Enteroatmospheric fistulas - the challenge of the open abdomen

Introduction: In the past two decades, the open abdomen (OA) technique has gained wide popularity as an effective approach in the cases with severe peritonitis, abdominal compartment syndrome and critical trauma. However, it is still associated with high complication rate. Enteroatmospheric fistulas are the most devastating complication. Despite the numerous techniques described in the literature, their management remains a challenging task.Material and methods: The present study analyses the frequency of enteroatmospheric fistulas in two cohorts managed by open abdomen and discussed the results from their treatment in the V.A.C. group. The first cohort includes 69 consecutive patients temporarily closed by V.A.C. abdominal dressing, whereas the other one encompasses 83 patients treated by mesh-foil laparostomy. The fistula effluent was isolated by 10 ml syringe barrel according to the technique of Verhaalen.Results: Overall, 5/69 (7.2%) fistulas were identified. All were high output (>500 ml) small bowel fistulas. One patient died before fistula closure (25%, 1/5). A controlled enterocutaneous fistula was achieved in 2 patients and spontaneous closure in one. In one case an extensive small bowel resection due to intractable ileus was performed. The mean ICU and hospital stay in the fistula group were 15.2 (7-28) and 55.6 (32-84) days versus 8.2 (2-30) and 16.7 (3-84) respectively.Conclusion: The enteroatmospheric fistulas are the most dangerous complication of the open abdomen. The best treatment is their isolation combined with V.A.C. at the early stages and resection with primary anastomosis after 3-12 months

Ingested fork impacted in stomach - challenge for risky endoscopy or primary surgery

The ingestion of metallic (radiopaque) foreign bodies remains a common problem amongst prison population. A 34-year-old male prisoner swallowed a dinner fork in an attempt to escape justice. Attempts for endoscopic extraction were unsuccessful. The patient underwent laparotomy and via gastrotomy a 15-cm length fork was removed. Based upon our previous experience, we recommend immediate surgical removal if the attempt for endoscopic retrieval had failed. Prevention measures in prison inmates may significantly decrease the incidence rate

Pseudomyxoma peritonei - a report of two cases and a review of the literature

Introduction: PMP is a rare disease with a slow but progressive course leading to death. According to the literature PMP encompass wide variety of conditions. To avoid the confusion and to facilitate the treatment and comparison of the results several authors suggested that the term `PMP` should include only the cases with appendiceal origin.Case report: We report two cases with low-grade paseudomyxoma peritonei. The first case was managed by debulking surgery alone with survival 2 years. The second case underwent complete cytoreduction plus HIPEC and 3 years later is still alive and free of disease. There was one patient with a benign appendiceal mucocele treated by appendectomy, who is free of disease 3 years later.Introduction: PMP is a rare disease with a slow but progressive course leading to death. According to the literature PMP encompass wide variety of conditions. To avoid confusion and to facilitate treatment and comparison of the results several authors suggested that the term `PMP` should include only the cases with appendiceal origin.Case report: We report two cases with low-grade paseudomyxoma peritonei. The first case was managed by debulking surgery alone with survival 2 years. The second case underwent complete cytoreduction plus HIPEC and 3 years later is still alive and free of disease. There was one patient with a benign appendiceal mucocele treated by appendectomy, who is free of disease 3 years later.Conclusion: Despite the high complication rate, cytoreductive surgery with HIPEC remains the gold standard in the treatment of pseudomyxoma peritonei. The tumor grade and completeness of cytoreduction are the main prognostic factors. Due to the rarity of the condition most of the surgeons are not experienced enough to manage these patients. Additionally, the incomplete cytoreduction is associated with poorer prognosis and significantly hampers the subsequent interventions. Thus, in the cases when it is found incidentally, the best strategy is the taking of biopsy, appendectomy and subsequent referral to a specialized center for a treatment by multidisciplinary team

Total parenteral nutrition-induced Wernicke's encephalopathy after oncologic gastrointestinal surgery

AbstractCarl Wernicke described the disease bearing his name in 1881 and reported three cases characterized by the presence of mental confusion, ataxia, and ophthalmoplegia. Wernicke's disease is mainly observed in alcoholic patients, due to decreased vitamin intake as a consequence of an unbalanced diet, and a reduction of absorption due to the effects of alcohol. Likewise, inadequate vitamin intake is prevalent in older patients. Wernicke's encephalopathy due to inappropriate total parenteral nutrition (TPN) occurs infrequently; recently, there is an increase in the literature concerning Wernicke's encephalopathy in patients after general and bariatric surgeries. We present two cases of Wernicke's encephalopathy after oncologic gastrointestinal surgery by failure to administer vitamin B1 during TPN; to our knowledge, these are the first two cases of Wernicke's encephalopathy after colorectal surgery for cancer. In our opinion, timely diagnosis and treatment are mandatory to avoid nonfunctional recovery and consequent malpractice legal actions as well as an increase in the health-care costs correlated with the prolonged hospital stay and with the nonfunctional recovery

Negative pressure wound therapy versus healing by secondary intention in pressure ulcers

Pressure ulcers are a highly prevalent source of morbidity with an equally high incidence of up to 38.0\% amongst different categories of healthcare institutions. Therefore, the management and therapeutic approach toward these often hospital- or facility-acquired problems remain critical aspects of long-term care. Negative pressure wound therapy (NPWT) has proven effective in addressing the barriers to pressure ulcer healing including increasing blood flow to previously ischemic wound areas by generating subatmospheric pressure which vacuums in circulation. The objective of this study was to compare negative pressure wound therapy (NPWT) versus surgical wounds healing by secondary intention (SWHSI). A systematic literature search was conducted using the PubMed and Scopus search engine up until the 20 Th January 2017 including the terms: "negative pressure wound therapy" and "pressure ulcers". In this systematic review, six randomized controlled trials were included. NPWT is deemed appropriate and effective method and widely used by clinicians to promote the healing of wounds and ulcers of different etiology. The heterogeneity found in individual trials regarding the inclusion criteria, therapeutic procedures, the criteria and methods of outcome evaluation, however, did not allow for a data evaluation with statistically valid conclusions. It is reasonable to assume that their subset of patients with pressure ulcers that can be effectively treated with NPWT, with optimal results and good cost-benefit ratio, also with respect to the quality of life

Surgical treatment of gastrointestinal stromal tumors of the duodenum. A literature review

Background: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4–5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment. Methods: An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST. Results: Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections). Conclusions: dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1–2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided

Perirectal hematoma after stapled surgery for hemorrhoidal prolapse and obstructed defecation syndrome: case series management to avoid panic-guided treatment

Perirectal hematoma (PH) is one of the most feared complications of stapling procedures. Literature reviews have reported only a few works on PH, most of them describing isolated treatment approaches and severe outcomes. The aim of this study was to analyze a homogenous case series of PH and to define a treatment algorithm for huge postoperative PHs. A retrospective analysis of a prospective database of three high-volume proctology units was performed between 2008 and 2018, and all PH cases were analyzed. In all, 3058 patients underwent stapling procedures for hemorrhoidal disease or obstructed defecation syndrome with internal prolapse. Among these, 14 (0.46%) large PH cases were reported, and 12 of these hematomas were stable and treated conservatively (antibiotics and CT/laboratory test monitoring); most of them were resolved with spontaneous drainage. Two patients with progressive PH (signs of active bleeding and peritonism) were submitted to CT and arteriography to evaluate the source of bleeding, which was subsequently closed by embolization. This approach helped ensure that no patients with PH were referred for major abdominal surgery. Most PH cases are stable and treatable with a conservative approach, evolving with self-drainage. Progressive hematomas are rare and should undergo angiography with embolization to minimize the possibility of major surgery and severe complications

Colorectal resections - clinical and immunological results

INTRODUCTION: Surgery induces a generalized state of postoperative immunosuppression responsible for a lot of complications in postoperative period. Magnitude and type of the intraoperative injury depend on the extent and duration of postoperative immune suppression. This study compared clinical outcomes and immune changes after minimally invasive and open colorectal resections in patients with colorectal cancer (CRC).MATERIAL AND METHODS: Study included 40 patients with CRC who underwent colorectal resections in our clinic last year. Twenty one of them underwent minimally invasive surgery, with a mean age of 64.8 years (49-86). The rest 19 patients underwent conventional surgery, with a mean age of 66.2 years (56-84). Blood tests were performed 24 hours prior to surgery, 24 hours and 7 days after surgery. Analysis included full blood count, total protein, albumin and markers of inflammation (CRP, ESR, fibrinogen). T- (CD3+), B- (CD19+) and NK-cell lymphocyte populations were studied by means of flow cytometry, as well as activation of leucocytes, according to the expression of HLA-DR, CD38, CD279, CD163 and some clinical parameters. All data were analyzed using SPSS version 21.RESULTS: There was no significant difference in preoperative results between minimally invasive group and conventional group. At 24 hours after surgery there were significant decrease in lymphocyte percentages and increased leucocyte count, granulocyte percentages and CRP levels in conventional group. This ratio maintained at 7 days after surgery. Activated monocyte (CD 163+), total protein and albumin, eosinophiles, percentage of monocytes, lymphocytes and NKT-cells (CD3+ CD16/CD56+) were significant decrease in conventional group compared with minimally invasive group at first postoperative day.CONCLUSIONS: Minimally invasive colorectal cancer resection is a technically feasible option, with comparable results in terms of oncologic clearance, lesser degrees of tissue injury, surgical metabolic stress, and immunosuppressive response to conventional open surgery. Patients undergoing minimally invasive resections demonstrated improved clinical recovery and shorter hospital stay than patients undergoing open surgery. 

Cystic Echinococcosis of the Breast - Diagnostic Dilemma or just a Rare Primary Localization

Introduction: Although the liver and lung are the most frequently affected organs in cystic echinococcosis, the cysts may develop in any viscera and tissues. Breast is a rare primary localization with few cases described in the literature. We present an updated and systematic review and discuss the possible mechanisms of spreading, diagnostic and treatment options.Materials and methods: We performed a literature search in PUBMED using the key words ‘hydatid disease’, ‘cystic echinococcosis’ and ‘breast echinococcosis’ without time limitation. Only studies reporting breast cystic echinococcosis were included.Results: Overall, 121 cases with cystic echinococcosis and 2 with alveolar echinococcosis were reported. A total of 52 cases were included in the analysis. The mean size of cysts was 5.5 cm (range 1.7-12). The most common clinical presentation was painless lump presented from 4 months to 19 years before the final diagnosis. Most cases had isolated breast CE, few cases had synchronous localizations – femoral, thigh and lung, and previous liver CE. Most were active CL and CE1-2 cysts (72%). Ultrasound was used in 83%, followed by mammography (35%). Fine needle aspiration was reported in 27 cases with positive finding in 59%.Conclusions: In cases with cystic breast lesions from endemic regions we recommend the US as a gold standard. CT and MRT are more accurate but expensive tools without the potential to change the surgical tactic. In contrast to the other localizations of CE, complete excision of the cysts is the best diagnostic and treatment approach

GASTRIC ULCER PENETRATING TO THE DUODENOJEJUNAL FLEXURE – MANAGEMENT AND PITFALLS. CASE REPORT AND REVIEW OF THE LITERATURE

Introduction: The penetration into adjacent organs is a classical complication of peptic ulcer despite being less frequent than the other complications. The current work presents a rare case of gastric ulcer penetrating the duodenojejunal flexure and discusses the diagnostic difficulties, pitfalls, and current treatment strategy. Case report: A 63-years-old woman was admitted complaining of intermittent black stools defecations, and a weight of 44 kg. The referral gastroscopy revealed a 10 cm ulcer on the posterior wall of the stomach. The histology demonstrated severe gastritis with atypical cells. The hemoglobin level was 88g/l. The patient was scheduled for elective resection for suspected gastric cancer. The intraoperative finding was completely different – there was an ulcer approximately 4-5 cm in diameter infiltrating the transverse mesocolon and duodenojejunal flexure. The case was considered T4 cancer and we decided against elective gastrectomy. The postoperative CT showed an ulcer penetrating the duodenojejunal flexure. The second gastroscopy found an ulcer with a size of 3-4 cm. The multiple biopsies showed exacerbated chronic peptic ulcer with H. pylori infection, which was treated with proton pump inhibitors and antibiotics. The follow-up gastroscopy four months later demonstrated shrinkage of the ulcer to 15 mm with complete epithelization. One year later she gained 23 kg and was free of complaints. Conclusion: Penetration and fistulization to the duodenojejunal flexure are uncommon but possible complications of peptic ulcer disease. They are not an absolute indication for surgery. Decision-making should take into account the clinical presentation, patient age, and comorbidity