Retroperitoneal abscess with concomitant hepatic portal venous gas and rectal perforation: a rare triad of complications of acute appendicitis. A case report

<p>Abstract</p> <p>Background</p> <p>While retroperitoneal abscess is a known complication, hepatic portal venous gas and rectal perforation have not been reported as a concomitant sequelae of acute appendicitis. Here we report a case of a patient with a perforated appendicitis that was associated with these triad of complications.</p> <p>Materials and Methods</p> <p>In addition to report our case, we carefully reviewed the literature in order to detect similar cases and the causes of such rare conditions.</p> <p>Results</p> <p>Only 26 cases (including our patient) of acute appendicitis complicated by retroperitoneal abscesses have been published in the English literature between 1955 and 2008. There was one case having hepatic portal venous gas, and one further case with a rectal perforation associated with acute appendicitis. All patients with retroperitoneal abscess presented with non specific clinic symptoms that not revealed any suspicion for such a complicated disease. Hence, delayed diagnosis and treatment are not uncommon.</p> <p>Conclusions</p> <p>So far, no patient has been described with such a triad of rare complications related to acute appendicitis. We want to emphasize the insidious onset of retroperitoneal abscess formation, and the need of prompt recognition and adequate treatment to avoid deleterious outcome.</p

Preoperative Upper Gastrointestinal Testing Can Help Predicting Long-term Outcome After Gastric Banding for Morbid Obesity

Background: Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB. Methods: Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manomatry) before GB. Results: One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P = 0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome. Conclusions: There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric bandin

A New Questionnaire for Quick Assessment of Food Tolerance after Bariatric Surgery

Background: Bariatric surgery is often associated with reduced food tolerance and sometimes frequent vomiting, which influence quality of life, but are not included in the overall evaluation of these procedures, notably the BAROS. Our aim was to develop a simple questionnaire to evaluate food tolerance during follow-up visits. Methods: A one-page questionnaire including questions about overall satisfaction regarding quality of alimentation, timing of eating over the day, tolerance to several types of food, and frequency of vomiting/ regurgitation was developed. A composite score was derived from this questionnaire, giving a score of 1 to 27.Validation was performed with a group of nonobese adults and a group of morbidly obese nonoperated patients. Patients were administered the questionnaire at follow-up visits since January 1999. Data were collected prospectively. Results: It takes 1-2 minutes to fill out the questionnaire. Food tolerance is worse in the morbidly obese population compared with non-obese adults (24.2 vs 25.2, P=0.004). Following Roux-en-Y gastric bypass, food tolerance is reduced after 3 months (21.2), but becomes comparable to that of the normal population and remains so at 1year postoperatively. Following gastric banding, food tolerance is already significantly reduced after 3months (22.3), and worsens continuously over time (19.03 after 7years). In the gastric banding population, the decision to adjust the band is based at least partially on food tolerance, and the questionnaire proved helpful in that respect. Conclusion: Our new questionnaire proved very easy to use, and helpful in day-to-day practice, especially after gastric banding. It was also helpful in comparing food tolerance over time after surgery, and in comparing food tolerance between procedures. Evaluation of food tolerance should be part of the overall evaluation of the results after bariatric surger

The Four Different Types of Internal Hernia Occurring After Laparascopic Roux-en-Y Gastric Bypass Performed for Morbid Obesity: Are There Any Multidetector Computed Tomography (MDCT) Features Permitting Their Distinction?

Background: Four different types of internal hernias (IH) are known to occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP) performed for morbid obesity. We evaluate multidetector row helical computed tomography (MDCT) features for their differentiation. Methods: From a prospectively collected database including 349 patients with LRYGBP, 34 acutely symptomatic patients (28 women, mean age 32.6), operated on for IH immediately after undergoing MDCT, were selected. Surgery confirmed 4 (11.6%) patients with transmesocolic, 10 (29.4%) with Petersen's, 15 (44.2%) with mesojejunal, and 5 (14.8%) with jejunojejunal IH. In consensus, 2 radiologists analyzed 13 MDCT features to distinguish the four types of IH. Statistical significance was calculated (p < 0.05, Fisher's exact test, chi-square test). Results: MDCT features of small bowel obstruction (SBO) (n = 25, 73.5%), volvulus (n = 22, 64.7%), or a cluster of small bowel loops (SBL) (n = 27, 79.4%) were inconsistently present and overlapped between the four IH. The following features allowed for IH differentiation: left upper quadrant clustered small bowel loops (p < 0.0001) and a mesocolic hernial orifice (p = 0.0003) suggested transmesocolic IH. SBL abutting onto the left abdominal wall (p = 0.0021) and left abdominal shift of the superior mesenteric vessels (SMV) (p = 0.0045) suggested Petersen's hernia. The SMV predominantly shifted towards the right anterior abdominal wall in mesojejunal hernia (p = 0.0033). Location of the hernial orifice near the distal anastomosis (p = 0.0431) and jejunojejunal suture widening (p = 0.0005) indicated jejunojejunal hernia. Conclusions: None of the four IH seems associated with a higher risk of SBO. Certain MDCT features, such as the position of clustered SBL and hernial orifice, help distinguish between the four IH and may permit straightforward surger

Comparison of morphological and functional alterations of human saphenous veins after seven and fourteen days of ex vivo perfusion

Résumé: L'hyperplasie intimale est un processus de remodelage de la paroi des vaisseaux qui menace la perméabilité de toute procédure vasculaire, qu'elle soit chirurgicale ou endovasculaire. Les mécanismes impliqués dans le développement de l'hyperplasie sont complexes, liés à la fois à des facteurs hémodynamiques et à des facteurs humoraux. Le modèle «idéal» pour étudier cette entité physiopathologique devrait tenir compte de ces différents facteurs. La compréhension de ces mécanismes est cruciale pour pouvoir élaborer une stratégie thérapeutique ciblée. Un système de perfusion ex vivo a été développé afin d'étudier les modifications fonctionnelles, histomorphométriques, immunohistochimiques et moléculaires de segments veineux après 7 et 14 jours de perfusion ex vivo. L'étude histomorphométrique a révélé le développement d'hyperplasie intimale à 7 et à 14 jours, ce dernier n'étant cependant statistiquement significatif qu'après 14 jours. L'expression du CD34, du facteur VIII de la coagulation, de l'alpha-actin ainsi que du MIB-1 a été démontrée dans tous les segments veineux, reflétant l'intégrité des fonctions vasomotrices et architecturales après 7 et 14 jours de perfusion ex vivo. De plus l'expression de PAI-1 était significativement augmentée après la perfusion, suggérant que la fonction endothéliale fibrinolytique pourrait être modulée dans ce modèle. Ce modèle de perfusion ex vivo permet donc de conserver l'intégrité fonctionnelle et morphologique de ces segments veineux. De plus, il permet le développement d'hyperplasie intimale jusqu'à 14 jours et pourrait être un outil déterminant pour la compréhension et le traitement de cette dernière. Abstract Intimal hyperplasia (IH) is a vessel wall remodeling pro¬cess responsible of early failure after vascular surgery or endovascular interventions. An ex vivo perfusion was used to study human venous segments regarding func¬tional, histomorphological, immunohistochemical and molecular alterations after 7 (group 1, n = 6) and 14 days (group 2, n = 6) of ex vivo perfusion. All vessel segments showed preserved smooth muscle function before and after perfusion. Histomorphometry revealed IH develop-ment which was more pronounced after 14 days rather than 7 days (p &lt; 0.05). Expression of CD34, factor VIII, a-actin and MIB-1 was demonstrated in all segments from both groups indicating that muscular and endothe¬lial integrity was preserved after ex vivo perfusion of up to 14 days. PAI-1 mRNA expression was significantly increased after perfusion (p &lt; 0.05), suggesting that the endothelial fibrinolytic function may be modulated in this ex vivo perfusion model of human saphenous veins

Abdominal Mondor disease mimicking acute appendicitis

Introduction: Mondor disease (MD), a superficial thrombophlebitis of the thoraco-epigastric veins and their confluents is rarely reported in the literature. The superior epigastric vein is the most affected vessel but involvement of the inferior epigastric vessels or their branches have also been described. There is no universal consensus on treatment in the literature but most authors suggest symptomatic treatment with non-steroid anti-inflammatory drugs (NSAIDs). Case report: We report the case of a marathon runner who presented with right iliac fossa pain mimicking the clinical symptomatology of an acute appendicitis. The history and the calculated Alvarado score were not in favor of an acute appendicitis. This situation motivated multiple investigations and we finally arrived at the diagnosis of MD. Discussion: Acute appendicitis (AA) is the most common cause of surgical emergencies and one of the most frequent indications for an urgent abdominal surgical procedure around the world. In some cases, right lower quadrant pain remains unclear in spite of US, CT scan, and exclusion of urological and gynecological causes, thus we need to think of some rare pathologies like MD. Conclusion: MD is often mentioned in the differential diagnosis of breast pathologies but rarely in abdominal pain assessment. It should be mentioned in the differential diagnosis of the right lower quadrant pain when the clinical presentation is unclear and when acute appendicitis has been excluded. Awareness of MD can avoid misdiagnosis and decrease extra costs by sparing unnecessary imaging

Preoperative upper gastrointestinal testing can help predicting long-term outcome after gastric banding for morbid obesity.

BACKGROUND: Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB. METHODS: Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manometry) before GB. RESULTS: One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P=0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome. CONCLUSIONS: There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric banding