Immediate Postoperative Parenteral Anticoagulant in the Patients with Mesenteric Infarction After Intestine Resection – A Retrospective Cohort Research in a Single Institute

Background: Bowel gangrene represents a major fatal event in acute mesenteric infarction. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulant in patients with intestinal resection. Methods: Patients with acute mesenteric infarction and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate enoxaparin (group A) and those with immediate enoxaparin (group B). Both 30-day and 90-day mortalities were analyzed.Results: A total of 85 patients were included, with 29 patients in group A and 56 patients in group B. Patients in group B had both lower 30-day mortality (16.1%) and 90-day mortality (37.5%), compared to patients in group A (30-day mortality: 51.7%, p=0.001; 90-day mortality: 65.5%, p=0.021). In the 30-day mortality multivariate analysis, patients in group B had a better outcome (odds ratio = 0.087, 95% confidence interval between 0.017 and 0.446, p = 0.003). In the 90-day mortality multivariate analysis, patients in group B also had a better outcome (odds ratio = 0.252, 95% confidence interval between 0.065 and 0.983, p = 0.047).Conclusion: Immediate postoperative parenteral anticoagulant improves short-term prognosis in patients with acute mesenteric infarction and intestinal resection.Trial registration: This research was retrospectively approved by Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. Informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Management of Symptomatic Meckel's Diverticulum in Infants and Children

Objectives The primary objective of the present study was to review the demographics of infants and children operated upon for Meckel's diverticulum. The secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and the outcome. Materials and Methods This study is a single-institutional, retrospective study and descriptive in nature. It consisted of infants and children below 12 years who were operated upon for Meckel's diverticulum. This study was conducted at the author's department of pediatric surgery, and it was performed for 21 years from January 1, 2000 to December 31, 2020. Results Eighty-four children below 12 years were operated upon for Meckel's diverticulum during the study period of 21 years. The ratio for males to females was 3:1. This study consisted of infants, (n = 22, 26.19%), children of 1 to 5 years of age (n =19, 22.61%), and children of 6 to 12 years of age (n = 43, 51.19%). Clinically, children with Meckel's diverticulum presented in the following order of frequency: (1) intestinal obstruction (n = 59, 70.23%), (2) perforation peritonitis (n = 17, 20.23%), (3) lower gastrointestinal bleeding (n = 4, 4.76%), and (4) incidental finding (n = 4, 4.76%). In 35 (41.66%) children, bowel gangrene was detected. One-fifth (n = 17) of Meckel's diverticulum was responsible for the secondary intussusception. In children (n = 84), for Meckel's diverticulum, surgical procedures were performed in the following order of frequency: (1) resection of Meckel's diverticulum, an adjacent segment of ileum and ileoileal anastomosis (n = 36, 42.85%); (2) Meckel's diverticulectomy (n = 32, 38.09%); (3) resection of Meckel's diverticulum, an adjacent segment of ileum with or without cecum and an ileostomy (n = 12, 14.28%); and (4) resection of Meckel's diverticulum, an adjacent segment of ileum, cecum, part of the colon, and ileocolic anastomosis (n = 4, 4.76%). In 8 (9.52%) children, complications were documented during the postoperative period. The present study observed three (3.57%) deaths during the postoperative period. Conclusion Meckel's diverticulum was one of the common causes of acute intestinal obstruction in infants and older children. Ninety percent of children with Meckel's diverticulum presented with features of an acute abdomen. Forty percent of children evidenced bowel gangrene during the surgical procedures. In these children, early diagnosis, timely referral, and institution of surgical therapy for acute abdomen/intestinal obstruction may prevent the development of bowel gangrene and the requirement of bowel resections to some extent.

Surgical Management of Intussusception in Children: A Retrospective Review of 212 Cases

Objectives The primary objective of this study was to analyze and review the demographics of children operated upon for intussusception. Secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and outcome. Materials and Methods It is a single-institution, retrospective study and consists of children below the age of 12 years. This study was conducted at the author’s department of pediatric surgery for the past 21 years, from January 1, 2000 to December 31, 2020. Results During the study period, 212 children were operated upon for intussusceptions and included 146 (68.86%) boys and 66 (31.13%) girls. This review consisted of infants 158 (74.52%), and children of 1 to 5 years of age (30; 14.15%), and 6 to 12 years of age (24; 11.32%). Clinically, 177 (83.49%) children presented with the features of acute intestinal obstruction, and the remaining 35 (16.5%) presented with features of perforation peritonitis. Primary (idiopathic) intussusception was documented in 188 (88.67%) of the cases. Gangrenous bowel was evident in 98 (46.22%) children. Sixty-two percent of the cases required bowel resection. Surgical procedures were executed in children for intussusception in the following order of frequency: (1) operative reduction with or without serosal tear/bowel perforation repair, n = 81 (38.2%); (2) resection of diseased ileum and ileoileal anastomosis, n = 52 (24.52%); (3) resection of diseased ileum ± part of colon and an ileostomy, n = 36 (16.98%); and (4) resection of diseased ileum, cecum, part of colon, and ileocolic (ileo-ascending or ileo-transverse) anastomosis, n = 43 (20.28%). Postoperatively, 9 (4.24%) children required reexploration for the management of their complications. Twenty-one (9.9%) children died during the postoperative period. Conclusion Intussusception remains the most common cause of acute intestinal obstruction in infants and young children. Delay in the referral, diagnosis, and seeking treatment were significantly associated with bowel gangrene, required bowel resection during the surgical therapy, and also culminated in significantly higher mortalities.

AN EMERGENT MANAGEMENT OF ACUTE SUPERIOR MESENTERIC ARTERY EMBOLISM WITH ILEAL GANGRENE

Acute mesenteric ischemia (AMI) occuring due to sudden, partial or complete interruption of blood ow in main visceral arteries of the abdomen eventually resulting in intestinal ischemia and/or bowel gangrene is a surgical emergency. It represents 0.1% of hospital admissions and 2% of the revascularization operations for atheromatous lesions. 50% of AMI is caused by embolic phenomenon, 25% by thrombotic episode and rest 25% by both. The most common vessel involved in AMI is superior mesenteric artery. Acute mesenteric embolic ischemia (AMEI) arises typically from a cardiac emboli in patients with atrial brillation or following MI. Patients usually presents with central abdominal pain, out of proportion to the physical ndings initially, later becoming diffuse associated with bloody diarrhoea during the episode. An early diagnosis, an aggressive resuscitation, intravascular or surgical restoration of blood ow and subsequent bowel resection based on bowel viability helps reduce morbidity and mortality.

Right paraduodenal hernia with extensive bowel gangrene treated with staged surgery: a Bogota bag followed by resection in a low-resource setting

We report a case of right paraduodenal hernia with strangulation of almost the entire small bowel at presentation. Since resection of all bowel of doubtful viability would have resulted in too little residual length to sustain life, a Bogota bag was fashioned using transparent plastic material from an urine drainage bag and the patient monitored intensively for 18 hours. At re-laparotomy, clear demarcation lines had formed with adequate length of viable bowel (100 cm) and resection with anastomosis was done with a good outcome on follow-up, 9 months after surgery. Our description of a rare cause of strangulated intestinal obstruction and a novel method of maximising length of viable bowel is reported for its successful outcome in a low-resource setting.

Midgut malrotation with volvulus discovered at an emergency caesarean section for placental abruption

Adult midgut malrotation with volvulus (AMMV) is an uncommon presentation which may be found incidentally during abdominal radiologic investigations or at laparotomy. We report a case of AMMV and small bowel gangrene in a 35-year-old Gravida four, Para three at 39 weeks, 4 days gestation who presented with a short history of worsening abdominal pain, repeated vomiting and abdominal wall guarding. Emergency caesarean section performed on account of a suspected placental abruption incidentally revealed a long segment of non-viable small intestine. Subsequent midline laparotomy disclosed a midgut malrotation with volvulus and bowel gangrene. This resulted in a 4.6m resection of non-viable small bowel with Ladd’s procedure. The patient developed moderate symptoms of short bowel syndrome in the post-operative period which was successfully managed non-operatively. This case report represents a rare diagnosis, in the West-African sub-region, of an adult midgut malrotation with volvulus mimicking a third trimester obstetric emergency.

A rare association of uterine leiomyoma with mesenteric vein thrombosis and bowel gangrene: case report

Uterine fibroids are the most common benign pelvic tumors in women. There are many complications reported with fibroids. However, mesenteric vein thrombosis and small bowel gangrene caused by a uterine fibroid are rare. This manuscript reports a rare case of 40 year female with a large uterine fibroid associated with mesenteric vein thrombosis and bowel ischemia. She underwent exploratory laparotomy in which resection of gangrenous bowel including jejunum and ileum was done along with left sided jejunostomy and right sided ileostomy. Total abdominal hysterectomy with bilateral salpingooophorectomy was done followed by jejunoileal anastomosis 6 weeks later. Hence, in patients presenting with acute abdomen and uterine fibroids, bowel gangrene must be included in the differential diagnosis.

Role of procalcitonin in predicting the bowel gangrene and ischemia in acute intestinal obstruction

Background: Acute intestinal obstruction being the most common presentation on intestinal ischaemia and bowel gangrene. This study mainly concentrated on need for new marker for early prediction mesenteric ischaemia. Procalcitonin as a marker for stoppage of conservative management in intestinal obstruction. Methods: Out 70 patients 45 underwent conservative and 25 eventually underwent surgery (midline laparotomy). Procalcitonin levels in both are observed at regular intervals and compared and analysis done using appropriate statistical tests. Results: Level of procalcitonin was found to be higher in patients who need surgery consistantly when compared with those who were in conservative line of management with mean PCT level 2.19 and 2.23 in conservative line with mean PCT of 3.68 and 6.58 for surgical need at presentation and after 48 hrs respectively with p value <0.0001 which is significant. Conclusions: PCT at presentation can be a very good tool for predicting the bowel ischaemia and gangrene as an early indicator and also it can be used as a marker for need for surgery in patients managing conservatively for intestinal obstruction.

Intramesenteric internal hernia with midgut volvulus: a rare case causing small bowel gangrene in an adult

Intramesenteric internal hernia is a rare type of small bowel mesentery related internal hernia which usually occur in pediatric population. It is characterized by herniation of small bowel loops through a congenital or acquired defect in one layer of the mesentery producing a mesenteric pouch type hernia. The defect usually occurs near the ileocaecal valve or ligament of treitz and the herniated bowel loops are prone to strangulation or volvulus, presenting as small bowel obstruction that warrants early recognition and emergency laparotomy to confirm the diagnosis and prevent bowel gangrene and its complication. We present a case of 59 year old male presenting with features of an acute intestinal obstruction since morning and a vague firm mass in the right upper quadrant which was confirmed by CT scan to be an internal hernia and patient was taken up for emergency laparotomy. Intraoperative findings revealed a sac of small bowel loops herniating into the mesentery through a defect near the terminal ileum. Upon reducing the contents a volvulus was evident and resulted in the gangrene of the small bowel loops. The gangrenous bowel was resected and a single layered end to end ileo-ileal anastamosis was done. The diagnosis of internal hernia in a adult with no previous history of abdominal surgery or trauma is a very rare entity and requires a high degree of suspicion and close monitoring of the patient to ensure early surgical intervention and optimal outcome.