Cecal volvulus in rural Kenya: delayed presentation contributes to high mortality

Background Cecal volvulus, which is a torsion involving the cecum, terminal ileum, and ascending colon around its own mesentery, results in a closed-loop obstruction. It is a rare reported cause of adult intestinal obstruction. This study aimed to review the clinical presentation, management, and outcomes at a rural, resource-limited referral center. Methods We performed a retrospective review of all patients with a diagnosis of cecal volvulus between January 1st, 2009 and December 31st, 2019 at Tenwek Hospital in Bomet, Kenya. The outcome of survival was compared by the time to presentation. Mortality was also compared with prior reports of intestinal obstruction at our institution. Results Thirteen patients were identified with a mean age of 52 years and a mean symptom duration of 5 days. All patients presented with abdominal pain and distension. Seven patients (54%) presented with perforation, gangrene, or gross peritoneal contamination. Identified risk factors were Ladds bands with malrotation, adhesions, and a sigmoid tumor. Procedures included primary resection and anastomosis (7), damage control (3) with anastomosis on second-look in 2 of these, simple surgical detorsion (1), and surgical detorsion and cecopexy (2). There were four mortalities (31%), of which all had delayed presentation with perforation and fecal contamination. Delays to presentation were associated with mortality (p = 0.03). Cecal volvulus resulted in increased perioperative mortality compared to all intestinal obstructions presenting to the institution (p < 0.0001). Conclusions Cecal volvulus carries a high risk of mortality. A high index of suspicion and early consideration in the differential diagnosis of intestinal obstruction should be considered to reduce the mortality associated with the delay in preoperative diagnosis.

Management of colonic diverticulitis

ABSTRACT Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient’s health and immune status, and the patient’s preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.

Diagnosis and management challenges of acute mesenteric venous thrombosis in patients with liver cirrhosis: a single institution's experience

Background: Acute mesenteric venous thrombosis (MVT) is a dreadful complication of liver cirrhosis that requires prompt diagnosis and aggressive management for better outcome. The aim of this work was to study the diagnostic tools and the optimal management of acute MVT in patients with liver cirrhosis.Methods: It was a retrospective study including 40 patients with liver cirrhosis who were admitted to the surgical emergency and were eventually diagnosed as acute MVT between May 2011 to September 2016. The preoperative clinicopathological data, operative data and postoperative follow up were recorded.Results: Forty patients had acute MVT. Twenty five patients (62.5%) had prolonged prothrombin time, 18 patients (45%) had thrombocytopenia and 22 patients (55%) had low protein C. triphasic CT scan was the main diagnostic image in 28 patients, with sensitivity 100% and accuracy 96.9% in detection of intestinal infarction. Ten patients (25%) underwent conservative treatment with anticoagulant, while 30 patients (75%) were surgically explored and 28 patients of them had gangrenous bowel loops and underwent primary resection and anastomosis. Three patients underwent second look operation. Three patients had recurrent symptoms after 1 month of the first presentation. The overall 30- and 90-day mortality was 27.5% and 37.5% respectively.Conclusions: Cirrhotic patients may have hypercoagulable state and the usual laboratory tests don’t accurately assess the coagulation status in these patient. Acute MVT in cirrhotic patients has a high early morbidity and mortality that needs early diagnosis and urgent management with selective surgical intervention and proper anticoagulant.

A clinical study on the management of sigmoid volvulus

Background: Sigmoid volvulus is a surgical emergency and significant cause of large bowel obstruction with high mortality and morbidity. The disease is more prevalent in India, especially rural population. It constitutes 15% of total bowel obstructions. This study analyzes various management options in our institute which caters mainly to patients from the surrounding rural areas.Methods: The present work is study of 36 cases, carried out as regards to the etiological factors which predispose to the sigmoid volvulus, the clinical features, modes of treatment and the outcome. Particular stress has been laid on the various treatments. The duration study was 2 years between November 2014 and October 2016 at Government Chengalpattu medical college, Tamil Nadu, India.Results: The mean age of sigmoid volvulus was 49 years (range 19-75) and male to female ratio was 2:1. Comparatively less frequent in less than 20 years and above 70 years. Distention of abdomen (100%), followed by constipation in 88% were common mode of presentation. Sigmoidopexy done in 22% patients with nil mortality and, for primary resection and anastomosis, it was 17%. Common post-operative complication found to be wound infections.Conclusions: Primary resection anastamosis is found to be definitive safe procedure if the colon is viable. Hartman’s procedure is suitable only if the bowel is gangrenous. Absence of co morbid conditions a notable feature. Pre operative X-RAY helpful in diagnosis. Mortality found to be 17.5% in our study.

A Study on Various Modalities of Surgical Management of Sigmoid Volvulus

<p><strong>Background</strong>: Worldwide incidence of sigmoid volvulus varies from 6-30%. In India the incidence varies from 11.8% in the west to 1.5 - 9.4 % in north and south India respectively, depending on the dietary constituents. The management of sigmoid volvulus varies depends on the timing of presentation and the condition of the large bowel.</p><p><strong>Objective</strong>: The aim of the study was to evaluate the effectiveness of the various surgical options in treatment of sigmoid volvulus.</p><p><strong>Methods</strong>: An analysis of 30 patients treated for sigmoid volvulus over a span of 1 year was done. The findings at exploration were carefully recorded. Following a suitable surgical procedure, the patients were monitored for complications and followed up.</p><p><strong>Results</strong>: In our study of 30 patients, 23 were male, 7 female. The age group ranged from 20 - 70 years, with maximum patients in age of 60 -70 years. Majority of these patients presented with abdomen distension and abdomen pain followed by constipation and vomiting. Plain Skiagram was diagnostic in 90% patients. Operative procedure undertaken in 23 cases was primary resection and anastomosis whereas 5 cases were gangrenous Sigmoid Volvulus for which Hartmann's procedure was done.</p><p><strong>Conclusion</strong>: This study showed that for non-gangrenous bowel, primary resection and anastomosis is ideal and for gangrenous bowel, Hartmann's procedure is ideal.</p>

Early Reoperations after Primary Repair of Jejunoileal Atresia in Newborns

Aim: To review nine-year experience in managing jejuno-ileal atresia (JIA) by primary resection and anastomosis and identify factors associated with reoperations.Methods: From April 2006 to May 2015, all consecutive neonates who underwent bowel resection and primary anastomosis for JIA were analyzed retrospectively. Patients with temporary enterostomy were excluded. Patient demographics, types of atresia, surgical techniques, need for reoperations, and long-term outcomes were investigated.Results: A total of forty-three neonates were included, in which nineteen (44.2%) of them were preterm and fourteen (32.6%) were of low birth weight. Thirteen patients (30.2%) had jejunal atresia whereas thirty patients (69.8%) had ileal atresia. Volvulus, intussusception and meconium peritonitis were noted in 12, 8, and13 patients, respectively. Eight patients (18.6%) had short bowel syndrome after operation. Ten patients (23.3%) required reoperations from 18 days to 4 months after the initial surgery due to anastomotic stricture (n=1), adhesive intestinal obstruction (n=1), small bowel perforation (n=2) and functional obstruction (n=6). Prematurity and low birth weight were associated with functional obstruction leading to reoperation (p=0.04& 0.01 respectively). The overall long-term survival was 97.7%. All surviving patients achieved enteral autonomy and catch-up growth at a median follow-up of 4.7 years.Conclusion: Long-term survival of JIA after primary resection and anastomosis are excellent. However, patients have substantial risk of early reoperations to tackle intraabdominal complications.