OPTIMAL SURGICAL METHOD SELECTION IN PATIENTS WITH ACUTE POSTOPERATIVE PERFORATING ULCERS OF THE SMALL INTESTINE

Blunt abdominal trauma is not uncommon, but traumatic small intestine perforation in the incisional hernia is very rare. Diagnosis is sometimes difficult. We present a patient who had undergone surgical resection of gastrointestinal stromal tumor (GIST) and sustained an incisional hernia with a segment of intestine falling into the right lower quadrant of the abdomen. He was kicked over the hernia and then sustained progressive severe pain. At the emergency department, an impression of peritonitis was made, and bladder rupture was highly suspected after obtaining an abdominal CT scan. Small intestine perforation was confirmed during emergency laparotomy. Due to lack of protection by the intact belly, the small intestine in the hernia sac is vulnerable to injury under direct contusion. Besides, accumulation of the intestinal content around the lower abdominal cavity may mask the manifestations of perforation and lead to the misdiagnosis of urinary bladder rupture. Therefore, one should be aware that hernia is a risk factor of small intestine perforation. Physicians should not forget the possibility of the risk of small intestine perforation in patients with hernia who sustain blunt abdominal contusion.

Factors Associated With Incomplete Colonoscopy: A Population-Based Study

Abusive parents often report that a fall on stairs resulted in their children's injuries. This review explores whether there is any evidence in the medical literature that a fall on stairs could be a plausible explanation for a small intestine perforation. The English-language medical literature was searched by Medline, for a 29-year period (1970-1998), for reports of the types of injuries sustained in falls on stairs and for reports of the types of blunt abdominal trauma that result in small intestine perforations. Articles that exclusively focused on infant walker injuries or the elderly were excluded. Duodenal, jejunal, and ileal perforations were included, whereas intestinal hematomas and undescribed intestinal injuries were excluded. All types of injuries to the stomach, colon, and rectum were excluded. Falls on stairs were not reported to be a cause for any of the 312 cases of small intestine perforations reviewed. There were no reports of any intraabdominal injuries, including small intestine perforations, in any of the 677 cases of falls on stairs reviewed. Falls on stairs rarely resulted in any type of truncal injury. Although falls on stairs have been reported to be the most common cause of injury in childhood, no evidence was found to support the contention that an unobstructed fall on stairs could be consistent with perforation of the small intestine.

Background: For patients with locally advanced rectal cancer, side effects such as nausea, vomiting and loss of appetite may occur during neoadjuvant chemotherapy, but small intestinal perforation is very rare. Case: We present a case of a 62-year-old man who suffered small intestinal perforation in the first cycle neoadjuvant treatment of locally advanced rectal cancer with capecitabine and oxaliplatin. Six days after the start of neoadjuvant chemotherapy, he began to develop intermittent abdominal pain, accompanied by diarrhea and abdominal distension. The CT scan revealed an abscess with free air in the pelvic cavity with proximal intestinal ileus. Then we performed a laparotomy. After enterolysis, the rectum with tumor was carefully examined with no perforative lesion, and the terminal ileum about 15cm from the ileocecum which adhere to the pelvic abscess had one about 0.8cm ulcer. The patient had a radical anterior resection and the morbid small bowel resection with protective ileostomy. The postoperative pathological examination showed the full-thickness necrosis of the intestinal wall in the ileal lesion with peripheral acute suppurative inflammation. AND the final pathological stage of the tumor was pT3N0M0 (American Joint Committee on Cancer, eighth edition). Conclusion: As a chemotherapy regimen based on fluorouracil and oxaliplatin, small intestinal perforation is a very rare complication. The most common complications of these two drugs are gastrointestinal symptoms such as diarrhea. Therefore, when the complications are not relieved during chemotherapy, we should think of a more serious possibility

Background. The goal is to demonstrate the possibilities of using various methods to stop bleeding from the liver due to a thoracoabdominal gunshot wound. Materials and methods. Male patient aged 25 years was wounded in the chest during mortar shelling. An hour after the wound, he was taken to the advanced surgical group in serious condition, and the right thoracocentesis, drainage of the pleural cavity according to Blau, and primary surgical treatment (PST) of the wounds were performed. After 2 hours, the patient was taken to the Military Medical Clinical Center of the Northern Region of the Military Medical Service of the Armed Forces of Ukraine, and hospitalized in the emergency department. The diagnosis was: combined gunshot shrapnel wound of the chest, abdomen, and extremities. Blind thoracoabdominal wound on the right with a comminuted fracture of the VIII rib, damage to the lower lobe of the right lung, right lobe of the liver, right kidney with the presence of a foreign body (metal fragment) in the retroperitoneal space. Right-sided hemopneumothorax, pneumonitis. Hemoperitoneum. Blind wound of the soft tissues of the right shoulder and the presence of a foreign body (metal fragment). Operations: thoracocentesis, drainage of the right pleural cavity according to Blau. PST of gunshot wounds. The patient was examined, laboratory tests were performed: general clinical blood, urine tests, biochemical blood test, blood coagulogram, blood group and Rh factor, thromboelastography, blood electrolytes, alkaline-base composition and blood gases, ultrasound examination of the chest and abdominal organs according to the FAST protocol, multislice computed tomography (MSCT) of the head, chest, abdominal organs and pelvis with and without contrast, radiographic examinations of the head, chest and abdominal organs, electrocardiography, angiographic diagnosis and final stoppage of bleeding, removal of a foreign body using a multifunctional magnetic instrument for the diagnosis and removal of metallic ferromagnetic foreign bodies. Hemostasis from the liver wound was achieved by suturing the liver wound, Pringle maneuver, tamponade with gauze, using a Bowa ARC 303 high-frequency electrosurgical device, an isolated output electrosurgical generator Valleylab™ LS10, and a Medtronic AEX™ generator Aquamantys. Surgical interventions were performed using the (DCS) technique. Results. Upon admission, chest and abdominal ultrasound using the FAST protocol was done: fluid in the right pleural cavity and abdominal cavity. MSCT of the head, chest, abdominal organs and pelvis was also performed, which revealed a gunshot fracture of the right VIII rib, post-traumatic pneumonitis of the lower lobe of the right lung, signs of damage to Sg6, Sg7, Sg8 of the liver, gauge in the liver, foreign body (metal fragment) in the area of the upper pole of the right kidney, pleural drainage in the pleural cavity, signs of small hemopneumothorax, signs of hemoperitoneum. On the first day, 3 hours after the injury, DCS I was performed. Laparotomy, revision of the abdominal organs and the right extraperitoneal space. Atypical resection of Sg6, Sg7, Sg8 of the liver. Suturing and hemostasis of the liver. Suturing of the right dome of the diaphragm. Removal of a foreign body (metal fragment) using a multifunctional magnetic instrument for the diagnosis and removal of metal ferromagnetic foreign bodies. “Sandwich” liver tamponade. Suturing of the upper pole of the right kidney. Sanitation and drainage of the abdominal cavity. Closed laparostomy. Revision of the abdominal organs, hemostasis and suturing of the liver, “sandwich” liver tamponade, sanitation and re-drainage of the abdominal cavity. Closed laparostomy. The diagnosis was established: combined gunshot shrapnel wound of the chest, abdomen, and extremities. Blind thoracoabdominal wound on the right with a comminuted fracture of the VIII rib, damage to the lower lobe of the right lung, right lobe of the liver (AAST IV), right kidney (AAST III) with the presence of a foreign body (metal fragment) in the retroperitoneal space. Right-sided hemopneumothorax, pneumonitis. Hemoperitoneum. Blind wound of the soft tissues of the right shoulder and the presence of a foreign body (metal fragment). Operation: thoracocentesis, drainage of the right pleural cavity according to Blau. PST of gunshot wounds. Signs of intra-abdominal bleeding appeared the next day with blood being removed from the abdominal cavity through drainage. MSCT of the head, chest, abdominal and pelvic organs with contrast was performed, signs of extravasation of contrast material into the abdominal cavity were detected. The next day, due to the presence of intra-abdominal bleeding from the liver, a re-look, revision of the abdominal organs, hemostasis and re-tamponade of the liver, sanitation, re-drainage of the abdominal cavity, and laparostomy were performed. Twelve hours after a re-look, intra-abdominal bleeding relapsed. The operation was performed: revision of the abdominal organs, hemostasis and re-tamponade of the liver, sanitation, re-drainage of the abdominal cavity, laparostomy. A day after the injury, endovascular embolization of the branches of the right hepatic artery was performed due to recurrence of intra-abdominal bleeding from the liver. Diagnostic angiography of the liver vessels was performed, during which the source of bleeding was identified as a pseudoaneurysm from one of the branches of the right hepatic artery. The right hepatic artery originates from the superior mesenteric artery. Superselective catheterization of the damaged branch of the right hepatic artery and its embolization were performed. Hemostasis was achieved. Two days after the injury, a re-look, revision of the abdominal organs, liver detamponade, sanitation, re-drainage of the abdominal cavity, and a closed laparostomy were performed. Four days after the injury, left re-thoracocentesis and drainage of the pleural cavity according to Blau were conducted due to an increase in the amount of fluid in the pleural cavity. On the fifth day after the injury, the patient was transferred to the next level of medical care. It is known that subsequently, on the 10th day, an atypical liver re-resection was performed with laparostomy closure, and the patient was discharged on the 21st day with presentation to the military medical commission and provision of sick leave for 30 calendar days. Conclusions. The presented clinical case of endovascular hemostasis in the comprehensive treatment of gunshot wounds of the liver complicated by abdominal bleeding using the damage control surgery against the background of anatomical features of the right hepatic artery origin showed its high effectiveness.

Rates of New or Missed Colorectal Cancers After Colonoscopy and Their Risk Factors: A Population-Based Analysis

Small intestine perforation in a 58-year-old man with Darier disease after 25 months of oral acitretin therapy

A case of an abdominal actinomycosis, seen in a 41-year-old woman, which concurred small intestine perforation suspected to be the result of a fishbone. The patient complained of able tender mass in the right lower quadrant. Explorative laparotomy was performed under a diagnosis of localized abscess. An inflammatory tumor of small intestine mesentery involving the distal ileum and cecum was treated by ileocecectomy. The resected specimen showed small intestine perforation with abscess, which was histologically diagnosed as actinomycosis but we were not able to find any fishbones. We will discuss possible pathogenesis and the therapeutic modalities.

The Effect of Complexity of the Surgical Field on Perioperative Outcomes of Robot-Assisted Radical Cystectomy

BACKGROUNDGastric mucosal heterotopia (GMH) is a rare, typically asymptomatic condition characterized by ectopic gastric mucosa in tissues outside the stomach. However, it can lead to severe complications, including small intestinal perforation. This case report highlights the unique clinical presentation of GMH-induced recurrent small intestinal perforations, which has been rarely documented. These findings emphasize the importance of considering GMH in patients with unexplained recurrent gastrointestinal perforations.CASE SUMMARYA 13-year-old female presented with acute abdominal pain. Her medical history included four prior surgeries for small intestinal perforations. Enhanced computed tomography revealed localized bowel thickening and perforation, prompting emergency surgery. A 20 cm segment of the ileum was resected and anastomosed. Pathological analysis confirmed extensive GMH with ulceration and perforation, identifying GMH as the cause of the recurrent perforations. Postoperatively, the patient recovered well with no recurrence by the 10-month follow-up.CONCLUSIONGMH should be considered in cases of recurrent unexplained intestinal perforations.

Effective treatment with mepolizumab in a patient with severe eosinophilic granulomatosis with polyangiitis complicated with small intestine perforation

With the widespread application of acupuncture, there is growing concern about the adverse events (AEs) related to therapy. Acupuncture can result in severe life-threatening AEs in very rare cases, so there are important clinical implications of identifying and reporting the cause of AEs to prevent similar incidents in the future. Herein, we report a rare life-threatening case of small intestine perforation caused by acupuncture. A 71-year-old man was transferred to our emergency department for further treatment due to intestine obstruction with a giant abdominal wall hernia. Before admitting to our hospital, the patient had previously been treated with acupuncture and the acupoints were located on the abdomen and limbs. In view of progressively worsening abdominal pain and intra-abdominal infection, he underwent an emergency exploratory laparotomy. Intraoperative findings confirmed that four perforations of the small intestine were caused by acupuncture. This case report demonstrates that abdominal acupuncture in patients with concurrent intestinal obstruction and a giant abdominal wall hernia carries an extreme risk of iatrogenic bowel perforation, due to the loss of normal anatomical safeguards. Therefore, in this specific high-risk scenario, abdominal needling should be approached with extreme caution or considered contraindicated. Meticulous pre-treatment anatomical assessment is imperative to prevent this life-threatening complication.

Bilateral ligation of the internal iliac arteries has been reported to be a safe procedure in pelvic surgery because there are five collateral pathways. Some of the five pathways are surgically interrupted after resection of the rectum and two cases in which necrosis developed in the perineum were reported. The aim of the study was to assess the degree of safety and blood flow reducing efficacy of internal iliac artery ligation in rectal cancer surgery. The subjects were 23 patients with advanced rectal cancer. Tissue blood flow on the surface of the bladder was measured using a laser Doppler flow meter when unilateral or bilateral internal iliac artery were clamped at a central site or at a peripheral site. Tissue blood flow of the bladder before clamping the internal iliac artery was 6 to 74 ml/min/100 g. Blood flow in the right half of the bladder decreased significantly when the right and both internal iliac arteries were clamped (both, P < 0.01), but it did not decrease significantly when only the left internal iliac artery was clamped. The results were the same whether the central site or peripheral site was clamped. When the central site was clamped, there was no difference between the decrease in blood flow in the right half of the bladder whether the right internal iliac artery was clamped or both internal iliac arteries were clamped. By contrast, when the peripheral site was clamped, the decrease in blood flow in the right half of the bladder was much greater when both internal iliac arteries were clamped than when the right internal iliac artery alone was clamped (P < 0.01). The results in the left half were the same as in the right half. Blood flow became 33 to 110 (mean, 73; median, 75) percent of the value before clamping when both internal iliac arteries were clamped at the central site, and 18 to 114 (mean, 52; median, 47) percent when both internal iliac arteries were clamped at the peripheral site. No changes in the color of the bladder or other pelvic organs were observed while the internal iliac arteries were clamped. Our study suggests that bilateral internal iliac artery ligation causes a temporary decrease in blood flow to the pelvic organs, but the reduction is not great enough to induce necrosis histologically. We recommend the ligation of the internal iliac arteries at the point below the takeoff of the superior gluteal artery to gain a considerable blood flow reducing effect on the pelvic organs.

Introduction: Postoperative adhesions are indeed a significant concern following abdominopelvic surgeries. These fibrous bands of tissue can form between abdominal or pelvic organs and tissues, leading to various complications. Postoperative Peritoneal Adhesions (PPAs) barriers are safer and better because they lower the risk of illness and the need for repeated interventions. Various agents and techniques have been studied to prevent PPAs, including activating fibrinolysis, interrupting blood coagulation, inhibiting collagen synthesis, reducing cellular inflammatory responses, and creating a physical barrier between the wound and surrounding tissue or organ. Seprafilm acts as a physical barrier on wounded tissue surfaces, minimising tissue adhesions during wound healing. Aim: To compare the outcomes of patients undergoing abdominopelvic surgery with and without Seprafilm application, in terms of adhesion formation and complication rates. Materials and Methods: The present prospective interventional study was conducted at SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India, from July 2023 to December 2024. In this study, group A, 50 patients underwent surgery with the use of Seprafilm, while group B (50 patients) underwent surgery without the use of Seprafilm. The outcomes measured were: postoperative complications, 20th day adhesions as seen in CT abdomen, postoperative pain, and intraoperative blood loss. Blood loss was estimated using a Gauze Visual Analogue (GVA), and pain was estimated using a visual pain analogue. Results: Among the 100 patients, the mean age was 44 years in group A and 45 years in group B, and among the gender distribution, group A had 21 males and 29 female patients, group B had 23 males and 27 female patients. A total of 42 patients (42%) belonged to the age group of &lt;40 years, of which 22 patients (44%) belonged to group A and 20 patients (40%) belonged to group B. In the present study, 10 patients developed postoperative complications in group A and 22 patients developed postoperative complications in group B (p-value=0.010). A total of 34 patients had developed adhesions, among which 8 (23.5%) patients belonged to group A and 26 (76.5%) belonged to group B (p-value=0.001). Conclusion: In this study, the group that used seprafilm as an adhesion barrier following abdominopelvic surgeries had a significant reduction in the incidence of postoperative adhesions compared to the group in which an adhesion barrier was not used.

This is a truly comprehensive textbook that covers the whole spectrum of female pelvic medicine and reconstructive surgery (FPMRS). It starts with reviewing the history of female pelvic surgery, gynecology, and female urology. This is a nice setup for covering the latest evolutions in FPMRS such as female sexual dysfunction, robotic surgery for pelvic organ prolapse, and surgical management of detrusor compliance abnormalities. The basic science part includes chapters that are dedicated to the physiology of the pelvic muscles, vagina, and anorectum. In addition, the chapter on the psychosocial impact of pelvic floor disorders provide the reasons for trying to master this difficult to learn field. A welcome addition to this edition is the step-by-step instructions on regular and video urodynamics. But perhaps more important may be the two dedicated two chapters and interspersed review of possible surgical complications and their method of management. Four chapters are dedicated to fecal incontinence and defecation disorders, and the book ends with explaining on what to use in measuring outcomes and quality of life in pelvic floor research. This book should be seriously considered by anyone involved in FPMRS.