Urgent Laparotomy Research Articles

Surgical Apgar scores predict complications after emergency general surgery laparotomy.

The Surgical Apgar Score (SAS) is a 10-point validated score comprised of three intraoperative variables (blood loss, lowest heart rate, and lowest mean arterial pressure). Lower scores are worse and predict major postoperative complications. The SAS has not been applied in emergency general surgery (EGS) but may help guide postoperative disposition. We hypothesize that SAS can predict complications in EGS patients undergoing a laparotomy. We performed a retrospective review of adult patients at a single, quaternary care center who underwent an exploratory laparotomy for EGS conditions within 6 hours of surgical consultation from 2015 to 2019. Patients were grouped by whether they experienced a postoperative complication (systemic, surgical, and/or death). Multivariable regression was performed to predict complications, accounting for SAS and other statistically significant variables between groups. Using this model, predicted probabilities of a complication were generated for each SAS. The cohort comprised 482 patients: 32.8% (n = 158) experienced a complication, while 67.2% (n = 324) did not. Patients with complications were older, frailer, more often male, had worse SAS (6 vs. 7, p < 0.0001) and American Society of Anesthesiologists scores, and higher rates of perforated hollow viscus ( p = 0.0003) and open abdomens ( p < 0.0001). On multivariable regression, an increasing SAS independently predicted less complications (adjusted odds ratio, 0.85; 95% confidence interval, 0.75-0.96; p = 0.009). An SAS ≤4 was associated with a 49.2% predicted chance of complications, greater rates of septic shock (9.7% vs. 3%, p = 0.01), respiratory failure (20.5% vs. 10.8%, p = 0.02), and death (24.1% vs. 7.5%, p < 0.0001). An SAS ≤ 4 did not correlate with surgical complications ( p = 0.1). The SAS accurately predicts postoperative complications in EGS patients undergoing urgent laparotomy, with an SAS ≤ 4 identifying patients at risk for septic shock, respiratory failure, and mortality. This tool can aid in rapidly determining postoperative disposition and resource allocation. Therapeutic/Care Management; Level IV.

Identifying Factors Associated With Code Status Changes After Emergency General Surgery

IntroductionSurgical emergencies are time sensitive. Identifying patients who may benefit from preoperative goals of care discussions is critical to ensuring that operative intervention aligns with the patient’s values. We sought to identify patient factors associated with acute changes in a patient’s goals using code status change (CSC) as proxy. MethodsA retrospective analysis of single-institution data for patients undergoing urgent laparotomy was performed. Patients were stratified based on whether a postoperative CSC occurred. Parametric, nonparametric, and regression analyses were used to identify variables associated with CSC. ResultsOf 484 patients, 13.8% (n = 67) had a postoperative CSC. Patients with postoperative CSC were older (65 versus 60 years, P < 0.001). Odds of CSC were significantly higher in patients who were transferred between facilities (odds ratio [OR] 2.1), had a higher Charlson Comorbidity Index (3-4: OR 3.9, 5+: OR 6.8), and had a higher quick sequential organ failure assessment score (2: OR 5.0; 3: OR 38.7). Patients with anemia (OR 1.9) and active cancer (OR 3.0) had higher odds of CSC. ConclusionsTimely intervention in emergency general surgery may result in high-risk interventions and subsequent complications that do not align with a patient’s goals and values. Our analysis identified a subset of patients who undergo surgery and have a postoperative CSC leading to transition to comfort-focused care. In these patients, a pause in clinical momentum may help ensure operative intervention remains goal concordant.

Early postoperative parastomal evisceration after explorative laparotomy: case report of a rare and potentially life-threatening surgical complication

BackgroundParastomal evisceration represents a preventable surgical complication that should not occur with appropriate technical diligence and surgical skills. While late parastomal hernias are well described in the literature, there is a paucity of reports on the early postoperative occurrence of parastomal intestinal evisceration.Case presentationAn urgent laparotomy was performed on a 58-year-old female patient for an acute cecal perforation with generalized peritonitis related to underlying colon cancer. Intraoperative revelations necessitated a carcinologic right colectomy and the creation of an end-loop ileocolostomy. Following six sessions of adjuvant chemotherapy, Computed tomography scans raised uncertainties about the presence of peritoneal carcinomatosis. Consequently, a collaborative decision was reached in a multidisciplinary discussion to conduct a surgical biopsy of these deposits before reinstating digestive continuity. The surgical procedure started with stoma mobilization. However, adhesions and a relatively confined aperture curtailed a comprehensive peritoneal cavity exploration. Thus, a midline incision was executed. The verdict from the frozen section examination affirmed metastatic presence, prompting the retention of the stoma. Within 48 h post-surgery, an early-stage parastomal evisceration occurred, stemming from an inadequately sealed aponeurotic sheath. The exposed bowel surface was encased in fibrin, necessitating meticulous irrigation with a warm saline solution before repositioning it within the peritoneal cavity. Accurate adjustment of the aponeurosis closure ensued, coupled with a meticulous reconstitution of the stoma. The postoperative course was uneventful. The patient was subsequently referred for hyperthermic intraperitoneal chemotherapy.ConclusionsPreventing parastomal evisceration requires adherence to established stoma-creation protocols, including creating a properly sized fascial opening and secure fixation. In instances of excessive fascial opening, ensuring a tension-free and meticulous closure is imperative.

Bowel perforation and peritonitis caused by a jejunal leiomyoma. A rare complication of jejunal leiomyoma

Small-bowel leiomyomas are rare, usually indolent, benign neoplasms, sporadically associated with complications, mainly including bleeding and obstruction. Herein we report a case of a 78-year-old female patient under high-dose corticosteroid treatment for systemic disease, presenting with clinical signs suggestive of peritonitis. Urgent exploratory laparotomy revealed an intraluminal jejunal mass complicated by bowel perforation and multiple enlarged mesenteric lymph nodes. Microscopic examination of the surgical specimen suggested the presence of a jejunal leiomyoma as the cause of perforation and lymph nodes’ infiltration by Hodgkin lymphoma. The patient died on the 15th post-operative day due to pulmonary complications. To our knowledge, this is the first reported case of a jejunal leiomyoma complicated by bowel perforation and peritonitis. A high index of suspicion for the presence of underlying neoplastic disease should be maintained in cases of non-traumatic small-bowel perforation. Additionally, the potentially detrimental effect of comorbidities on a patient’s outcome should be considered even in the context of successful management of primary disease.

Tardive transvaginal small bowel evisceration after colpohysterectomy: a case report of a rare surgical emergency

Transvaginal small bowel evisceration is a rare surgical emergency after gynaecological surgery with around 100 cases described in literature from 1864. Its diagnosis is merely clinical. The surgical treatment is time-depending because of the risk of acute small bowel ischemia. A 71-year-old female presented in our emergency room complaining abdominal pain, vomiting, and small bowel evisceration through the vagina. She suffered gynaecological prolapse and underwent transvaginal hysterectomy four years earlier. At the clinical examination, intestinal loops were oedematous, dusky, vascular sufferance, and without peristalsis. An urgent laparotomy was performed to reduce the prolapsed bowel, resect the ischemic loop, and vaginal cuff closure. Transvaginal bowel evisceration is a delay complication after hysterectomy. It is a life-threatening condition that requires prompt recognition and surgical management.

Spontaneous Heterotopic Pregnancy: As One of the Most Challenging Emergency Cases in Obstetrics

Spontaneous Heterotopic Pregnancy “SHP”: is defined as the presence of multiple gestations, in which, intrauterine and extrauterine pregnancy occur simultaneously, it is a life-threatening condition that requires immediate and accurate diagnosis and treatment. Here, we present a case of a 38-year-old pregnant female who conceived spontaneously, at her sixth week of gestation, was presented to the emergency department with acute pain in lower abdomen and minimal vaginal bleeding, she underwent previous falsely reassuring ultrasound imaging for two times and her symptoms were ignored until the diagnosis was finally made by us. Pelvic ultrasound showed evidence of an IUP and a left adnexal mass, raising suspicion for a heterotopic pregnancy. An urgent exploratory laparotomy and a left salpingectomy were performed, postoperative, the patient recovered well but she had an early pregnancy loss at 8 weeks of gestation. Clinicians should keep in mind that confirmation of an Intrauterine Pregnancy (IUP) should not preclude the existence of a heterotopic pregnancy.

Evaluation of clinical abdominal scoring system for predicting outcomes of blunt abdominal trauma

Background Trauma has been called the neglected disease of modern society and the most common cause of death under 45 years. Determining the optimal prospective course of action may be aided by the adoption of a scoring system to evaluate urgent laparotomy intervention. A quick and easy technique to identify whether there are any intra-abdominal injuries is to use the clinical abdominal scoring system (CASS). The objective of this study was to evaluate CASS in predicting the outcomes in patients with blunt abdominal trauma (BAT). Methods A retrospective observational study was conducted involving 80 patients with suspected BAT that arrived at the emergency department. All patients with suspected BAT were scored using CASS and radiological investigations that were done in the ED. The decision to proceed with the surgery would be made if the patient had CASS &gt;12 and/or if the radiological investigation showed features of BAT such as air under the diaphragm. Results Mean CASS score was 10.28 ± 1.340. The majority of the subjects (75 or 93.5%) had successful laparotomies, whereas only five (6.3%) had unsuccessful ones. Injuries to the spleen (42.6%), and liver (32%), combined injuries to the spleen and liver (2.6%), intestine (16%), pancreas (1.3%), bladder (4%), and kidneys (1.5%) were all found in positive laparotomies. The CASS has specificity of 60%, sensitivity of 80%, PPV 96.7%, and NPV 16.6%. Conclusions According to our data results, The CASS has a poor ability to predict the need for laparotomy in cases of blunt abdominal injuries as it shows low specificity.

Tubular intestinal duplication extending from the stomach to the ileum associated with multiple intestinal atresia and situs inversus: a case report

BackgroundDuplication of the alimentary tract can occur in any of its parts. For duodenal duplication, complete resection is particularly difficult when the ampulla of Vater is on the duplicated lumen and a deliberate management is necessary.Case presentationA 0-day female baby was referred to our department due to abdominal distention. The X-ray examination showed dextrocardia and opacity of the liver on the left side and abdominal ultrasonogram revealed remarkable intestinal dilatation. Therefore, urgent laparotomy was performed on the day of birth. Complete situs inversus of the abdominal organs was revealed, and the origin of the jejunum was on the left side and was accompanied by tubular intestinal duplication. The origin of the duplicated intestine was at the pancreatic head’s dorsal area. There were two points of type Шa atresia on the ileum. Therefore, we spared the duplicated intestine with a length of 3 cm to secure the passage of the biliary and pancreatic juices by a functional-side-to-side anastomosis with a 45-mm Endo-GIA™ camel load (Medtronic, Minneapolis, MN, USA). The ileum was transected at the distal side of the atresia point, and end-to-end jejunoileostomy was performed. Postoperative gastrointestinal series revealed remnants of the duplicated alimentary tract on the dorsal area of the stomach.ConclusionsIdentifying the position of the ampulla of Vater is crucial in the surgery of alimentary tract duplication with duodenal involvement. However, in the present case, it was difficult to identify whether the ampulla of Vater was on the true or duplicated lumen, and we had to spare the duplicated duodenum. Stapler anastomosis could be performed safely even in neonatal cases.

Sarcopenia and visceral fat in patients with incisional hernia after urgent laparotomy.

Various risk factors have been associated with the development of incisional hernia (IH). Some recent papers underlined that visceral fat could be a reliable indicator. Another risk factor which is of increasing clinical interest is sarcopenia. Recent studies have identified it as an independent predictor of poor postoperative outcomes following abdominal surgery. We aimed to investigate the role of visceral fat and skeletal muscle as emerging risk factors for IH after urgent laparotomy. Patients aged 18 years or older who underwent urgent median laparotomy and with continuous direct suturing of the laparotomy were included. They were categorized into two groups: those with a median IH and those without IH at 12-month follow-up. Demographic data were prospectively collected while CT scans were retrospectively reviewed. The data were compared among two groups. From January 2018 to May 2021, 364 patients underwent urgent surgery in our Department, of whom 222 were aged >18 years old and underwent median laparotomy. Forty-four patients had diagnosis of median IH, while 41 patients without IH were identified as the control group. Statistically significant differences emerged for BMI and for the area of visceral fat. The association with the presence/absence of sarcopenia was not significant. Even when surgery is performed in urgent settings, it could be important to identify patients at risk, especially as CT scans are generally available for all patients with urgent abdominal disease.

The importance of early diagnosis and surveillance in Peutz-Jeghers Syndrome: A case report

Abstract Introduction: Peutz-Jeghers syndrome is a rare autosomal dominant inherited disorder characterized by hamartomatous intestinal polyps and mucocutaneous pigmentation. Most cases appear to be linked to the mutation of the STK11 gene. Patients are at a lifetime risk of gastrointestinal and non-gastrointestinal cancers. Case Presentation: The present study offers the case of this rare disorder in a young woman revealed by jejunal obstruction caused by intussusception. A 32-year-old woman was referred to the surgical department with symptoms suggestive of an obstructive syndrome. On examination, there were multiple perioral pigmented lesions. An urgent exploratory laparotomy revealed bowel obstruction caused by an intussusception with a large polyp. The patient suffered another similar episode 4 years before leading to the diagnosis of Peutz-Jeghers Syndrome, however she was under no surveillance. Patients with pigmented lesions and a family member suffering from the mentioned syndrome should perform endoscopy and genetic tests to diagnose early and avoid complications. Conclusion: Peutz-Jeghers Syndrome is difficult to treat due to its nonspecific symptomatology and late diagnosis. Life-threatening complications such as intussusception and various types of cancer are unanticipated. It is vital to diagnose and perform routine screening, which will make it possible to prolong the survival of many patients.

Strangulated giant inguinal scrotal hernia with traction perforation at lesser curve of the stomach

A giant inguinoscrotal hernia is typically associated with a low risk of bowel obstruction or strangulation. When the hernia is complicated with acute gastric perforation, it is an exceedingly rare clinical entity. The operative strategy may be definitive at the index surgery or staged. The technical challenge is the severity of the peritoneal contamination contradicting mesh placement, coupled with the loss of domain. Herein we report a 58-year-old man with a long-standing right giant inguinoscrotal hernia, who presented with strangulation with a 1 day history. An urgent midline laparotomy access revealed a large tear over the lesser curvature of the stomach, attributable to choking at the hernia neck. Furthermore, there was severe contamination with total bowels herniation into the sac. We performed a complete reduction of hernia content, primary repair of stomach perforation, and primary closure of midline access and hernia neck repair with posterior wall reinforcement using prolene via an inguinal incision. The patient made an uneventful recovery and was discharged well. The perioperative clinical events and technical strategies are discussed in the current report.

Journey of a denture through the gastrointestinal tract

Foreign-body ingestion and its complications are widely reported and discussed in literature. However, ingested foreign body causing a large-bowel perforation is extremely rare. We present a case of a 49-year-old man who presented to us with complaints of abdominal pain, abdominal distension, fever and obstipation. The patient gave a history of accidental swallowing of his dentures 11 days back. The patient presented with shock in the emergency department and X-ray erect abdomen showed massive air under the diaphragm. The patient was taken for urgent exploratory laparotomy where a sigmoid perforation with ingested denture at the perforation site was found. The perforation was repaired, and a diverting ileostomy was made. The patient had an uneventful post-operative period and was discharged subsequently.

Repair of Bowel Perforation: Endoscopic State of the Art

Background: Intestinal damage from various etiologies can result in the potentially dangerous complication of bowel perforation. Emergent treatment of small bowel perforation includes surgical repair with or without small bowel resection. As the number of therapeutic and diagnostic endoscopic procedures increase, more studies may be required to properly evaluate and report incidences of bowel perforation. Given the advantages of interventional procedures, novel endoscopic technologies which may prove beneficial in bowel perforation repair are continuously undergoing development. Bowel perforation can lead to peritonitis and sepsis – a medical emergency requiring immediate attention. Following diagnosis, hemodynamically stable patients may be treated conservatively whereas unstable patients undergo more intensive surgical procedures. Endoscopic procedures for bowel perforation repair also exist and recent advances in technology are furthering the scope of such closure methods. Methods and Findings: Endoscopic suturing technologies, while capable, require extensive training and entail prolonged activation processes. Wound vacuum sponge closure via endoscopy provides convergence of wound defects but may not be efficacious in defects larger than 5 cm. Furthermore, this method may be limited by inadequate seal and placement in the intestine. Endoscopic clipping is another modality beneficial for smaller perforations only. T-tag suturing has shown promising results in ex-vivo studies but entails blind placement of T-tags for perforation closure. Stents can be inserted endoscopically under fluoroscopic visual guidance. This technique, however, may result in stent migration, perforations and potential occlusions. Sealants can be injected for perforation closure but have not demonstrated clear efficacy. Robotic flexible endoscopy provides several novel features yet may require advanced training and sometimes more than one operator. As interventional procedures continue to gain popularity, a better understanding of endoscopic modalities is helpful for furthering their development. Regarding bowel perforation, this review aids in an overall understanding of the technologies which exist and are advancing further into more standard modalities for practical medical applications. Conclusion: There are currently various methods to repair perforation of the gastrointestinal wall and except for urgent exploratory laparotomy when indicated, there is likely no single method that is superior to others. It may be beneficial for the physician to consider all options for repair when evaluating a potential bowel perforation, considering physician preference and individual success or difficulty with a given modality. In more recent years as the focus has narrowed on minimally invasive procedures, future modalities will likely include increased automation and ease of use with the help of robotics, which will hopefully lead to decreased time to diagnosis, faster recovery and reduced morbidity and mortality.

Small bowel segment with Meckel’s diverticulum volvulus related to short mesodiverticular band: a case report

BackgroundMeckel’s diverticulum is a remnant of the omphalomesenteric duct and occurs in only about 2% of people. Mesodiverticular band is the congenital remnant of the vitelline artery and is an even less often occurring phenomenon.Presented caseWe present the case of a 56-year-old Caucasian male who was admitted to the emergency department with a very intense, sudden abdominal pain, without past abdominal surgery history. Contrast enhanced computed tomography showed a possibly ischemic closed loop of the small intestine. Urgent laparotomy was performed, during which bloody content in the peritoneal cavity and torsed loop of the small intestine with Meckel’s diverticulum were found. The bowel loop and Meckel’s diverticulum were ischemic. At the tip of Meckel’s diverticulum there was a broken fibrous band extending to mesentery with pulsating artery. We did segmental resection of small intestine including Meckel’s diverticulum and primary end-to-end anastomosis. The patient had an unremarkable postoperative hospital stay and was discharged home after 5 days.ConclusionIn our case, we describe a patient with the volvulus of a segment of small bowel and Meckel’s diverticulum, which eventually led to small bowel obstruction and ischemia. It was a very rare case that required urgent surgical treatment.

Severe Abdominal Pain Due To Gastrointestinal Obstruction in Patient With Lung Adenosquamous Metastases in Colon

Background: Lung cancer is the most common cause of cancer-related death globally. Moreover, metastatic cancer from the lungs frequently occurs and is commonly identified at the first diagnosis. The primary cancer must be identified in order to establish the most effective treatment. However, colonic metastases are rare with incidence of 0,1%.&#x0D; Aim: This report describes an unusual case of colonic metastases from lung adenocarcinoma.&#x0D; Methods: Patient (58-year-old male) was examined with Fiber Optic Bronchoscopy and core biopsy in the lungs, and the results were suspicious for squamous cells. The patient had severe abdominal pain and bloating for 1 week and had signs of gastrointestinal obstruction in his second visit. The result of urgent laparotomy was adenosquamous and the result of immunohistochemical examination was negative P40 and positive Napsin A in both lungs and colon.&#x0D; Results: The lung biopsy result indicated squamous cell and the ceccum showed adenosquamous. The immunohistochemical examination using P40 and Napsin A of both lung and ceccum specimens indicated that the lung was the primary source of metastases to the colon.&#x0D; Conclusion: The patient suffered from a squamous cell lung tumor and reported severe abdominal pain due to metastases to the colon with adenosquamous results.

Bowel Perforation Due to Complicated Jejunal Diverticulitis: A Rare Case Report and Literature Review

Small bowel diverticulosis is a rare and acquired disease usually diagnosed as an incidental radiological finding. We report the case of a 65-year-old man admitted to our Emergency Department with abdominal pain and fever. The CT-scan showed multiple jejunal diverticular eversions and oedema of the surrounding tissues. At urgent laparotomy the radiological finding was confirmed with microperforation of one diverticula. Bowel resection was performed and histology revealed erosive inflammation with ischemic mucosa. Small bowel diverticula do not require any treatment if asymptomatic, nevertheless cases like this could be life-threatening. Urgent surgical procedure must be the treatment of choice in these patients.

Palliative management of a patient with gastric outlet obstruction (GOO) due to caput pancreatic cancer during COVID-19 pandemic

Background: Pancreatic cancer is associated with a poor prognosis and high cancer-related deaths in developed and developing countries because most of the patients are symptomatic until the advanced stage. A small percentage of pancreatic cancer could develop gastric outlet obstruction (GOO) when the tumor causes intestinal obstruction. This case report aimed to highlight the palliative management of GOO due to caput pancreatic cancer. Case presentation: A 48 years-old male was admitted to Dr Soetomo General Academic Hospital in Surabaya during coronavirus disease 2019 (COVID-19) pandemic with complaint of severe heartburn and pain for the last two months with lump around the upper right abdomen. The pain was not related to diet and only slightly relieved by pain relievers and ulcer medication. The patient also complained of nausea and vomiting after eating and drinking with significant weight loss. Unclear borders mass was palpable. The magnetic resonance imaging (MRI) of upper abdomen yielded the mass of head pancreatic that invaded the duodenum, the involvement of the superior mesenteric artery and multiple lymphadenopathies in the paraaortic. Pathology examination confirming the malignant, ductal adenocarcinoma. With other examinations, the patient was diagnosed as GOO due to T4N1M0 head pancreatic cancer. The tumor was unresectable. The patient underwent urgent double bypass biliodigestive laparotomy as part of palliative management. loop gastrojejunostomy, cholecystectomy and choledocujejunostomy Roux en Y was performed. Celiac plexus block was performed to reduce the cancer pain in the patient. Conclusion: This case highlights that the GOO case's selected management depends on the stage disease and evaluation of multidisciplinary involvement even in the COVID-19 pandemic. Therefore, collaboration between surgeons, medical oncologists, gastroentero-hepatologist, radiologists, and supportive and palliative care specialists is required to reduce mortality.

Metastatic Small Cell Lung Cancer Presenting as Acute Appendicitis: A Case-Report

Introduction and Importance: We present a case of extensive stage small cell lung cancer presenting as perforated appendicitis secondary to an appendiceal metastasis. This is a rare presentation with only 6 reported cases in the literature. Surgeons must be aware of unusual causes for perforated appendicitis as in our case the prognosis can be dire. Case Presentation: A 60-year-old man presented with an acute abdomen and septic shock. Computed tomography demonstrated perforated appendicitis and a widespread malignant process initially suspected as colonic origin malignancy. Urgent laparotomy and a subtotal colectomy was performed. Further imaging suggested the malignancy was secondary to a primary lung cancer. Histopathology demonstrated a ruptured small cell neuroendocrine carcinoma in the appendix with TTF1 positive immunohistochemistry. Unfortunately, the patient deteriorated due to respiratory compromise and was palliated on day 6 postoperatively. Discussion: The appendix is a rare site for metastasis of lung cancer and these metastases usually present as acute perforated appendicitis. Distinguishing the site of the primary tumor can be difficult when there is extensive metastatic disease, and this differentiation relies on immunohistochemistry. In our case the patient was managed surgically, however rapidly deteriorated post operatively from multi-organ metastatic disease. This demonstrates the diagnostic challenges in metastatic small cell lung carcinoma presenting as an acute appendicitis as well as the poor prognosis with advanced disease. Conclusion: Surgeons should consider a broad differential diagnosis for the cause of acute perforated appendicitis as this can rarely be due to a secondary metastatic deposit from a widespread malignant process.

Emphysematous gastritis in a patient with neutropenic sepsis: A case report and literature review with comment on management.

Emphysematous gastritis is a severe form of gastritis caused by gas-forming infectious organisms and is most frequently encountered in critically unwell patients. Diagnosis rests on the radiographic appearances of air within the gastric wall, which may extend into the portal venous system. Not previously described in the context of neutropenic sepsis, our case involves a 77-year-old patient with emphysematous gastritis who was admitted to the intensive care unit with a neutrophil count of 0.1 × 109/L and managed successfully with conservative treatment. Presenting complaints usually include abdominal pain, nausea, vomiting and occasionally haematemesis, in the context of systemic upset. Predisposing factors may include diabetes and immunosuppression, ingestion of corrosive substances, alcohol abuse, and abdominal surgery. The historical approach to management which previously involved urgent exploratory laparotomy with gastrectomy, has largely been replaced with conservative therapy, including broad-spectrum antimicrobials, gut rest and parenteral nutrition, with improved outcomes. Previously considered a commonly terminal diagnosis with mortality rates as high as 60%, this recent shift in approach to management has contributed to mortality rates being halved. The role of oesophago-gastro-duodenoscopy has not been established and is unlikely to be indicated in every case. Longterm complications may be of concern and include fibrosis and gastric contractures.

Vesical Explosion during Transurethral Resection of Prostate: A dreadful Complication associated with Common Endoscopic Procedure

Vesical explosion during transurethral resection of the prostate (TURP) is an extremely rare, serious and dreadful complication, which should be considered as a blast injury requiring urgent exploratory laparotomy and repair. Until 2019, only 38 cases have been reported in the International English literature. The underlying mechanism for this rare intravesical explosion is the generation and trapping of explosive gases under the dome of the bladder, which eventually detonates by sparks from the cutting electrode during TURP. Herein, we report a case of a 67- years- old man where an explosion occurred during TURP, resulting in a large intraperitoneal rupture of the urinary bladder. After confirmation of the diagnosis clinically, endoscopic ally and radio logically the patient underwent a successful emergency laparotomy to repair the bladder tear. He had uneventful postoperative recovery and he is symptoms free at 6months and one year of follow-up. Although uncommon, vesical explosion during TURP may occur and some preventive measures, discussed here, can be carried out to avoid this dreadful complication. In addition to the discussion of its mechanism, we will discuss the preventive measures of this dreadful event. To the best of our knowledge, this is the first case of a Vesical explosion reported in our department.