Surgical outcome of inflammatory bowel disease - experience of a tertiary center

BACKGROUNDS/AIM: Despite advances in medical treatment, a large number of patients with inflammatory bowel disease(IBD) require surgery. We aim to evaluate the efficacy and outcome of surgical interventions in patients with chronic inflammatory bowel diseases.

MATERIAL AND METHODS

We retrospectively analysed the medical records from 221 patients admitted to our institution between 2009-2012 with the diagnosis of IBD. Out of these patients, 55 (24.88 %) were diagnosed with Crohn's disease,while the remaining 166 patients (75.11%) had ulcerative colitis.

RESULTS

Seventeen of 55 patients with Crohn's disease (30.91%)required surgical management before or during this period. Nine with disease proximal to the transverse colon underwent segmental resections (enteral or colonic) with primary anastomosis, without morbidity. The other 8 patients, with disease distal to the transverse colon, underwent segmental colonic resections (two with primary anastomosis, three with stoma formation) or major colonic resection- subtotal colectomy with ileostomy (1 case) and total proctocolectomy with ileostomy(2 cases). Sixteen of 166 patients with ulcerative colitis(9.64%) required surgery before or during this period. The surgical procedure used included total proctocolectomy with definitive ileostomy (3 cases) and total colectomy with ileostomy(13 cases). 7 of the 13 patients had restorative surgery after total colectomy, 1 remaining with definitive ileostomy due to short vascular pedicle and 5 patients refused restorative surgery. Median daily stool frequency after reconstructive surgery was 7(range 3-12).

CONCLUSION

For patients with Crohn's disease proximal to the transverse colon, limited resection with primary anastomosis is safe. Major colonic resection (subtotal colectomy or proctocolectomy)is indicated if the disease is located distal to the transverse colon and primary anastomosis should be avoided. Due to unsatisfactory quality of live after reconstructive surgery(stool frequency remains high), total proctocolectomy with end-ileostomy remains a viable alternative for patients with ulcerative colitis.

Intestinal obstruction secondary to appendiceal mucocele

Few cases of intestinal obstruction complicating an appendiceal mucocele have been recorded. We report the case of a young woman who presented to the emergency room with diffusely abdominal pain, nausea, vomiting and disruption of bowel movements. Her abdomen was mildly distended and tympanic. A flat film of the abdomen revealed dilated small bowel loops with air-fluid levels suggestive of small bowel obstruction. She also had leukocytosis. An emergency operation was performed under the diagnosis of intestinal obstruction. The intraoperatory findings showed a tumoral appendiceal mass permeated into the ileum in two distinct points, causing an enteral stenosis. We performed an appendectomy "en bloc" with two enteral loop resections of the permeated ileum followed by two T-T enteral anastomoses. The pathologic examination revealed appendiceal mucinous cystadenoma. Postoperative course was favorable, the patient being discharged on the seventh postoperative day. Postoperative checks performed at 3, 6, 12 and 24 months (including colonoscopy) have not showed pathological changes.

Perforated appendix with periappendicular abscess in a inguinal hernia sac--Amyand's hernia

Amyand's hernia is a rare form of inguinal hernia, where the appendix is included in the hernia sac. We present the emergency case of an 81-year-old patient with right inguinal pseudo-tumor, accompanied by marked local pain, nausea, low grade fever and bowel disorders. Emergency surgery is indicated due to a suspected incarcerated inguinal hernia with imminent strangulation. The intraoperatory findings reveal the presence of a periappendicular abscess as the cause of gangrenous appendicitis, perforated in the right indirect inguinal hernia sac. The practice includes the evacuation of the abscess, appendectomy and surgical cure of the inguinal hernia--Bassini's procedure, Douglas drainage and subcutaneous drainage. The postoperative outcome was favorable, the patient being discharged on the fifth postoperative day. Postoperative checks performed at 3 and 9 months have not revealed the presence of a hernia recurrence.

[Risk factors for anastomotic leakage following colorectal resection for cancer]

PURPOSE

To identify the risk and prognosis factors and their predictive value for anastomotic leakage after colorectal resections following cancer.

PATIENTS AND METHODS

1743 consecutive patients who underwent colic resections or rectal resections for colo-rectal cancer between 1996-2005 in Surgical Clinic no. 3 (Cluj-Napoca, Romania) were retrospectively analysed.

RESULTS

A total of 54 (3.09 percent) anastomotic leaks were confirmed. Univariate analisys showed that the preoperative variables significantly associated with anastomotic leakage included weight loss, smoking, cardiovascular disease, lung disease, hypoproteinemia, diabetes, anemia, leukocitosis, presence of two or more underlying diseases. Use of alcohol, cerebrovascular disease, bowel preparation, mode of antibiotic prophylaxis, type of handsewn anastomosis, tumor location, tumor stage and tumor histology were nonsignificant variables. Hipoproteniemia (S - proteins < 60g/dl) and anemia (S Hb < 11) remained significant in logistic regression model.

CONCLUSIONS

Our study shows that a value of S-proteins lower than 60 g/l and s-Hb lower than 99 g/l can be consider as predictive marker for anastomotik leak deshiscence.

[Surgical management of malignant large bowel obstructions]

INTRODUCTION

Despite significant progress, the management of acute colonic obstruction still remains a challenging problem. The purpose of this study was represented by the evaluation of the clinical results of different techniques of resection for malignant colorectal (primary or staged) obstruction.

METHODS

We performed a non-randomized clinical study. 590 patients with malignant colorectal occlusion who underwent surgery treatment an 3rd Surgical Clinic Cluj-Napoca between 1996-2005 were included.

RESULTS

Patients with large bowel obstruction underwent one-stage primary resection with anastomosis in 267 cases or staged interventions in 323 cases. The groups were matched in: age, sex, comorbidities, tumor staging, serum preoperative levels of hemoglobin and proteins. The analysis of mortality and morbidity following surgical treatment for large bowel obstruction returned no significant difference among the two groups (p > 0.05). Moreover, the presented results showed a higher incidence of mortality (11.45% vs 9.33 %), morbidity (25.38% vs 14.6%) and increased hospitalization period (p = 0.029) among the patients that undergone seriate resections.

CONCLUSIONS

One stage primary resections with anastomosis of the large bowel can be performed safely in case of emergency whenever patient comorbidities and local conditions do not stand as major restrictions.

[Laparoscopic treatment of a large trichobezoar in the stomach with gastric perforation and abdominal wall abscess]

Trichobezoar represents a mass of swallowed hair inside the stomach. Here we report a 17-year-old girl who presented in our department with symptoms of gastric ulcer. Ultrasound examination followed by upper endoscopy revealed a large trichobezoar in the stomach with simultaneous gastric perforation. Laparoscopy also revealed a penetration into the anterior abdominal wall accompanied by abscess at this level. We performed a laparoscopic gastrotomy with trichobezoar extraction and laparoscopic treatment of perforation and abdominal wall abscess. The postoperative evolution was normal and the patient was discharged on the fifth postoperative day. We show that laparoscopic approach may be safely used in the treatment of the large gastric complicated trichobezoar. Several laparoscopic approaches were described for the treatment of tricobezoar and its complications but as far as we know this is the first report of laparoscopic treatment of large tricobezoar and associate gastric perforation.