Bowel Perforation in Vascular Ehlers-Danlos Syndrome: Case Report and Comprehensive Review

INTRODUCTION

Ehlers-Danlos syndromes (EDS) comprise a rare variety of genetic disorders, affecting all types of collagen. Herein, we describe a case of the vascular type of EDS, with coexisting segmental absence of intestinal musculature, while simultaneously performing a narrative review of the existing literature.

CASE PRESENTATION

A 23-year-old male patient with a history of multiple abdominal operations due to recurrent bowel perforations and the presence of a high-output enterocutaneous fistula was admitted to our surgical department for further evaluation and treatment. After detailed diagnostic testing, the diagnosis of vascular-type EDS (vEDS) was made and a conservative therapeutic approach was adopted. In addition, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

RESULTS

The diagnosis of vEDS was molecularly confirmed by means of genetic testing. The patient was treated conservatively, with parenteral nutrition and supportive methods. Thirty-four cases of bowel perforation in vEDS have been reported so far. Interestingly, this case is the second one ever to report co-existence of vEDS with Segmental Absence of Intestinal Musculature.

CONCLUSIONS

Establishing the diagnosis of vEDS promptly is of vital significance in order to ensure that patients receive appropriate treatment. Due to initial non-specific clinical presentation, EDS should always be included in the differential diagnoses of young patients with unexplained perforations of the gastrointestinal tract.

Looking for the Ideal Probiotic Healing Regime

Wound healing is a multi-factorial response to tissue injury, aiming to restore tissue continuity. Numerous recent experimental and clinical studies clearly indicate that probiotics are applied topically to promote the wound-healing process. However, the precise mechanism by which they contribute to healing is not yet clear. Each strain appears to exert a distinctive, even multi-factorial action on different phases of the healing process. Given that a multi-probiotic formula exerts better results than a single strain, the pharmaceutical industry has embarked on a race for the production of a formulation containing a combination of probiotics capable of playing a role in all the phases of the healing process. Hence, the object of this review is to describe what is known to date of the distinctive mechanisms of each of the most studied probiotic strains in order to further facilitate research toward the development of combinations of strains and doses, covering the whole spectrum of healing. Eleven probiotic species have been analyzed, the only criterion of inclusion being a minimum of two published research articles.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published “case reports” concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Uroperitoneum as a Complication of Laparoscopic Cholecystectomy: A Case Report

BACKGROUND

Bladder rupture is more frequently encountered in blunt pelvic trauma, but can also be spontaneous or iatrogenic. Laparoscopic repair has been widely used during the last few years as a treatment for intraperitoneal bladder perforation. The bladder is the genitourinary organ most often affected by iatrogenic injury. The purpose of this article is to report what is, to our knowledge, the first documented case of bladder rupture as a complication of laparoscopic cholecystectomy.

CASE DESCRIPTION

A 51-year-old female presented to the emergency department complaining about generalized abdominal pain on the sixth postoperative day after laparoscopic cholecystectomy. Laboratory results highlighted a significant impact on renal function while the abdominal CT scan demonstrated free intraperitoneal fluid collection and surgical clips in the anatomic region of the liver and in an ectopic position near the ileocecal valve. An explorative laparoscopy revealed a 2 cm defect in the superior bladder wall, which was repaired in one layer in a continuous-locking fashion. The patient was discharged home on the fifth postoperative day having an uneventful recovery.

CONCLUSION

Bladder rupture frequently presents with non-specific clinical signs; as a result, it is easily misdiagnosed, especially when it occurs with a non-typical mechanism of injury. Pseudorenal failure is a relatively obscure entity that may help the clinician suspect a bladder perforation. Laparoscopic repair with a single-layer continuous suture technique is a safe and feasible treatment in hemodynamically stable patients. Prospective research is required to specify the optimal timing of catheter removal after bladder repair.

Surgical Management of Groove Pancreatitis: A Case Report

Groove pancreatitis (GP) is a chronic type of pancreatitis involving the groove area between the head of the pancreas, the duodenum, and the common bile duct. Alcohol abuse is one of the main pathogenetic factors, although its etiology is not clearly defined. Differential diagnosis of pancreatic disorders remains difficult. The lack of diagnostic management and the restrictive number of patients are the main barriers. This article presents a case of a 37-year-old male diagnosed with GP after several episodes of epigastric pain and vomiting, with a history of chronic alcohol consumption. The patient's radiological and laboratory results excluded the possibility of malignancy and suggested the diagnosis of groove pancreatitis with duodenal stenosis. After initial conservative treatment failed, surgical management was decided. A gastroenteroanastomosis was made in order to bypass the duodenum aiming for a total resolution of the symptoms and an uneventful recovery of the patient. Although most studies suggest pancreatoduodenectomy (Whipple's procedure) as the treatment of choice, a less major procedure can be performed in evidence of malignancy absence.

Buried bumper syndrome: A critical analysis of endoscopic release techniques

Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the “push” and the “push and pull T” techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.

Gastrocolic fistula in Crohn's disease: A case report and review of the literature

Gastrointestinal fistulas constitute a rare type of abdominal fistula and an uncommon complication in the setting of Crohn's disease. In this case presentation we study the treatment of a gastrointestinal fistula between the transverse colon and the stomach in a patient with Crohn's disease and present a review of the available literature. A 53-year-old female patient with history of Crohn's disease presented to the Emergency Department of our Hospital due to reported abdominal pain and clinical symptoms of incomplete ileus with no other specific symptoms. Imaging investigation included plain radiography and computed tomography of the abdomen and revealed mural thickening of the transverse colon for an approximately 10 cm long segment, with the possible presence of gastrocolic fistula. During the exploratory laparotomy, an inflammatory mass was found in the middle of the transverse colon and the communication with the stomach was confirmed. Excision of the affected part of the transverse colon and cuneiform resection of the stomach in the area of the fistula was performed. The patient presented smooth and uncomplicated postoperative period and was discharged on the 10th postoperative day. Gastrointestinal fistulas are an uncommon complication of Crohn's disease, often with an intense clinical manifestation from the upper and lower digestive tract. Surgical treatment, either open or laparoscopic, of gastrointestinal fistulas due to Crohn's disease is the "gold-standard" method, both to control the disease and avoid further complications.

Thromboprophylaxis in surgically treated colorectal cancer patients with tinzaparin: Intermediate results from the Onco-CAST trial

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Background: The incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) after colorectal surgery is approximately 29% and 1.6% respectively. The incidence of asymptomatic postoperative DVT in colorectal cancer (CRC) patients has been reported as high as 20%, even under thromboprophylaxis. Thus, thromboprophylaxis after surgical treatment for CRC is crucial. Latest guidelines from International Initiative on Thrombosis and Cancer (ITAC 2019) recommend use of highest prophylactic dose of Low Molecular Weight Heparin (LMWH). Methods: Onco-CAST is a prospective, phase IV, observational, non-interventional cohort study evaluating a) current management approach for CRC surgical prophylaxis and b) efficacy and safety of tinzaparin at 8.000 Anti-Xa IU, once daily (OD), for at least one month post hospital discharge. Patients enrolled after signing informed consent. Onco-CAST was conducted by the Hellenic Society of Coloproctology. Results: Results from 175 CRC patients from 9 Onco Surgical Clinics are reported. Participation completed 79% of patients at report time: 66% males, 67±12 years, BMI: 27.4±5.5. Histology: adenocarcinomas NOS 81%, mucinous adenocarcinomas 9%, small cell neuroendocrine carcinomas 2%, and others. High grade differentiation indicated: 26% and 5% metastatic. 32% treated with right hemicolectomy, 20% with low anterior resection, 12% with sigmoid colectomy, 9% with abdominal-perineal resection, 9% with left hemicolectomy and other methods. 67% treated open and 33% laparoscopic while the median number of lymph nodes dissected for left and right hemicolectomy was 32.5 (Q1-Q3:26-38) and 24 (Q1-Q3: 14.5-32), p = 0.0253. Factors related to thrombosis risk are presented in table, notably, 95% of patients accumulated ≥3 risk factors. Median thromboprophylaxis duration with tinzaparin 8.000 Anti-Xa IU, OD, was: 37 days (1st-3rd quartile: 33-45 days). Three thrombotic events occurred (efficacy 98.3%, 95% CI: 95.1-99.4%), one DVT+PE, one DVT and one due to Central Venous Catheter (CVC). Eight patients experienced bleeding events (4.6%, 95%CI: 2.3-8.8%), 3 minor, 3 major and 2 CNMB, 2 had a possible relation to thromboprophylaxis (1.1%, 95%CI: 0.3-4.1%). Conclusions: Thromboprophylaxis in Surgically Treated Colorectal Cancer Patients with Tinzaparin intermediate dose seems safe and efficient approach.[Table: see text]

Composite Paraganglioma of the Celiac Trunk: A Case Report and a Comprehensive Review of the Literature

Introduction

Composite paragangliomas consist of two components, paraganglioma and ganglioneuroma, representing a rare subgroup of paragangliomas. The purpose of the study is to describe a case of composite paraganglioma of the celiac trunk and a brief review of the existing literature.

Case Presentation

A 64-year-old female patient with a history of epigastric abdominal pain and a 51 mm-diameter tumor found in a Computerized Tomography of the abdomen was admitted to our surgical department for further evaluation and treatment. After a brief preoperative surgical assessment, the patient underwent a mini-laparotomy for the excision of this tumor. After having the results of the pathology report, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

Results

As it was found intraoperatively, the tumor was located at the cephalad aspect of the common hepatic artery, over the portal vein and the inferior vena cava. A negative-margin resection was achieved and the tumor was sent for pathology analysis. The final pathology report revealed a composite paraganglioma, with α paraganglioma and a ganglioneuroma component. Seventeen cases of extra-adrenal composite paraganglioma have been reported in the international literature so far. This case was the first one found in the area of the celiac trunk.

Conclusions

Composite paragangliomas comprise rare and potentially malignant tumors with variable prognosis. Establishing their diagnosis promptly is of vital significance. Due to the first-described location of the composite paraganglioma in our case, the differential diagnosis of tumors in this area should also include composite paragangliomas.

Translation of the Pasieka's Parathyroid Assessment of Symptoms Questionnaire (PAS-Q) for Use in the Greek Population

INTRODUCTION

In Europe, primary hyperparathyroidism is mainly considered an asymptomatic disorder, although there is evidence that patients' health-related quality of life is impaired. This aspect is mostly evaluated using Pasieka's Questionnaire: a disease-specific diagnostic tool. The purpose of this study was to translate the Pasieka's Questionnaire into the Greek language and adapt it to the Greek population.

MATERIALS AND METHODS

Pasieka's Questionnaire consists of 13 questions. Two bilingual, native Greek experts were selected for step one, each of whom offered a blinded Greek version of the questionnaire. In the second step, these two versions were merged into one which was retranslated back into the English language (step three) by two bilingual translators (English native speakers). In the fourth step, a committee was formed to draft the pre-final version of the questionnaire which was then submitted to the co-authors for final approval. Finally, after the approval of the final version, 50 patients with primary hyperparathyroidism were recruited for the pilot study of the questionnaire.

RESULTS

All 13 questions of the Pasieka's Questionnaire were translated without any major discrepancy. A high level of internal consistency was achieved (Cronbach's alpha was 0.904) and agreement between test-retest was excellent for every question.

CONCLUSION

The Greek version of Pasieka's Questionnaire was validated and can be applied to evaluate the health-related quality of life of patients with primary hyperparathyroidism in Greek-speaking populations.