In the Death of a Phoenix

The male form classically elicits thoughts of certain characteristics, including strength, security, power, all of which lie deep within a hardened outer shell. But on closer inspection there is something much more primal to the nature of a man . Man tends to fall short of their female counterparts when it comes to understanding and verbalizing their emotions. Thus they are faced with strange tumultuous insecurities, fears, judgements, and expectations, with no way to express the struggles they may face within themselves. Man has many stories to tell, but lacks the language to begin speaking. This poem is the closest I came to finding words for these primal emotions

Colo-cutaneous fistula following A pull-through for Hirschsprung disease, A case series

Introductions: Three patients presented with a colo-cutaneous fistula from the neo-rectum to previous laparoscopic port sites, following an otherwise technically correct pull-through for Hirschsprung disease. We evaluated each case to provide guidance to pediatric surgeons on how to avoid this previously unreported complication. Case presentation: All three patients were male and had a laparoscopic-assisted pull-through for Hirschsprung disease as neonates. All patients underwent intra-operative colonic biopsies above the transition zone, that were closed using an Endoloop ligature (Ethicon), which later proved to be the source of the fistula. The fistulas manifested at variable times: ten days, six months, and five years after the index pull-through. Clinical findings were skin changes, abscess or drainage at previous laparoscopic port sites. Contrast studies were performed to diagnose the underlying pathology. Two patients had primary fistula closure with a diverting ileostomy, followed by ileostomy closure. One patient with delayed symptom presentation had a temporary ileostomy, redo pull-through, and ultimately an ileostomy closure. All three patients recovered without long term sequelae. Conclusion: The technical error in all of these cases was the utilization of an endoloop ligature for the biopsy site. Furthermore, when the biopsy is taken above a transition zone, it can be postulated that the increased physiologic back-pressure from the sphincter could lead to fistula development and propagation. As more cases are performed with minimally invasive techniques, we must be adamant about evaluating for new, previously un-encountered complications such as this one. An adequate closure of the full-thickness biopsy site could prevent this complication

Asymptomatic Intestinal Malrotation Progressing to Midgut Volvulus in a Decompensated Alcoholic Cirrhotic Adult: A Rare Scenario Requiring Special Considerations

Intestinal malrotation usually presents in the pediatric population with midgut volvulus requiring emergency Ladd’s procedure. Rarely, it remains asymptomatic and is discovered incidentally only during adulthood when it seldom causes intestinal complications. The scenario of a cirrhotic adult being diagnosed with asymptomatic intestinal malrotation with subsequent intestinal complications is thus extremely rare and to our knowledge has not been previously reported. We describe a 56-year-old man with decompensated alcoholic cirrhosis (Child-Pugh class C, MELD score 22) who was initially observed after an incidental diagnosis of intestinal malrotation on computed tomography. Observation continued as his liver disease improved with alcohol cessation (Child-Pugh class A, MELD score 8). He later presented with a closed loop bowel obstruction secondary to midgut volvulus at the time of alcohol relapse and liver redecompensation (Child-Pugh class C, MELD score 22-29). He underwent emergency Ladd’s procedure during which his midjejunum was volvulized into an internal hernia space created by a thick Ladd’s band containing large varices. The postoperative course was complicated by ileus and loculated bacterial peritonitis. Based on our experience, we discuss special considerations with regard to the surgical technique and timing of Ladd’s procedure when encountering intestinal malrotation in a cirrhotic adult with portal hypertension