Gastrointestinal involvement in STEC-associated hemolytic uremic syndrome: 10 years in a pediatric center

BACKGROUND

The gastrointestinal (GI) tract represents one of the main targets of typical hemolytic uremic syndrome (HUS) in children. In this observational study, we tried to establish (1) the main features of GI complications during STEC-HUS and (2) the relationship between Escherichia coli serotypes and Shiga toxin (Stx) variants with hepatopancreatic involvement.

METHODS

A total of 79 STEC-HUS patients were admitted to our pediatric nephrology department between January 2012 and June 2021. Evidence of intestinal, hepatobiliary, and pancreatic involvements was reported for each patient, alongside demographic, clinical, and laboratory features. Frequency of gastrointestinal complications across groups of patients infected by specific E. coli serotypes and Stx gene variants was evaluated.

RESULTS

Six patients developed a bowel complication: two developed rectal prolapse, and four developed bowel perforation which resulted in death for three of them and in bowel stenosis in one patient. Acute pancreatitis was diagnosed in 13 patients. An isolated increase in pancreatic enzymes and/or liver transaminases was observed in 41 and 15 patients, respectively. Biliary sludge was detected in three, cholelithiasis in one. Forty-seven patients developed direct hyperbilirubinemia. Neither E. coli serotypes nor Shiga toxin variants correlated with hepatic or pancreatic involvement.

CONCLUSIONS

During STEC-HUS, GI complications are common, ranging from self-limited elevation of laboratory markers to bowel perforation, a severe complication with a relevant impact on morbidity and mortality. Hepatopancreatic involvement is frequent, but usually short-lasting and self-limiting.

Sensorineural hearing loss as an atypical presentation of typhoid fever: A case report

Typhoid fever, also known as enteric fever, is a multisystemic infection primarily caused by Salmonella enterica serotype Typhi, and less commonly by Salmonella enterica serotypes Paratyphi A, B, and C. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. If left untreated, typhoid fever can progress to delirium, obtundation, intestinal haemorrhage, bowel perforation, and death within a month of onset. However, the clinical course can deviate from the classic stepladder fever pattern, which now occurs in as few as 12% of cases.1 In this report, we describe an atypical presentation as sensorineural hearing loss in an otherwise healthy young male.

IMPACT OF THE COVID-19 PANDEMIC ON THE EMERGENCY SURGICAL TREATMENT OF COLORECTAL CANCER

BACKGROUND

Colorectal cancer (CRC) is the most common malignancy of the gastrointestinal tract and the third most common type of cancer worldwide. The COVID-19 pandemic, during the years 2020 and 2022, increased the difficulties in offering adequate early diagnosis and treatment to CRC patients worldwide. During this period, it was only possible to treat patients who evolved with complications, mainly intestinal obstruction and perforation.

AIMS

To assess the impact of the COVID-19 pandemic on the treatment of patients with CRC.

METHODS

A review of data from a total of 112 patients undergoing emergency surgical treatment due to complications of CRC was carried out. Of these, 78 patients underwent emergency surgery during the COVID-19 pandemic (2020/2021), and 34 were treated before the pandemic (2018/2019). Ethnic aspects, clinical symptoms, laboratory tests, histopathological variables, intra and postoperative complications, and 90-day postoperative follow-up were compared between the two groups.

RESULTS

Between the years 2018 and 2019, 79.4% (27/34) of patients had intestinal obstruction, while 20.6% (7/34) had intestinal perforation. During the period of the COVID-19 pandemic (2020/2021), 1.3% (1/78) of patients underwent surgery due to gastrointestinal bleeding, 6.4% (5/78) due to intestinal perforation, and 92.3% (72/78) due to intestinal obstruction. No statistically significant differences were recorded between the two groups in ethnic aspects, laboratory tests, type of complications, number of lymph nodes resected, compromised lymph nodes, TNM staging, pre or intraoperative complications, length of stay, readmission, or mortality rate. When considering postoperative tumor staging, among patients operated on in 2018/2019, 44.1% were classified as stage III and 38.2% as stage IV, while during the pandemic period, 28.2% presented stage III and 51.3% stage IV, also without a statistically significant difference between the two periods. Patients operated on during the pandemic had higher rates of vascular, lymphatic and perineural invasion.

CONCLUSIONS

The COVID-19 pandemic increased the rate of complications related to CRC when comparing patients treated before and during the pandemic. Furthermore, it had a negative impact on histopathological variables, causing worse oncological prognoses in patients undergoing emergency surgery.

Novel pathogenic GATA6 variant associated with congenital heart disease, diabetes mellitus and necrotizing enterocolitis

BACKGROUND

Pathogenic GATA6 variants have been associated with congenital heart disease (CHD) and a spectrum of extracardiac abnormalities, including pancreatic agenesis, congenital diaphragmatic hernia, and developmental delay. However, the comprehensive genotype-phenotype correlation of pathogenic GATA6 variation in humans remains to be fully understood.

METHODS

Exome sequencing was performed in a family where four members had CHD. In vitro functional analysis of the GATA6 variant was performed using immunofluorescence, western blot, and dual-luciferase reporter assay.

RESULTS

A novel, heterozygous missense variant in GATA6 (c.1403 G > A; p.Cys468Tyr) segregated with affected members in a family with CHD, including three with persistent truncus arteriosus. In addition, one member had childhood onset diabetes mellitus (DM), and another had necrotizing enterocolitis (NEC) with intestinal perforation. The p.Cys468Tyr variant was located in the c-terminal zinc finger domain encoded by exon 4. The mutant protein demonstrated an abnormal nuclear localization pattern with protein aggregation and decreased transcriptional activity.

CONCLUSIONS

We report a novel, familial GATA6 likely pathogenic variant associated with CHD, DM, and NEC with intestinal perforation. These findings expand the phenotypic spectrum of pathologic GATA6 variation to include intestinal abnormalities.

IMPACT

Exome sequencing identified a novel heterozygous GATA6 variant (p.Cys468Tyr) that segregated in a family with CHD including persistent truncus arteriosus, atrial septal defects and bicuspid aortic valve. Additionally, affected members displayed extracardiac findings including childhood-onset diabetes mellitus, and uniquely, necrotizing enterocolitis with intestinal perforation in the first four days of life. In vitro functional assays demonstrated that GATA6 p.Cys468Tyr variant leads to cellular localization defects and decreased transactivation activity. This work supports the importance of GATA6 as a causative gene for CHD and expands the phenotypic spectrum of pathogenic GATA6 variation, highlighting neonatal intestinal perforation as a novel extracardiac phenotype.

Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital

BACKGROUND

International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable.

OBJECTIVE

To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness.

MATERIALS AND METHODS

A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded.

RESULTS

A total of 131 children (age range 2 months to 6 years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24 h after initial reduction which were again reduced by the same method.

CONCLUSION

Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.

Clinical course and management of an unknown multiple-magnet ingestion in a teenage male

Foreign body ingestion in the paediatric population, especially when the details surrounding the ingestion are unknown, can be particularly difficult to manage. Magnets pose a unique challenge, as their magnetic field and caustic properties can instigate significant damage to the gastrointestinal tract if not treated in a timely manner. We report the case of a teenage male who presented to the emergency department with a chief complaint of cramping and abdominal pain. He was found to have multiple metallic foreign bodies within the lumen of the stomach, the distal ileum and the ascending colon/ileocecal valve region, which he did not have any recollection of ingesting. The management of an unknown multiple-magnet ingestion in the older paediatric population is not well documented, and this case may provide unique insight for the management of similar cases.

Antenatal Steroids, Prophylactic Indomethacin, and the Risk of Spontaneous Intestinal Perforation

OBJECTIVE

To estimate if the odds of spontaneous intestinal perforation (SIP) are increased when antenatal steroids (ANS) given close to delivery are combined with indomethacin on day 1 after birth (Indo-D1).

STUDY DESIGN

A retrospective cohort study using the Neonatal Research Network (NRN) database of inborn infants, gestational age 220-286 weeks or birth weight of 401-1000 g, born between January 1, 2016 and December 31, 2019, and surviving >12 hours. The primary outcome was SIP through 14 days. Time of last ANS dose prior to delivery was analyzed as a continuous variable (using 169 hours for durations >168 hours or no steroid exposure). Associations between ANS, Indo-D1, and SIP were obtained from a multilevel hierarchical generalized linear mixed model after covariate adjustment. This yielded aOR and 95% CI.

RESULTS

Of 6851 infants, 243 had SIP (3.5%). ANS exposure occurred in 6393 infants (93.3%) and IndoD1 was given to 1863 infants (27.2%). The time (median, IQR) from last dose of ANS to delivery was 32.5 hours (6-81) vs 37.1 hours (7-110) for infants with or without SIP, respectively (P = .10). Indo-D1 was given to 51.9 vs 26.3% of infants with SIP vs no SIP, respectively (P < .0001). Adjusted analysis indicated no interaction between time of last ANS dose and Indo-D1 for SIP (P = .7). Indo-D1 but not ANS was associated with increased odds of SIP (aOR: 1.73, 1.21-2.48, P = .003).

CONCLUSION

The odds of SIP were increased after receipt of Indo-D1. Exposure to ANS prior to Indo-D1 was not associated with an increase in SIP.

Electro-microenvironment modulated inhibition of endogenous biofilms by piezo implants for ultrasound-localized intestinal perforation disinfection

Endogenous bacterial infections from damaged gastrointestinal (GI) organs have high potential to cause systemic inflammatory responses and life-threatening sepsis. Current treatments, including systemic antibiotic administration and surgical suturing, are difficult in preventing bacterial translocation and further infection. Here, we report a wireless localized stimulator composed of a piezo implant with high piezoelectric output serving as an anti-infective therapy patch, which aims at modulating the electro-microenvironment of biofilm around GI wounds for effective inhibition of bacterial infection if combined with ultrasound (US) treatment from outside the body. The pulsed charges generated by the piezo implant in response to US stimulation transfer into bacterial biofilms, effectively destroying their macromolecular components (e.g., membrane proteins), disrupting the electron transport chain of biofilms, and inhibiting bacterial proliferation, as proven by experimental studies and theoretical calculations. The piezo implant, in combination with US stimulation, also exhibits successful in vivo anti-infection efficacy in a rat cecal ligation and puncture (CLP) model. The proposed strategy, combining piezo implants with controllable US activation, creates a promising pathway for inhibiting endogenous bacterial infection caused by GI perforation.

circFLNA promotes intestinal injury during abdominal sepsis through Fas-mediated apoptosis pathway by sponging miR-766-3p

BACKGROUND

Intra-abdominal infections are the second most common cause of sepsis in the intensive care unit. Intestinal epithelial injury due to abdominal sepsis results in a variety of pathological changes, such as intestinal bacteria and toxins entering the blood, leading to persistent systemic inflammation and multiple organ dysfunction. The increased apoptosis of intestinal epithelial cells induced by sepsis further exacerbates the progression of sepsis. Although several studies have revealed that circRNAs are involved in intestinal epithelial injury in sepsis, few studies have identified the roles of circRNAs in intestinal epithelial apoptosis.

METHODS

We used laser capture microdissection to obtain purified epithelial cells located in intestinal crypts from four patients with abdominal sepsis induced by intestinal perforation and four samples from age and sex-matched non-septic patients. Microarray analysis of circRNAs was conducted to assess differentially expressed circRNAs between patients with and without sepsis. Lastly, in vitro and in vivo assays were performed to study the mechanism of circFLNA in intestinal epithelial apoptosis during sepsis.

RESULTS

circFLNA was upregulated in the intestinal epithelium after abdominal sepsis induced by intestinal perforation. Inhibition of miR-766-3p impaired si-circFLNA-mediated inhibition of apoptosis and inflammation factor levels in lipopolysaccharide (LPS)-treated HIEC-6 cells. circFLNA aggravated apoptosis and inflammation through the Fas-mediated apoptosis pathway in both LPS-treated HIEC-6 cells and a mouse cecal ligation and puncture model.

CONCLUSION

Our findings showed that circFLNA promotes intestinal injury in abdominal sepsis through the Fas-mediated apoptosis pathway by sponging miR-766-3p. The circFLNA/miR-766-3p/Fas axis has potential as a novel therapeutic target for treating intestinal injury in sepsis.

Model for severe intracranial hemorrhage and role of early indomethacin in extreme preterm infants

BACKGROUND

To develop a model for prediction of severe intracranial hemorrhage (ICH) or death based on variables from the first 12 h of age and to compare mortality and morbidities with and without exposure to early indomethacin.

METHODS

This retrospective cohort study included extreme preterm (220/7-266/7 weeks) infants born at National Institute of Child Health and Human Development Neonatal Research Network sites. Primary outcome was a composite of severe ICH and/or death.

RESULTS

Of 4624 infants, 1827 received early indomethacin. Lower gestation, lack of antenatal steroids exposure, lower 1-min Apgar, male sex, and receipt of epinephrine were associated with severe ICH or death. Early indomethacin was associated with a lower risk of patent ductus arteriosus, bronchopulmonary dysplasia, and higher risk of spontaneous intestinal perforation.

CONCLUSIONS

A model for early prediction of severe ICH/death was developed and validated. Early indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of spontaneous intestinal perforation.

CLINICAL TRIAL REGISTRATION

Not applicable.

IMPACT

Modern data on severe ICH and neonatal morbidities in relation to prophylactic indomethacin are scarce in the published literature. Prophylactic indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of intestinal perforation. A risk estimator for severe intracranial hemorrhage/death was developed in a large cohort of extremely preterm infants. The risk estimator developed based on a large cohort of patients provides an estimate of severe intracranial bleeding for an individual infant.

The Metabolome and the Gut Microbiota for the Prediction of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation: A Systematic Review

Necrotizing enterocolitis (NEC) is the most devastating gastrointestinal emergency in preterm neonates. Research on early predictive biomarkers is fundamental. This is a systematic review of studies applying untargeted metabolomics and gut microbiota analysis to evaluate the differences between neonates affected by NEC (Bell’s stage II or III), and/or by spontaneous intestinal perforation (SIP) versus healthy controls. Five studies applying metabolomics (43 cases, 95 preterm controls) and 20 applying gut microbiota analysis (254 cases, 651 preterm controls, 22 term controls) were selected. Metabolomic studies utilized NMR spectroscopy or mass spectrometry. An early urinary alanine/histidine ratio >4 showed good sensitivity and predictive value for NEC in one study. Samples collected in proximity to NEC diagnosis demonstrated variable pathways potentially related to NEC. In studies applying untargeted gut microbiota analysis, the sequencing of the V3−V4 or V3 to V5 regions of the 16S rRNA was the most used technique. At phylum level, NEC specimens were characterized by increased relative abundance of Proteobacteria compared to controls. At genus level, pre-NEC samples were characterized by a lack or decreased abundance of Bifidobacterium. Finally, at the species level Bacteroides dorei, Clostridium perfringens and perfringens-like strains dominated early NEC specimens, whereas Clostridium butyricum, neonatale and Propionibacterium acnei those at disease diagnosis. Six studies found a lower Shannon diversity index in cases than controls. A clear separation of cases from controls emerged based on UniFrac metrics in five out of seven studies. Importantly, no studies compared NEC versus SIP. Untargeted metabolomics and gut microbiota analysis are interrelated strategies to investigate NEC pathophysiology and identify potential biomarkers. Expression of quantitative measurements, data sharing via biorepositories and validation studies are fundamental to guarantee consistent comparison of results.

A young child with acute perforated appendicitis due to Comamonas kerstersii: a rare case report

Comamonas species are rarely associated with human infections. Recent reports found that Comamonas kerstersii was associated with severe diseases such as abdominal infection and bacteremia. However, Comamonas kerstersii may be confused with Comamonas testosteroni using the automatic bacterial identification systems currently available. An 8-year-old boy who had a right iliac fossa pain and classic migration of pain at the temperature of 38.9°C. The positive strain of aerobic and anaerobic bottles of blood cultures was identified. The patient was diagnosed as acute peritonitis and perforated appendix with abdominal abscess. The bacterium was identified by routine methods, MALDI-TOF-MS. The patient was treated with exploratory laparotomy, appendectomy, tube drainage, and prescribing antibiotic treatment. The patient was discharged with complete recovery. The organisms were confirmed as Comamonas kerstersii by MALDI-TOFMS and a combination of the other results. Our findings suggest that Comamonas kerstersii infection occurs most often in association with perforated appendix and bacteremia. We presume that Comamonas kerstersii is an opportunistic pathogen or commensal with the digestive tract and appendix bacteria.

Wheel-like Magnetic-Driven Microswarm with a Band-Aid Imitation for Patching Up Microscale Intestinal Perforation

Microscale intestinal perforation can cause considerable mortality and is very difficult to treat using conventional methods owing to the numerous challenges associated with microscale operations, which require the development of new body-friendly and effective treatment methods. Swarming micro- and nanomotors have shown great potential in biomedical applications in complex and hard-to-reach environments. Herein, we present a wheel-like magnetic-driven microswarm (WLM) with a band-aid imitation to patch microscale intestinal perforations by pasting on the perforation point in mucus-filled environments. A method called "packing under rolling" was applied to make the formed microswarms denser and rounder. Microswarms with variable aspect ratios can be fabricated by tuning the frequency and strength of the external magnetic field. Actuation and navigation in a confined complex environment, locomotion on three-dimensional surfaces, and multiple switchable motion modes have been realized by combining AC and DC magnetic fields. Moreover, we demonstrated WLM controllable navigation, movement, and microscale perforation patching in the chicken intestines ex vivo. The proposed strategy will contribute to the treatment of microscale intestinal perforation and may be applicable to novel, precise topical medication and microsurgery.

Acute Perforated Appendicitis Associated with Appendiceal Diverticulitis in a Young Man: A Case Report with Literature Review

BACKGROUND Diverticulosis of the vermiform appendix is rare. In patients who present with appendicitis, appendiceal diverticulitis as a cause due is also rare. We report the case of a 35-year-old man who presented with typical symptoms and signs of acute appendicitis, which was confirmed by histopathology to be due to perforated acute appendiceal diverticulitis. CASE REPORT A 35-year-old man presented to our Emergency Department with a 1-day history of right lower-quadrant abdominal pain that radiated to the left lower quadrant, which was associated with fever, vomiting, and abdominal distention. Biochemical analysis revealed mild leukocytosis. Computed tomography (CT) revealed signs of acute perforated appendicitis and early mass formation. The patient underwent laparoscopic appendectomy. Histopathological examination revealed appendiceal diverticulitis (pseudo-diverticulum). CONCLUSIONS Appendiceal diverticulitis is a rare surgical entity and is often an overlooked diagnosis. The differential diagnosis of appendiceal diverticulitis in patients presenting with signs of acute appendicitis is important as it is associated with a higher rate of complications such as perforation and an increased risk of appendiceal neoplasms. Appendectomy is a safe and appropriate treatment for appendiceal diverticulitis.

[The 491st case: thrombocytosis, gastrointestinal hemorrhage, intestinal perforation]

Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm (MPN) featured by clonal proliferation of platelets, thrombosis and hemorrhage. Portal hypertension is a serious complication of ET associated with poor prognosis. We report a patient with ET complicated with acute upper gastrointestinal hemorrhage and intestinal perforation due to portal hypertension. She had an uneventful recovery after surgical and endoscopic treatment.

Evaluation of Mannheim's Peritonitis Index in Prediction of Mortality in Patients with Non-traumatic Hollow Viscus Perforation Peritonitis

BACKGROUND

Hollow viscus perforation peritonitis is one of the commonest surgical emergencies with high mortality and morbidity. The objective of this study was to evaluate the effectiveness of Mannheim's peritonitis index in prediction of mortality in these patients.

METHODS

This is a retrospective, observational cohort study in these patients managed in a single-center from January 1, 2013 to December 30, 2019. Total index scores were plotted in the receiver operating characteristic curves to find out the cut-off point. Sensitivity, specificity, relative risk, positive and negative predictive values were calculated. The individual risk factors were analyzed for mortality as well.

RESULTS

Case records of 395 cases of non-traumatic hollow viscus perforation peritonitis were available, there were 33 mortalities (8.2%), mean score was 22.96 (+7.6) points (range 10-43 points). The sensitivity and specificity with score cut-off of 25 came to be 75.8% and 56.35%; positive and negative predictive value being 13.7% and 96.2%. Risk of patients for mortality with scores >25 was 3.62 times those with scores <25 for mortality. Mortality rate was 2.4% with scores <21, 8.9% with 21-29 and 20.9% with >29 respectively (p-value <0.05). Univariate analysis showed age >50 years, presence of organ dysfunction, diffuse peritonitis, non-colonic origin and character of exudates were significant factors; multivariate analysis showed only organ failure as significant.

CONCLUSIONS

Mannheim peritonitis index is very useful in stratification of severity of the disease and prediction of mortality in patients with peritonitis, and should be included in management of all these patients.

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection

IMPORTANCE

Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown.

OBJECTIVE

To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants.

EXPOSURES

Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis.

MAIN OUTCOMES AND MEASURES

The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset.

RESULTS

In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality.

CONCLUSIONS AND RELEVANCE

The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

Successfully endoscopic retrieval of ingested toothpicks in colorectum : a report of four cases

BACKGROUND

Toothpick ingestion is a rare event, but due to the low efficacy of radiographic examination, it can induce severe complications including perforation, abscess, and sepsis.

CASE REPORT

Four patients with either defecation problems or abdominal/anal pain were admitted to our hospital. Colonoscopy showed all four cases had a toothpick impacted in the colorectal wall without perforation. Direct retrieval of the toothpick under endoscopy was achieved. All four patients were relieved and remained well during the follow-up.

CONCLUSION

Endoscopy is the most effective method to discover or retrieve ingested wooden foreign bodies when there are no severe complications.

[Non-surgical management of small bowel diverticulitis with localized perforation:a case report]

A 40-year-old man presented to the emergency department with periumbilical pain and fever. A computed tomographic scan confirmed multiple jejunal diverticulum with localized extraluminal air and panniculitis around it, and jejunal diverticulitis with localized perforation was suspected. His symptoms were mild, and extraluminal air was localized;therefore, he was advised bowel rest and administered only antibiotics. The patient's symptoms resolved without surgical treatment, and at the time of writing this report, there had been no recurrence. Small bowel diverticulitis is rare, and careful analysis of imaging studies is necessary for establishing a diagnosis. This was a rare case where small bowel diverticulitis was resolved without surgical treatment.

Interleukin 28 is a potential therapeutic target for sepsis

Identification of new therapeutic targets for the treatment of sepsis is imperative. We report here that cytokine IL-28 (IFN-λ) levels were elevated in clinical and experimental sepsis. Neutralization of IL-28 protected mice from lethal sepsis induced by cecal ligation and puncture (CLP), which was associated with improved bacterial clearance and enhanced neutrophil infiltration. Conversely, administration of recombinant IL-28 aggravated mortality, facilitated bacterial dissimilation and limited neutrophil recruitment, in the model of sepsis induced by CLP. This study defines IL-28 as a detrimental mediator during sepsis and identifies a potential therapeutic target for the immune therapy in sepsis.

[A Case of Duodenal Perforation during Bevacizumab Combination Chemotherapy in a Patient with Multiple Lung Metastasis after a Sigmoidectomy]

A 73-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Two years after the operation, multiple lung metastasis was diagnosed and chemotherapy with bevacizumab, irinotecan, and TS-1®was started in the patient. However, epigastric pain developed 73 days after the initial course of chemotherapy. Abdominal CT revealed duodenal perforation and generalized peritonitis. Emergency operation with omental patch closure was immediately performed. The patient was discharged 15 days after the emergency operation without any complication. This is an extremely rare case of bevacizu- mab-related duodenal perforation.

Hepatic STAT3 inhibition amplifies the inflammatory response in obese mice during sepsis

The purpose of this study was to better understand the role obesity plays in the inflammatory response during sepsis, specifically regarding the Janus kinase/signal transducers and activators of transcription (JAK/STAT) pathway in the liver. We hypothesized that inhibiting STAT3 would lead to an increase in the inflammatory response and that obesity would amplify this effect. To investigate this, we inhibited STAT3 in two ways: pharmacological systemic inhibition and genetic hepatic-specific inhibition. In pharmacological inhibition studies, male C57BL/6 mice were randomized to a high-fat (60% kcal fat) or normal (16% kcal fat) diet for 6-7 wk and pretreated with Stattic before inducing sepsis by cecal ligation and puncture. In genetic inhibition studies, mice were randomized by genotype before induction of sepsis. To investigate obesity in mice with hepatic-specific STAT3 inhibition, we randomized mice to a high-fat or normal diet as described above for 6 mo before induction of sepsis. Body composition was analyzed using EchoMRI. We found that systemic STAT3 inhibition by Stattic resulted in an increased inflammatory response and that obesity amplified this effect. We also found that genetically inhibiting STAT3 in the liver resulted in higher mortality, increased inflammation, and liver injury. High-fat-fed mice with hepatic STAT3 inhibition gained more weight and had more fat than control mice on the same diet, and obesity increased neutrophil infiltration to the liver of these mice during sepsis. In conclusion, STAT3 plays an important regulatory role in the inflammatory response during sepsis, and obesity contributes to the dysregulated response observed when STAT3 is inhibited.

Reply to the Letter to the Editor: Comment to Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature

Dear Editor, We thank the authors of this letter to the editor for the valuable information that they provided. We are familiar to the fact that conservative management is gaining ground against surgical treatment and this fact is mentioned in our article. This fact is better highlighted through the references that the authors of the letter to the editor provided and their comments.

Comment to Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature

Dear Editor, I would like to congratulate the authors of this well written article and to thank them for the contribution to the literature. There is, however, one point that needs to be addressed, and that is the outcomes of surgical versus conservative treatment. Areview article1 has published data on 266 patients (106 patients derived from published case reports containing individual patient data, 113 patients derived from the Norwegian patient registry and data on 47 patients as historical controls from a previous publication and used as historical controls(Chendrasekhar et al2). It seems that conservatively treated patients had similar hospital length of stay as operated patients. Age did correlate with hospital stay, howeverno difference in outcomes for operated or non-operated patients was found. The historical control group did show a significantly higher mortality, implying that attempting conservative therapy after diagnosis through an abdominal CT scan (which often does show pneumoperitoneum) can only benefit this frail patient group.

Gastrointestinal complications after lung transplantation in Japanese patients

PURPOSE

Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx.

METHODS

Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications.

RESULTS

Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications.

CONCLUSIONS

Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.

Letter to the Editor: Colonic Perforation

N/A.

Bowel injury following gynecological laparoscopic surgery

Background

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.

Methods

We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.

Results

Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.

Conclusion

Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

Jejunal pseudodiverticulosis. Three cases report

Jejunal pseudodiverticulosis is an uncommon entity. Pseudodiverticulum are usually asymptomatic and an incidental finding. They can have a less frequent acute onset with perforation, obstruction or bleeding and they could have high morbidity and mortality. We report three patients who debuted with an acute abdomen.

[Application of laparoscopy in gastrointestinal abdominal emergency operation for patients over 65 years old]

OBJECTIVE

To explore the clinical application of laparoscopy in gastrointestinal abdominal emergency operation for patients over 65 years old.

METHODS

Clinical data of 138 cases (age>65 years) with acute abdomen undergoing laparoscopic surgery from January 2006 to June 2014 were analyzed retrospectively. Data of 170 cases treated by laparotomy during the same period were enrolled as controls.

RESULTS

The laparoscopy group and the laparotomy group showed statistically significant differences in blood loss [(107.1±47.7) ml vs. (163.6±106.5) ml, P=0.000], postoperative complications rate [2.9%(4/138) vs. 12.9%(22/170), P=0.022], hospital stay [(10.5±7.5) d vs. (16.5±9.9) d, P=0.044], postoperative ambulation time [(25.6±7.7) h vs. (33.2±5.6) h, P=0.020], and recovery time of postoperative gastrointestinal function [(36.9±9.1) h vs. (49.3±10.6) h, P=0.031]. Patients with acute appendicitis, upper digestive tract perforation and bowel obstruction in the laparoscopy group were superior to those in the laparotomy group in hospital stay, postoperative ambulation time, recovery time of postoperative gastrointestinal function and intraoperative blood loss(all P<0.01), while no significant differences in colon perforation and mesentery diseases were found in hospital stay, intraoperative blood loss and recovery time of postoperative gastrointestinal function between the two groups (all P>0.05).

CONCLUSIONS

Compared with laparotomy, the laparoscopy offers the advantages of less trauma, faster recovery, shorter hospital stay, and lower postoperative complications rate for patients over 65 years with acute abdomen.

True Primary Enterolith Treated by Balloon-assisted Enteroscopy

Primary enterolith is a rare condition that can induce ileus and intestinal perforation. We report the first case of a true primary enterolith treated by balloon-assisted enteroscopy. The patient presented with a small intestinal ileus. After its improvement following the insertion of an ileus tube, radiography with amidotrizoate sodium meglumine detected a round, movable defect in the ileum measuring 42 mm diameter. The patient was diagnosed with a primary enterolith based on her past history. The enterolith was fractured and removed using balloon-assisted enteroscopy. This case suggests that balloon-assisted enteroscopy may be an effective non-invasive treatment option for enteroliths.

[Stapled vs. hand-sewn colorectal anastomosis in complicated colorectal cancer--a retrospective study]

Emergens in colorectal pathology are in most cases by complications of cancer. The prognosis for colorectal cancer is poor when this pathology is addressed in emergency situations because, on one hand, of the organ specific structure, blood supply, septic content and, on the other hand, because of the special group of patients with this pathology: aged, immunosuppressed and with various comorbidities. The high rate of postoperative complications of these patients requires a specific management. The development and improvement of medical devices has brought to the surgeons new products among which mechanice devices for anastomoses. In this study we compared two groups of operated patients (with hand sutured and stapled anastomoses) who presented as emergences with complications of colorectal cancer.

MATERIAL AND METHOD

Retrospective clinical study with a total of 72 patients who underwent a colorectal resection procedure in emergency in our clinic (Emergency Hospital Bucharest) over a period of 2 years (2007-2008).

RESULTS

The 72 patients who required emergency surgery were randomly assigned to 2 categories according to the type of anastomosis: hand sutured (group 1, n = 34) and stapled (group 2, n = 38). Age, sex, comorbidities, and tumor staging were comparable in both groups. The emergency was represented by obstruction (56.94%), hemorrhage (8.33%) and perforation (34.72%). The mortality (10.5% vs. 8.8%) and orbidity rate (20.83% vs. 15.27%) was higher in the stapled anastomosis group. The average duration of the surgical procedure performed in emergency was also quantified and was 118 min. (group 2) vs. 236 min. (group 1) respectively.

CONCLUSION

Comparison did not disclose any significant difference in the number of complications in these two groups. Anastomosis is safe in emergency colorectal surgery and the reduction of the operative time may also improve the outcome of these patients.

The effect of β-glucan on trace element levels in intra-abdominal sepsis in rats

Sepsis is associated with the development of progressive damage in multiple organ systems. The beneficial effect of glucans has been attributed to modulation of immune function and enhances defense against bacterial, viral, fungal, and parasitic infections. The aim of this study was to investigate the putative protective effect of ß-glucan on changes of trace element levels in various tissues after experimental sepsis in rats. Sepsis was induced by cecal ligation and perforation (CLP) in 28 male Wistar albino rats. To evaluate this, rats were divided into four groups as sham operated, ß-glucan treated sham operated, CLP, and ß-glucan treated CLP. Sixteen hours after operation, rats were decapitated and zinc (Zn) and copper (Cu) levels were determined in the liver, kidney, heart, diaphragm, and lung tissues. The results demonstrate that sepsis significantly decreased zinc and copper levels of all tissues. The decrease in tissue zinc and copper levels demonstrates the role of trace elements in sepsis-induced tissue damage. Our results indicated that ß-glucan administration did not return the zinc and copper levels to the control group level, and it seems likely that the given dose of ß-glucan was insufficient to prevent sepsis-induced organ injury.