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. 50 cm from the ICV, we identified an adjacent dilated loop of small bowel (Fig. 1C). Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstream from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue (Fig. 1D). We then created an EUS-guided entero-enterostomy using a 15mm lumen-apposing metal stent (Hot-AXIOS; Boston Scientific, Massachusetts, USA; Fig. 1E). Passage of methylene blue &amp; contrast through the stent confirmed accurate deployment (Fig. 1F&amp;G). With both the ECF &amp; stricture bypassed, the patient’s colostomy output returned and ECF output diminished. Conclusions Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and deep enteric stenosis. Figure 1: Retrograde EUS-guided entero-enterostomy Funding Agencies None

A119 ACUTE COLONOC PSEUDO-OBSTRUCTION AFTER ENDOSCOPIC RESECTION OF A FULLY CIRCUMFERENTIAL LARGE NON-PEDUNCULATED COLORECTAL POLYP

Abstract Background Complex large non-pedunculated colorectal polyps (LNPCPs), including those involving the full circumference of the bowel, are now readily managed by minimally invasive endoscopic resection techniques. Established procedure-related adverse events include sedation related adverse events, deep mural injury, clinically significant post-resection bleeding, delayed perforation and serositis. An appreciation for potential procedure-related adverse events is critical to the effective implementation of these techniques. Aims To describe a case of acute colonic pseudo-obstruction after endoscopic resection of a fully circumferential LNPCP. Methods Case report and review of the literature Results A 91-year-old male with a history of atrial fibrillation, chronic kidney disease and suspected McKittrick-Wheelock syndrome underwent successful endoscopic mucosal resection (EMR) of a 100mm fully circumferential LNPCP in the sigmoid colon. Histopathology diagnosed a tubulovillous adenoma with high-grade dysplasia. After elective admission, he suffered from clinically significant post-EMR bleeding requiring 2 units of packed red blood cells. On post-operative day 1 he began to suffer from nausea, abdominal pain and obstipation. On examination, he was visibly distended. Abdominal X-ray revealed extensive gas-filled loops of small and large bowel with the absence of gas in the rectum. He was managed conservatively with nasogastric tube decompression. Total duration of hospital stay was 9 days. Conclusions Critical to the continued expansion of minimally invasive endoscopic resection techniques is an awareness for potential procedure-related adverse events. To our knowledge this is the first description of acute colonic pseudo-obstruction after endoscopic resection Funding Agencies None