A Case of Successful Endovascular Aortic Repair of Primary Aortoenteric Fistula Without Aortic Explantation

Purpose: The objective of this study is to report a case of a primary aortoenteric fistula successfully treated with endovascular repair without aortic explant. Case Report: A 48-year-old man presented with a 24-hour history of hematemesis and malena. A computed tomography (CT) abdomen and pelvis demonstrated a 6 cm infrarenal aortic aneurysm with periaortic stranding and contrast enhancement within the lumen of the third part of the duodenum. The patient underwent emergency Endovascular Aortic Repair (EVAR). The patient was discharged on day 8 of his admission on oral antibiotics. He returned 7 weeks postindex procedure and underwent a laparotomy with omental patch repair of the aortic defect. Intraoperative cultures grew candida albicans, and the patient was discharged on lifelong oral Fluconazole and Amoxycillin-Clavulanic Acid. At 18 months postoperatively, the patient was clinically stable with improved appearances on CT aortogram. Conclusion: We discuss the use of EVAR without aortic explant as a possible treatment option in the management of patient with primary aortoenteric fistulae. This may potentially avoid the significant morbidity and mortality associated with aortic explant in suitable candidates without perioperative signs of sepsis.

Perforated Duodenal Ulcer in a Young Nepalese Girl: An Infrequent Diagnosis for Age

Perforated duodenal ulcer (PDU) is exceedingly uncommon in children. In a child with acute abdomen and pneumoperitoneum, an appendiceal etiology is more often suspected as a likely cause. Failure or delay to diagnose a PDU can result in significant morbidity and even mortality. We report a case of acute abdomen in a girl with PDU with a successful outcome. A 12-year-old school girl presented to emergency room (ER) with acute generalized abdominal pain for 2 days. Clinical examination revealed florid peritonitis, and abdominal radiographs showed free peritoneal air. At emergency laparotomy, PDU was noted with general peritoneal contamination. Omental patch repair and continued supportive care resulted in gradual improvement. PDU is an uncommon cause of peritonitis in children and poses significant challenges in management. Strong suspicion and prompt appropriate intervention is necessary to avoid untoward outcomes.

Perforated Peptic Ulcer of the Duodenum After the Laparoscopic Roux-en-Y Gastric Bypass

Perforated ulcers of the gastric remnant and duodenum seem to be a rare complication after a Roux-en-Y gastric bypass. Diagnosis of this complication can be difficult given a vague presentation, however, early intervention is critical to prevent further morbidity. We present the case of a 38-year-old male with a perforated duodenal ulcer nearly a year after Roux-en-Y gastric bypass. Upon presentation, he complained of 8 hours of epigastric pain. His medical history was significant for chronic peptic ulcer disease and a negative history of H. pylori. Recently, he had been prescribed naproxen by his primary care physician for knee pain. His vital signs were normal with the exception of his systolic blood pressure which was 190 mmHg. He was diaphoretic and peritonitic on exam. He was taken emergently for a diagnostic laparoscopy and found to have a perforation of ∼5 mm of the anterior portion of his duodenum. This was repaired laparoscopically with an omental patch and the patient recovered without any further intervention required. While this is a rare complication reported in the literature, this or similar complications of the remnant stomach may be underrepresented in publications. The surgical intervention of this disease will either be resection of the remnant or an omental patch. However, controversy remains as to the proper post-operative medical treatment. For our patient, the inciting agent was likely the naproxen he was given and this was stopped immediately. Patient education and ownership should remain a cornerstone for patients that have undergone a Roux-en-y gastric bypass.

Pyopneumopericarditis from a gastropericardial fistula: a case report

Background Pyopneumopericarditis is a very rare diagnosis that requires prompt recognition and urgent treatment. It denotes the presence of pus and air in the pericardium with associated inflammation of the fibrous pericardial sac. Case summary A 49-year-old gentleman was admitted with pyopneumoperciarditis on a background of a previous uncomplicated Roux-en-Y gastric bypass surgery performed 7 years prior. He underwent emergency surgery for an omental patch repair of an ulcer perforation involving the diaphragm and pericardium. His inpatient stay was complicated by persistent seropurulent output from the pericardial drain, loculated pleural effusion, and deconditioning. Discussion Management is extrapolated from the literature regarding purulent pericarditis. This condition albeit rare, requires swift recognition as without treatment mortality approaches 100%. Colchicine is an important adjunctive therapy postoperatively to prevent constrictive physiology.

Primary Repair of Traumatic Complete Pancreatic Rupture

Isolated pancreatic injury with transection of the pancreatic duct is generally treated with pancreatic resection, but the optimal management is not based on high-level evidence. Herein, we report a case of primary repair of complete rupture of the pancreas and pancreatic duct after a blunt abdominal trauma and a review of the literature. A 33-year-old patient had an isolated pancreatic injury after blunt abdominal trauma. At laparotomy, an even transection was found with minimal necrosis and tissue loss and an end-to-end anastomosis of the duct and the parenchyma with omental patch was performed. Patient’s postoperative course was complicated by a 6 cm pseudocyst and a low output pancreatic fistula which did not require any intervention and were self-limited. In the literature, 17 cases with primary repair of similar grade IV pancreatic injuries have been reported. Postoperative complications included mostly fistulas and pseudocysts.

Traumatic damage to the liver capsule: an unusual cause of small bowel obstruction

A 61-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side while cycling, but had not sought medical attention. On admission, a CT scan showed small bowel obstruction (SBO) and he underwent an emergency open laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis. We believe this is the first reported case of SBO secondary to small bowel herniation into the liver capsule following trauma.

Pedicled Tubular Omental Patch for Tamponade of Transfixing Gunshot Bilobar Liver Injury: A Case Report

Introduction: Liver injuries are frequent in abdominal trauma and may be managed using a variety of methods. The operative management of deep, penetrating wounds generally involves balloon tamponade of the wound tract using a Sengstaken-Blakemore catheter. Case Presentation: A haemodynamically unstable 34-year-old male with multiple thoracoabdominal gunshot wounds was transferred to the operating theatre. At laparotomy, a grade 3 transfixing (through and through) bilobar hepatic wound was discovered with active hemorrhage. Unfortunately, no suitable balloon catheters were available, so, as an alternative, tamponade of the wound tract was successfully achieved using a tubular omental patch. Discussion: Omental patches are commonly used in the management of perforated duodenal ulcers and have been used to prevent recurrence following hepatic cyst de-roofing. To the authors’ knowledge, this is the first description of this technique for the management of penetrating bilobar transfixing hepatic injury. Conclusion: A tubular omental patch may be used to achieve tamponade of deep wounds in penetrating hepatic trauma. This could be a particularly useful technique in resource-poor environments, or where a suitable balloon catheter is otherwise unavailable.