Protrusion of ventriculoperitoneal shunt catheter tip through anus with silence abdomen

Introduction: Ventriculoperitoneal shunt (VPS) is most commonly performed surgical treatment for hydrocephalus by draining excessive cerebrospinal fluid (CSF) in ventricles to peritoneal cavity. Despite significant improvement in shunt procedure and being a relatively simple procedure, shunt complications remain common. Aim: The aim of this paper is to report a case of perforated bowel presented with silence abdomen following VPS insertion. Case study: We report a case of protrusion of distal VPS catheter through anus with silent abdomen, managed successfully with minimal intervention. Patient, 11-months-old male infant, diagnosed with congenital communicating hydrocephalus and VPS placement was done at 6 months of life, presented with tip of VPS protruding from anus after 4 months of VPS insertion. Patient was scheduled for removal of VPS, where shunt was disconnected through superficial abdominal incision, distal portion removed through anus without resistance. Postoperative patient recovers well without abdominal complication. Results and discussion: Perforation of bowel by distal peritoneal catheter is rare and only accounts for 0.1%–0.7% of complication. The exact pathogenesis for spontaneous bowel perforation is unclear. Management of bowel perforation secondary to VPS is highly individualized, mainly depending on its clinical symptoms and signs. Conclusions: Although bowel perforation following VPS insertion is rare, it carries high mortality up to 15% especially if unrecognized and delayed in treatment. Early detection and appropriate management are key in reducing VPS related morbidity and mortality.

Patent Vitello - Intestinal Duct: A Case Report

A wide variety of anomalies may occur as a result of the vitello- intestinal duct (VID) failing to obliterate completely. These anomalies occur in approximately 2% of the population and may remain silent throughout life or may present incidentally with an intra-abdominal complication. Complete patency of vitello-intestinal duct is the rarest of all the anomalies of VID. We report a case of 27 day old female presenting with pinkish umbilical mass since birth referred to us by a paediatrician as umbilical granuloma, which turned out to be patent vitello- intestinal duct.

Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy—a retrospective study

Background Delayed gastric emptying (DGE) is one of the most common complications after pylorus-preserving partial pancreaticoduodenectomy (ppPD). The aim of this retrospective study was to assess whether an intraoperative pyloromyotomy during ppPD prior to the creation of duodenojejunostomy reduces DGE. Methods Patients who underwent pylorus-preserving pancreaticoduodenectomy between January 2015 and December 2017 were divided into two groups on the basis of whether an intraoperative pyloromyotomy was performed (pyloromyotomy (PM) group) or not (no pyloromyotomy (NP) group). The primary endpoint was DGE according to the ISGPS definition. The confirmatory analysis of the primary endpoint was performed with multivariate analysis. Results One hundred and ten patients were included in the statistical analysis. Pyloromyotomy was performed in 44 of 110 (40%) cases. DGE of any grade was present in 62 patients (56.4%). The DGE rate was lower in the PM group (40.9%) compared with the NP group (66.7%), and pyloromyotomy was associated with a reduced risk for DGE in univariate (OR 0.35, 95% CI 0.16–0.76; P = 0.008) and multivariate analyses (OR 0.32, 95% CI 0.13–0.77; P = 0.011). The presence of an intra-abdominal complication was an independent risk factor for DGE in the multivariate analysis (OR 5.54, 95% CI 2.00–15.36; P = 0.001). Conclusion Intraoperative endoluminal pyloromyotomy during ppPD was associated with a reduced risk for DGE in this retrospective study. Pyloromyotomy should be considered a simple technique that can potentially reduce DGE rates after ppPD.

Prognostic markers and assessment of a previously published clinical severity index in 109 hospitalised dogs with acute presentation of pancreatitis

BackgroundAcute pancreatitis (AP) is common in dogs. Nevertheless, validated clinical severity index (CSI) scoring systems to assess severity and guide treatment in current, large-scale studies are unavailable.MethodsThis is a retrospective study including 109 dogs. Pancreatitis was diagnosed based on clinical signs, abdominal sonographic evidence, positive pancreatic lipase assays and experts’ assessment consensus.ResultsThe survival rate was 75 per cent (82 dogs). Azotaemia and presence of local complications (ie, ascites) and secondary complications (ie, acute kidney injury and acute respiratory distress syndrome) were significantly associated with death. In agreement with the previously published CSI, respiratory anomalies were significantly associated with death. However, in disagreement with that study, high scores in the kidney and local abdominal complication categories and the sum of scores of all nine categories, but not high gastrointestinal category score, were also significantly associated with death. A final CSI score of at least 4 was associated with death.ConclusionsThis study has validated a nine-category CSI, proven a useful assessment tool in dogs with AP. Several previously reported and novel prognostic markers were assessed.

The prognostic factors for advanced gastric cancer with para-aortic nodal involvement after extended gastrectomy.

158 Background: The prognosis of patients with advanced gastric cancer with para-aortic lymph node (PAN) involvement is poor. We retrospectively investigated the prognostic factors for advanced gastric cancer with PAN involvement. Methods: The patients who underwent radical gastrectomy with PAN dissection for advanced gastric cancer between 1992 and 2014 in our institution included in this study. The clinicopathological features and prognostic factors of the patients who identified pathologically PAN involvement after curative gastrectomy were analyzed. Results: In this period, a total of 704 patients underwent gastrectomy with PAN dissection and 65 patients were identified as pathologically PAN positive and eligible for this study. Total gastrectomy and combined resection of other organs were performed for 48 patients and 51 patients, respectively. Complete PAN dissection (a2/b1) was performed for 32 patients. Postoperative abdominal complication was 20% with no hospital deaths. The 3 year and the 5 year overall survival (OS) were 33.8% and 21.2%, respectively. Multivariate cox regression analysis revealed nodal involvement (any of the station No.8a, No.9 and No.11; hazard ratio, 4.04; 95% confidence interval, 1.55-10.5), tumor diameter (over 120mm; HR, 3.37; 95%CI, 1.18-9.63) and total number of PAN involvement (over 2 nodes; HR, 2.24; 95%CI, 1.21-4.15) were poor prognostic factor. The patients without these poor prognostic factors had survived significantly longer than the patient with any of these factors in Kaplan-meier analysis (the 5 year OS: 87.5% vs 9.4%, P <0.001). Conclusions: Tumor size, nodal involvement of the station No.8a, No.9 and No.11 and total number of PAN involvement were poor prognostic factors for advanced gastric cancer with PAN involvement. The candidates for extensive nodal dissection for advanced gastric cancer should carefully be selected.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.