Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis

BACKGROUND

In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial.

OBJECTIVES

We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children.

METHODS

We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic.

RESULTS

A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists.

CONCLUSIONS

In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.

Intussusception Management in Children: A 15-Year Experience in a Referral Center

OBJECTIVE

To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes.

METHODS

A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes.

RESULTS

A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001).

CONCLUSIONS

Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.

An Infant with COVID-19-Associated Intussusception

Intussusception is the most common cause of bowel obstruction in infants four to ten months old and is commonly idiopathic or attributed to lymphoid hyperplasia. Our patient was a 7-month-old male who presented with two weeks of intermittent abdominal pain associated with crying, fist clenching and grimacing. Ultrasound demonstrated an ileocolic intussusception in the right abdomen. Symptoms resolved after contrast enemas, and he was discharged home. He re-presented similarly the next day and was found to be COVID-19 positive. Computed tomography scan demonstrated a left upper quadrant ileal-ileal intussusception. His symptoms spontaneously resolved, and he was discharged home. This suggests that COVID-19 may be a cause of intussusception in infants, and infants presenting with intussusception should be screened for this virus. Additionally, recurrence may happen days later at different intestinal locations. Caregiver education upon discharge is key to monitor for recurrence and need to return.

Recurrent Ileo-ileal Intussusception Caused by Inflammatory Fibroid Polyp: A Rare Case Report

An inflammatory fibroid polyp is a rare benign lesion of the gastrointestinal tract, which can cause obstruction or intussusception when it reaches a large diameter. We present a case of a 46-year-old female admitted to our clinic with recurrent ileus attacks. We performed segmental resection of the small bowel due to a 3-cm pedunculated polypoid lesion located in the terminal ileum that caused ileo-ileal intussusception and whose pathology was reported as an inflammatory fibroid polyp. In adults presenting with ileus, the possibility of intussusception should be kept in mind.

[A young teenager with chronic postprandial emesis]

A girl, 11 years of age, presented with progressive abdominal pain and emesis after eating since 9 months. Her blood count only showed an iron deficiency anaemia. Diagnostic work-up suggested an ileo-ileal intussusception caused by a pedunculated polyp. Diagnosis was confirmed by laparoscopic-assisted resection of the involved small bowel.

Meckel's Diverticulum Bleeding Missed by the First but Detected by the Second Capsule Endoscopy

A 13-year-old boy was admitted to our hospital because of bloody stools. Although a Meckel's diverticulum (MD) was suspected, capsule endoscopy (CE) revealed no remarkable findings. Seven months later, he was admitted again because of rebleeding. CE was performed again and revealed an elevated lesion and fresh blood in the ileum. A single balloon endoscopic examination revealed a diverticulum with an elevated lesion in it. Histologic findings showed ectopic gastric mucosa, thus we diagnosed this patient as having MD. Although CE is useful for the examination of obscure gastrointestinal bleeding, a single CE is not enough to diagnose MD bleeding. The timing in performing CE and the evaluation of other modalities would be valuable for patients suspected of having MD.

[A Case of Intussusception Due to Ileal Malignant Lymphoma of AYA Generation]

The case is a 17-year-old man. He had complained of right lower abdominal pain for a week. He had no symptoms such as fever, weight loss, or night sweats. He was diagnosed with intussusception by abdominal contrast-enhanced CT and was hospitalized. The day after hospitalization, lower gastrointestinal endoscopy was performed, and a tumor 25 mm in size was found in the invagination of the ileum. Intussusception was recovered by intestinal scope insufflation, and the tumor was found to be a type 1 tumor located approximately 5 cm proximal to the Bauhin's valve. On day 17 of hospitalization, he had intussusception again at the time of surgery, and performed laparoscopic reduction before performing laparoscopy-assisted partial resection of the small intestine and appendectomy. The postoperative course was good and he was discharged on POD12(on day 29 of hospitalization). Histopathological diagnosis was diffuse large B-cell lymphoma(DLBCL), and chemotherapy was to be administered at the referral hospital. In intussusception of the adolescents and young adults(AYA)generation, such as this case outside of childhood, it is necessary to treat the patient with consideration for the presence of neoplastic lesions such as malignant lymphoma. We report our case with some literature considerations.

Adult Ileo-ileal Intussusception Due to Inflammatory Fibroid Polyp: A Case Report

INTRODUCTION

Intussusception occurs when one part of the intestines slides into the adjacent intestine resulting in bowel obstruction. It is a rare condition in adults, accounting for only 5% of all intussusceptions. It has multiple causes, with inflammatory fibroid polyps (IFPs) very infrequently being the cause. We present a rare case of intussusception in an adult due to an IFP.

CASE PRESENTATION

A 72-year-old woman visited our hospital complaining of abdominal pain. Abdominal contrast-enhanced computed tomography (CT) demonstrated an ileo-ileal intussusception due to a round mass. An emergency surgery involving a partial ileal resection with laparoscopic assistance was performed. Pathological findings of the tumor showed proliferation of spindle-shaped cells, edematous stroma, dilation of lymphatic vessels, and infiltration of inflammatory cells, which were mainly eosinophils. Immunohistochemistry was positive for vimentin and SMA and negative for CD117, CD34, S-100, and desmin. Based on these findings, the tumor was diagnosed as an IFP.

CONCLUSION

Bowel obstruction in adults due to intussusception is rare, and those due to IFPs are even more rare. Preoperative diagnosis of IFP is difficult, but surgeons must keep in mind that it can be a cause of adult intussusception.

Development of a uniform, very aggressive disease phenotype in all homozygous carriers of the NOD2 mutation p.Leu1007fsX1008 with Crohn's disease and active smoking status resulting in ileal stenosis requiring surgery

BACKGROUND

NOD2 variants are the strongest genetic predictors for susceptibility to Crohn's disease (CD). However, the clinical value of NOD2 on an individual patient level remains controversial. We aimed to define the predictive power of the major NOD2 mutations regarding complicated CD in a large single center cohort.

METHODS

1076 CD patients were prospectively genotyped for the three common CD-associated NOD2 mutations rs2066844, rs2066845, and rs2066847, followed by detailed genotype-phenotype analyses.

RESULTS

Overall, 434 CD patients (40.3%) carried at least one of the three main NOD2 mutations. A significantly higher minor allele frequency (15.6%) of the NOD2 frameshift mutation p.Leu1007fsX1008 (rs2066847) was seen in patients with aggressive disease compared to 8.2% in patients with mild disease (p = 2.6 x 10-5). Moreover, a total of 54 CD patients (5.0%) were homozygous for this NOD2 frameshift mutation. 100% of these patients had ileal disease compared to 82% of NOD2 wild-type carriers (p<0.0001). In homozygous carriers of the NOD2 frameshift mutation, 87% presented with ileal stenosis, 68.5% had fistulas, and 72.2% required CD-related surgery despite immunosuppressive therapy in 87% of these patients. All homozygous carriers of the 1007fs mutation who were active smokers had ileal stenosis and required CD-related surgery.

CONCLUSION

Homozygosity for Leu1007fsX1008 is an excellent biomarker for predicting complicated CD on an individual patient level. Active smoking and homozygosity for this mutation is associated with a 100% risk for developing ileal stenosis requiring CD-related surgery. In these patients, smoking cessation and early initiation of immunosuppressive strategies may be beneficial.

Simultaneous intussusception associated with adenovirus infection in monozygotic twins: A case report

RATIONALE

Intussusception, a common cause of intestinal obstruction in children, typically requires medical reduction. Here, we describe the case of a pair of twins who had simultaneous intussusception and were positive for fecal adenovirus-strongly indicating that adenovirus infection may be a main cause of the intussusception.

PATIENT CONCERNS

Two 1-year-old twin girls were brought to Cathay General Hospital one after another on the same day. Both presented with intermittent abdominal pain, abdominal distension, diarrhea, and loss of appetite.

DIAGNOSES

Their laboratory data were adenovirus positivity in rectal swab culture. Intussusception was diagnosed through a lower gastrointestinal series.

INTERVENTIONS

The twins were treated with reduction for intussusception.

OUTCOMES

Both patients recovered well, without recurrence.

LESSONS

Most cases of intussusception are idiopathic. However, some potential risk factors-as strongly suggested by the current cases-are genetic factors and adenovirus infection.

An Extraordinary Complication in a Child With Combined Familial Mediterranean Fever and Inflammatory Bowel Disease: Multiple Ileal Perforations

Familial Mediterranean fever (FMF) is a recurrent disease with autosomal recessive trait and fever that is generally self-limiting. Clinical manifestations are pain in the abdomen, chest, and joints as a result of inflammation in the serous surfaces. No case of multiple intestinal perforations has been reported in children with FMF, whereas cases with a single intestinal perforation have been encountered, although very rarely. In addition, co-occurrence of FMF and inflammatory bowel disease is a situation that is very rarely reported in the literature. Here, we report a case of a 5-year-old girl who was being followed up with the diagnosis of FMF and who also had inflammatory bowel disease, which was complicated with multiple ileal perforations. Our aim is to point out a rarely encountered co-occurrence and also the importance of evaluation of additional diseases with FMF that are unresponsive to treatment so as to prevent complications.

Pancreatitis following bariatric surgery

BACKGROUND

The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the second most performed bariatric surgical procedure. With the increasing number of patients undergoing bariatric surgery, the number of complications is also growing. Early diagnosis and treatment of the complications is crucial.

CASE PRESENTATION

A very unusual complication was met after an uneventful laparoscopic gastric bypass (LGBP) procedure due to an obstructing blood clot in the biliairy limb resulting in an acute pancreatitis and gastric distention, accompanied by an obstructing blood clot in the distal ileum causing small bowel obstruction. A review of the occurrence of these complications and the diagnosis and treatment is presented.

CONCLUSION

Post-bariatric acute pancreatitis is uncommon, but could be fatal. Blood clots should be considered as possible causes of small bowel obstruction, ileus or pancreatitis.

A rare case of ileo-ileal intussusception due to a bleeding lipomatous mass treated by laparoscopic ileal resection

INTRODUCTION

Adult intussusception is a rare cause of bowel obstruction with atypical presentation. It can be associated with primary or secondary intestinal tumors and, rarely, with lipomatous masses.

CASE REPORT

We report the case of a 69-year old man presenting with a history of gastrointestinal bleeding and anemia. Upper and lower endoscopies were negative for bleeding. On abdominal contrast enhanced computerized tomography (CT) scan, a trans-omental hernia in the right lower abdominal quadrant was diagnosed with no active bleeding or evidence of tumor. On exploratory laparoscopy we detected an ileo-ileal intussusception caused by a submucosal mass in the distal ileum, which was reduced and we then performed a segmental resection of the involved small bowel tract. The patient fully recovered by postoperative day 3 when he was discharged home. Final pathology confirmed an ileal lipoma.

CONCLUSION

Ileal intussusception caused by lipoma is a rare condition, which can be diagnosed with endoscopy, barium enema, and abdominal ultrasound or CT scanning, but preoperative diagnosis may be difficult. The treatment of choice is the reduction of the intussusception and the resection (laparoscopic or open) of the involved tract.

KEY WORDS

Intussusception, Lipoma, Ileum, Laparoscopy, Bleeding.

Paediatric burkitt lymphoma presenting as a mandible swelling and intussusception

Burkitt lymphoma is a rare entity especially in this part of the world. We had an 11-year-old patient presented with swelling of the mandible for a short one-month duration. He was planned for excision biopsy. However developed severe abdominal pain while in the hospital and was diagnosed as intussusception after ultrasound was done. We proceeded with right hemicolectomy and excision of buccal mass. Early recognition and close monitoring of insidious jaw lesions is recommended even in young adults not within the modal age category of endemic Burkitt.

Intestinal lymphangiectasia: a rare cause of intussusception in an adolescent

Intussusception in adolescents is usually idiopathic in nature. A 17-year-old woman with diffuse large B cell lymphoma presented with signs of intestinal obstruction after initiation of induction chemotherapy. On evaluation, the patient was diagnosed to have ileoileal intussusception with intestinal lymphangiectasia as the lead point. Intestinal lymphangiectasia as a rare cause for intussusception and its relationship with lymphoma is discussed in this case report.

Recurrent Acute Abdomen as the Main Manifestation of Hereditary Angioedema

A diagnosis of hereditary angioedema is usually made with recurrent episodes of swelling of the subcutaneous tissue with a family history. We herein report a case in which recurrent acute abdomen was the main manifestation of hereditary angioedema. A 45-year-old womon presented with a 10-year history of recurrent severe abdominal pain. Abdominal computed tomography revealed remarkable submucosal edema of the ileum. A blood examination revealed grossly reduced complement C4 and CH50 with deficiency of C1-inhibitor. Genetic testing revealed a heterozygous nonsense mutation of the SERPING1 gene, and a diagnosis of hereditary angioedema was made. Hereditary angioedema should be listed as a differential diagnosis of recurrent acute abdomen.

Intestinal obstruction due to congenital bands in adults who have never had abdominal surgery Two case reports and a review of the literature

Congenital abdominal bands are a very rare entity and are often silent for a person's entire life. In a very few circumstances, however, they can manifest with clinical symptoms. Diagnosis of these bands is very challenging as the patient has never submitted for abdominal surgery and imaging, laboratory tests and clinical examination can be silent or unspecific. Two patients were admitted to and operated on in our hospital between June 2017 and July 2018. All patients had a bowel obstruction at the time of presentation, presenting no emission of faeces or gas. Conservative therapy was tried in one case, and surgical intervention was required. At surgery, both patients were found to have congenital bands causing the occlusion. The postoperative courses were uneventful. Small bowel obstruction (SBO) by congenital bands remains a challenging disease for surgeons. Diagnosis of SBO has to be suspected even if radiology does not indicate any relevant features. Laparoscopy should be the preferred approach, but if not feasible, then open surgery can resolve the case. KEY WORDS: Adhesions, Congenital bands, Intestinal occlusion, Laparoscopy.

Rare acute abdominal condition caused by mesenteric fibromatosis perforation: A case report

RATIONALE

Mesenteric fibromatosis is a rare benign neoplasm with a tendency to spread and recur locally, without metastasis. It may present with a wide spectrum of clinical features; however, onset as a perforation is extremely rare.

PATIENT CONCERNS

The present patient was an 18-year-old female with a 10-hour history of increasing abdominal pain that arose suddenly with nausea and vomiting. She had experienced an appendectomy 2 years before this admission.

DIAGNOSES

A gastrointestinal perforation was initially suspected on the basis of complaints and physical examination. The patient was thoroughly investigated for further diagnosis. Computed tomography showed a large well-defined intra-abdominal mass measuring 7.1 × 6.7 × 5.9 cm in the right lower quadrant, with adjacent small intestine compression and free intraperitoneal air. Then, the patient underwent a laparotomy. Finally, postoperative pathology and immunohistochemistry confirmed mesenteric fibromatosis, with a consecutive perforation from ileum to the bottom of tumor.

INTERVENTIONS

The patient has been treated by a resection of the mass with the adhesive small intestine, without chemotherapy or radiotherapy postoperatively.

OUTCOMES

The patient had an uneventful postoperative recovery. Three months after surgery, the patient reviewed the colonoscopy, no intestinal polyps were noted. The present case has been followed up for 17 months without tumor recurrence.

LESSONS

Our case illustrates another possible cause of acute abdominal pain. Although rare, treating physicians should maintain a high suspicion index while managing a patient with an abdominal mass and pain. Close follow-up is essential because of the high incidence of local tumor recurrence.

Pneumatosis intestinalis and hepatic portal venous gas associated with gas-forming bacterial translocation due to postoperative paralytic ileus: A case report

RATIONALE

Pneumatosis intestinalis (PI) and hepatic portal venous gas (HPVG) are rare but potentially lethal conditions in which gas pathologically accumulates in the portal vein and intestinal wall, respectively. Proposed mechanisms include flatus escaping through an injured intestinal mucosa into the submucosa and thence into the portal venous system, or bacterial translocation (BT) of gas-forming enteric microorganisms from the gut into and through the intestinal wall to other organs. However, there has been no clear histopathological evidence to support these hypotheses.

PATIENT CONCERNS

A 61-year-old man underwent sigmoidectomy for colonic adenocarcinoma. Postoperatively, he developed paralytic ileus and then had a sudden cardiopulmonary arrest.

DIAGNOSES

PI and HPVG were found at autopsy, presumably caused by the postoperative paralytic ileus and associated with BT of gas-forming organisms.

INTERVENTIONS

Cardiopulmonary resuscitation was unsuccessful.

OUTCOMES

Postmortem imaging indicated the presence of massive PI and HPVG. At autopsy, there was marked intestinal emphysema with diffuse ischemic mucosal necrosis and severe pneumatosis in the stomach and intestine and marked gaseous dilation of the intrahepatic portal veins. Postmortem bacterial cultures revealed enteric bacteria in the peripheral blood and liver tissue.

LESSONS

Postoperative ileus leading to intestinal mucosal damage may be associated with BT of gas-forming enteric bacteria and the rapid onset of PI and HPVG with a lethal outcome.

Obstructive ileus caused by metal staples 6 years after the initial surgery: A case report

RATIONALE

Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands installed after a surgical procedure. However, SBO caused by surgical staples used in a previous operation is unusual. Herein, we report a rare case of adhesive ileus induced by surgical staples.

PATIENT'S CONCERNS

A 58-year-old woman visited our Emergency Department with right lower quadrant (RLQ) pain and vomiting. The patient had undergone laparoscopic total hysterectomy with the Endo GIA stapler for uterine myoma 6 years prior.

DIAGNOSES

Computed tomography (CT) revealed a closed-loop obstruction with volvulus involving the distal ileum.

INTERVENTIONS

After suspected failure of conservative therapy with fluid resuscitation and Levin tube decompression, emergency laparoscopic surgery was performed. A fibrous band around the surgical staples considered to have been used in a previous operation was observed which extended to the greater omentum, through which a segment of the bowel formed a closed-loop obstruction around the right ovary.

OUTCOMES

The patient's symptoms resolved and a follow-up on post-operative day 14 showed no symptoms.

LESSONS

Surgeons using surgical staples should be aware that adhesion may occur when the staples are exposed to the abdominal cavity, which can lead to the risk of SBO several years after surgery. Thus, staples should not be exposed to the abdominal cavity, or anti-adherent substances should be used to minimize the possibility of such complications.

A case of gossypiboma diagnosed with transanal double-balloon enteroscopy

Gossypiboma is an iatrogenic granuloma caused by retained surgical gauze. A 48-year-old woman with a history of cesarean section was incidentally found to have a pelvic mass on preoperative computed tomography examination for pectus excavatum. Abdominal enhanced computed tomography showed a 40-mm mass containing air in the pelvis. The mass was suspected to be continuous with the ileum. Transanal double-balloon enteroscopy showed a small fistula that was likely caused by penetration of the ileum dozens of centimeters from the ileocecal valve. A yellow–brown, movable, and fibrous body was found in the fistula. A part of the fibrous body was extracted with forceps. Pathological examination revealed that it was gauze. This is the first reported case of an asymptomatic gossypiboma penetrating the ileum that was diagnosed with double-balloon enteroscopy. Our results suggest that double-balloon enteroscopy is useful for early diagnosis of pelvic mass penetrating intestine, including gossypiboma.

Ileal perforation in the setting of atezolizumab immunotherapy for advanced bladder cancer

Atezolizumab is a promising immunotherapy for advanced urothelial carcinoma. Like other immune checkpoint inhibitors, it can produce rare immune-related adverse events (IRAEs). Here we present the recent case of a patient with metastatic bladder cancer who developed diarrhea and abdominal pain months after beginning atezolizumab therapy. He presented to our institution with an ileal perforation secondary to atezolizumab-induced enterocolitis. After surgical repair, the patient's condition improved, and he was discharged. We discuss the management of atezolizumab-induced enterocolitis, including the importance of early recognition and intervention to prevent more devastating complications.

Adult intussusception : A 14-year retrospective study of clinical assessment and computed tomography diagnosis

BACKGROUND AND STUDY AIMS

Intussusception in adults often remains unrecognized. Our aim was to report our experience with this entity to determine the usefulness of CT scan in its preoperative diagnosis.

PATIENTS AND METHODS

The medical records and imaging studies of all patients ≥16 years of age with intussusception, who were managed at our hospitals, were retrospectively reviewed.

RESULTS

17 cases of adult intussusception (7 males, 10 females; mean age 35.9 years; age range of 16-78) were identified. The diagnosis was possible in all patients using CT scan. The underlying etiologies were colon cancer (n=2), lymphoma (n=2), small bowel polyps (n=2), jejunal lipoma (n=1), metastatic melanoma (n=1), Meckel's diverticulum (MD) (n=1) and idiopathic (n=1). In the remaining 7 patients, the intussusceptions were of the transitory form and were treated conservatively and no significant sequela occurred after a follow-up of 2-60 months. CT scan findings in transient cases characteristically showed that the intussusception was localized to the proximal intestine and all of them had a short segment (2-4 cm) of intussusception.

CONCLUSIONS

The important role of the CT in the preoperative diagnosis of intussusception and characterizing its causes cannot be overemphasized. All transient cases had a short segment of intussusception.

Endoscopic fistulotomy in inflammatory bowel disease (with video)

BACKGROUND AND AIMS

Fistulas in patients with inflammatory bowel disease (IBD) pose a key challenge in the management of these patients. We aimed to describe a novel endoscopic method to treat patients with IBD who have fistulas.

METHODS

A cohort of 29 consecutive patients with fistulas and IBD were identified in the registry of our interventional IBD unit. An endoscopic fistulotomy with needle-knife was performed. The primary outcome was healing of the fistula without the need for surgical intervention.

RESULTS

A total of 29 patients underwent endoscopic fistulotomy; and the mean (± standard deviation) age of patients undergoing the procedure was 44.2 ± 14.6 years. Thirteen patients were male (44.8%), and 16 were female (55.2%). Twenty-six patients (89.6%) achieved complete resolution of the fistula as confirmed by endoscopy with a guidewire and/or cross-sectional abdominal imaging, with 10 patients (34.4%) requiring a single endoscopic treatment session. Three patients (10.3%) had a persistent fistula and required surgical intervention. One patient had postoperative bleeding requiring blood transfusion and hospitalization.

CONCLUSION

Endoscopic fistulotomy with a needle-knife appears to be safe and effective in treating IBD-related fistulas.

Laparoscopic treatment of a vesicointestinal fistula due to a Meckel's diverticulum: a case report and review of the literature

While there have been numerous reports about colovesical fistulas and ruptured intestinal diverticula, there have been far fewer reports about vesicointestinal fistulas caused by Meckel's diverticula. Most Meckel's diverticula are asymptomatic. Furthermore, they seldom cause vesicointestinal fistulas, and the associated complications are non-specific. Thus, their preoperative diagnosis is difficult. We experienced a case in which a vesicointestinal fistula was caused by a Meckel's diverticulum and was treated with laparoscopic surgery. A 46-year-old male was referred to our hospital after exhibiting hematuria. Cystoscopy revealed a fistula between the small intestine and bladder. Contrast-enhanced computed tomography and magnetic resonance imaging showed a diverticulum in the ileum and a fistula between the ileum and bladder, which passed through the diverticulum. A Meckel's diverticulum was suspected. We conducted a laparoscopic operation. We dissected the Meckel's diverticulum with an automatic suturing device and removed it together with part of the ileum. The patient's postoperative course was good. We experienced a case in which a vesicointestinal fistula was caused by a Meckel's diverticulum and was successfully treated with laparoscopic surgery. In selected cases of Meckel's diverticulum, the dissection of the diverticulum with an automatic suturing device is appropriate.

Neonatal Intestinal Obstruction Syndrome

Neonatal intestinal obstruction is caused by an anatomical abnormality that produces bowel movement failure. Intestinal obstruction presents with three classic clinical signs: vomiting, abdominal distention, and failure to pass meconium. Intestinal obstruction is one of the most common causes for admitting a pediatric patient to the pediatric surgery unit in his or her first weeks of postnatal life. Congenital obstruction of the digestive tract in neonates is a common problem, with the most frequent cause being anorectal malformations (41%), followed by esophageal obstruction (24%), and duodenal obstruction (20%). [Pediatr Ann. 2018;47(5):e220-e225.].

Blunt abdominal trauma following gunshot wound Case report and literature review

Blunt abdominal trauma following gunshot wound. Case report and literature review Introduction: Similarly to blast weapons, every firearm produces explosion at the moment of shooting, which can cause injuries in every region of the body. The aim of this paper is to present the mechanism of blunt abdominal injury following gunshot wounds, bringing this uncommon disease to the clinicians' attention and to review the literature available.

CASE REPORT

A patient developed a delayed bowel perforation following a gunshot injury of the abdomen without breaking of the peritoneum. It was clinically suspected eight hours later and confirmed with contrast-enhanced computed tomography scan. The patient underwent immediate laparotomy. Resection, end-to-end anastomosis, and large lavage of the peritoneal cavity was performed. The patient was discharged ten days after operation in good condition.

CONCLUSION

Failure to recognize blunt trauma mechanism following firearm wounds increases the risk of missed injuries. Distant injuries should be suspected in all cases after blast wave and firearms exposure and a follow up should be done for many days to make sure such injuries are excluded. CT scan total body is recommended in all such cases. Key words: Blunt trauma, Distant Injuries, Firearm injuries, Pressure Waves.

Small Bowel Obstruction: A Review of 456 Cases in a West of Ireland Region

A retrospective study was carried out of 456 patients with small bowel obstruction (SBO). The operative findings of all patients who presented with SBO between 1977 and 1982 were compared and contrasted with those who presented during equivalent periods in the previous three decades. Obstructed hernias still account for the highest percentage of cases. Surprisingly, adhesions as a causative factor are not significantly more common than they were three decades ago, despite the enormous increase in the frequency with which abdominal surgery is now being carried out. The postoperative mortality rate for the period 1977–82 was 14%.

Development of a total colectomy and ileorectal anastomosis rat model to evaluate colonic metaplasia

BACKGROUND

Ulcerative colitis is an idiopathic inflammatory condition of the colon that may require surgical intervention including proctocolectomy and either ileal pouch-anal anastomosis or in the pediatric population, low ileorectal anastomosis (IRA). Often, subsequent physiologic alteration (or colonic metaplasia) occurs in the anastomosed small bowel that includes changes in mucin content, villous blunting, and increased expression of WNT5A, a marker of colonic crypt regeneration. We developed a rat low IRA model to assess and study the development of colonic metaplasia.

MATERIALS AND METHODS

We subjected male Sprague-Dawley rats (n = 17) to total colectomy and low IRA surgery and evaluated healing periodically by endoscopic evaluation. The ileum upstream of the anastomosis was assessed by hematoxylin and eosin staining, and the mucin content was measured by high iron diamine-Alcian blue staining. Wnt5a transcripts were quantified by reverse transcription and quantitative polymerase chain reaction at the 8-wk study end point.

RESULTS

Although no gross endoscopic evidence of inflammation was seen throughout the course of the study, colonic metaplasia in the small bowel was detected in 7 out of 10 (70%) rats at the study end point. In rats with colonic metaplasia, enhanced expression of Wnt5a was evident at the study end point compared to levels in the terminal ileum at the time of surgery.

CONCLUSIONS

Within 4-8 wk, the majority of rats subjected to IRA developed colonic metaplasia defined by villous blunting, changes in mucin content, and increased expression of Wnt5a. This model provides a method to study small bowel colonic metaplasia.

A Rare Case of MALT Lymphoma Underlying Ileocecal Intussusception

Intussusception is an extremely rare diagnosis in adults, with an etiologic process identified in the majority of cases. The authors describe an unusual case of mucosa-associated lymphoid tissue (MALT) lymphoma as the underlying cause of ileocecal intussusception in an elderly woman. The patient presented with complaints of abdominal pain of variable intensity that had increased in severity over the past several months. A contrast-enhanced computed tomographic scan revealed evidence of ileocecal intussusception, and a subsequent exploratory laparotomy revealed high-grade bowel obstruction. Early recognition of intussusception is critical to appropriate management and resolution.

Small bowel obstruction caused by Anisakis and Meckel's diverticulum: a rare case

INTRODUCTION

Anisakiasis is a parasitic infection caused by the ingestion of raw fish contaminated by larval nematodes of Anisakis species. Intestinal or extraintestinal manifestations are rated to > 4% and >1% respectively.

PRESENTATION OF CASE

A 61-year old patient was admitted to our General Surgical and Emergency Unit because of sudden abdominal pain, vomit and constipation. He had eaten raw fish 3 days before admission. Laboratory data showed high levels of WBC and PCR. CT scanning showed "dilation of jejunum and ileum loops, thickening of the terminal ileum and cecum and signs of inflammation of the intestinal wall and mesentery". The following emergency surgical procedure was performed: laparotomy with evidence of obstruction of the small bowels, a giant Meckel's diverticulum, resection of terminal ileum and cecum and ileocolonic anastomosis. At the microscopic examination, the intestinal wall appeared occupied by a transmural inflammatory infiltrate, mainly eosinophilic, edema and nematode larvae, referable to Anisakis, surrounded by necrotic-inflammatory material. Moreover, there was evidence of giant a Meckel's diverticulum.

DISCUSSION

Normally, enteric anisakiasis exhibits leukocytosis with eosinophilia and high CRP levels. There are cases of successful medical treatment and other cases of endoscopic treatment avoiding surgical procedure. In our case, enteric Anisakias had not been taken into consideration at the moment of the operation and only histopathology could reveal Anisakis larvae inside the intestinal wall.

CONCLUSION

Our surgical approach is considered in literature as the best one for this clinical presentation. Those patients need to be better studied and more attention should be paid to their history.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn's disease. A single center experience

INTRODUCTION

The terminal ileum is the most involved tract in Crohn's disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy.

PATIENTS AND METHODS

We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications.

RESULTS

21 patients underwent an ileocecal resection for complicated Crohn's disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The preintervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line.

DISCUSSION

Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn's disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical.