Characteristics, treatment, and outcome of patients with bowel perforation after immune checkpoint inhibitor exposure

PURPOSE

Exposure to immune checkpoint inhibitors (ICIs) can predispose to immune-related adverse events (irAEs) involving the gastrointestinal tract. The association between ICIs and bowel perforation has not been well studied. We aimed to describe the clinical course, complications, treatment, and outcomes of patients experiencing bowel perforation during or after ICI treatment.

METHODS

This retrospective, single-center study included adult cancer patients with bowel perforation that occurred between the first dose of ICI treatment and up to 1 year thereafter between 1/1/2010 and 4/30/2021. Patients' clinical course, imaging, treatment, and outcomes related to bowel perforation were collected and analyzed.

RESULTS

Of the 13,991 patients who received ICIs during the study period, 90 (0.6%) met the inclusion criteria. A majority were male (54.4%), the most common cancer type was melanoma (23.3%), and most patients had received PD-1/L1 inhibitor treatment (58.8%). Onset of perforation occurred after a median of four ICI treatment cycles. The most common symptom was abdominal pain (95.5%). The colon was the most common location for the perforation (37.7%). Evidence of diverticulitis, enterocolitis, or appendicitis was seen in 32 (35.6%) patients, and 6 (6.6%) patients had luminal cancer involvement at the time of perforation. The overall hospitalization rate related to perforation was 95.5%, with mortality of 15.5% during the same admission. Antibiotics were given in 95% of our sample; 37.8% of patients also required surgical/interventional radiology intervention. Forty-six patients (51.1%) had perforation-related complications (e.g., sepsis, fistula, abscess), which were associated with a higher mortality rate (30%).

CONCLUSION

Our findings suggest a low incidence of bowel perforation after ICI treatment (0.6%), with 40% of patients having coexisting bowel inflammation as a potential contributing factor. Patients with bowel perforation had an aggressive disease course and high rates of hospitalization, complications, and mortality. Early recognition and prompt intervention is critical to improve patient outcomes. Future studies are warranted to further investigate the cause, predictive markers, and optimal treatment for this patient population.

Salvage camrelizumab for an intractable NK/T cell lymphoma patient with two instances of intestinal perforation: a case report and literature review

BACKGROUND

The prognosis of natural killer/T cell lymphoma (NKTCL) with multifocal small intestine involvement complicated by intestinal perforation is extremely poor. There is no evidence-based treatment strategy for this intractable condition.

CASE PRESENTATION

A 30-year-old male was admitted to our hospital in April 2017 and presented with recurrent fever for three months and multiple painless subcutaneous nodules in the abdominal wall. An excision biopsy of the subcutaneous nodules in the abdominal wall revealed NKTCL. The patient was diagnosed with stage IVB NKTCL with skin and multifocal small intestinal involvement according to the imaging results. The first intestinal perforation occurred due to tumor infiltration before the initial treatment. The second intestinal perforation occurred after receiving two cycles of chemotherapy with a modified SMILE regimen. The histone deacetylase inhibitor (HDACi) chidamide was administered as a single-agent therapy after recovery from the second intestinal perforation. Complete remission was achieved. Unfortunately, five months later, the patient was confirmed to have relapsed and received the salvage chemotherapy. The patient suffered from disease progression again after the fourth cycle of chemotherapy. At this point, from May 29, 2018, the patient started to receive injections of the anti-programmed death 1 (PD-1) antibody camrelizumab as a salvage treatment. Two months after the initial anti-PD-1 antibody camrelizumab injection, the response was partial remission. Disease progression was confirmed in March 2021, with a progression-free survival time of 34 months.

CONCLUSIONS

NKTCL patients with multifocal small intestine involvement have a high risk of intestinal perforation. The possible etiologies of bowel perforation include tumor infiltration, tumor necrosis in response to therapy, and acute inflammation. The anti-PD-1 antibody camrelizumab may be a new candidate agent for treating this type of intractable NKTCL. Further observations are necessary to identify the efficacy and safety of new agents in the future.

Synergistic effect of enteral nutrition on remission induction in a patient with penetrating Crohn disease: A case report

RATIONALE

Crohn disease includes 3 phenotypes, inflammatory, stricturing, and penetrating. In cases where corticosteroids and immunosuppressive agents are not suitable treatment options, enteral nutrition (EN) can be used to reduce disease severity and enhance barrier defense with fewer potential adverse effects.

PATIENT CONCERNS

A 23-year-old man with abdominal pain and diarrhea presented at our hospital in 2014. The frequency of defecation was 3 or 4 times a day without mucus or blood in the stool. His body mass index was 15.8, and in laboratory tests the erythrocyte sedimentation rate was 42.4 mm/h, serum C reactive protein was 65.2 mg/L, the leukocyte count was 11.64 × 109/L, and hemoglobin was 111 g/L.

DIAGNOSIS

In computed tomography (CT) enterography the ascending colon was thickened, and there was effusion and enlarged lymph nodes around the colon. Colonoscopy revealed ulcer, polypoid proliferation, and bowel stenosis in many segments. Chronic inflammation was evident in multiple biopsies. Crohn disease was diagnosed based on the above observations.

INTERVENTIONS

Mesalazine was administered at a dose of 4 g daily for 2 years. The patient was hospitalized again due to severe abdominal pain and ongoing fever. Intestinal perforation was detected via CT. Percutaneous drainage was performed followed by administration of intravenous metronidazole (0.5 g) and ciprofloxacin (0.2 g) twice a day. Peptison liquid was used as exclusive EN. After 2 weeks the antibiotics regimen was changed to metronidazole 0.4 g twice a day and ciprofloxacin 0.25 g 3 times a day, both administered orally.

OUTCOMES

CT revealed that the infection was eliminated and the fistula was healed after 10 weeks, at which point antibiotics and exclusive EN was discontinued. Azathioprine was prescribed at a dose of 2 mg/kg daily to maintain clinical remission. The patient did not report any pain or diarrhea at a 1-year follow-up visit.

LESSONS

The present case suggests that exclusive EN combined with antibiotics is useful in inducing remission in Crohn disease patients with active disease and penetrating complications.

Intestinal Behçet's Disease with Primary Myelofibrosis Involving Trisomy 8

Behçet's disease (BD) is a disorder characterized by systemic inflammation of multiple organs, including the intestines. Several studies have reported a relationship between myelodysplastic syndrome and BD, and trisomy 8 was frequently seen, especially in intestinal BD. However, the association of BD with primary myelofibrosis (PMF) has not been well documented. A 58-year-old Japanese female was diagnosed with PMF in 2014. The symptoms of PMF resolved with ruxolitinib. However, she developed fever and intestinal perforation due to multiple ulcers in the terminal ileum in 2017. Intestinal perforation recurred 1 month later, and the dose of ruxolitinib was tapered. After discontinuation of ruxolitinib, she presented with recurrent oral aphthous ulcers and uveitis. Subsequently, intestinal perforation recurred, and she was diagnosed with intestinal BD. Trisomy 8 was identified in her peripheral blood. She underwent steroid therapy, azathioprine, and infliximab. This case suggests relationships between PMF, trisomy 8, and BD.

Caffeine exposure and acute kidney injury in premature infants with necrotizing enterocolitis and spontaneous intestinal perforation

BACKGROUND

Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7-10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association.

METHODS

We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review.

RESULTS

A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02-0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01-0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not.

CONCLUSIONS

Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.

Counteraction of perforated cecum lesions in rats: Effects of pentadecapeptide BPC 157, L-NAME and L-arginine

AIM

To study the counteraction of perforated cecum lesion using BPC 157 and nitric oxide (NO) system agents.

METHODS

Alongside with the agents’ application (after 1 min, medication (/kg, 10 mL/2 min bath/rat) includes: BPC 157 (10 μg), L-NAME (5 mg), L-arginine (100mg) alone or combined, and saline baths (controls)) on the rat perforate cecum injury, we continuously assessed the gross reappearance of the vessels (USB microcamera) quickly propagating toward the defect at the cecum surface, defect contraction, bleeding attenuation, MDA- and NO-levels in cecum tissue at 15 min, and severity of cecum lesions and adhesions at 1 and 7 d.

RESULTS

Post-injury, during/after a saline bath, the number of vessels was significantly reduced, the defect was slightly narrowed, bleeding was significant and MDA-levels increased and NO-levels decreased. BPC 157 bath: the vessel presentation was markedly increased, the defect was noticeably narrowed, the bleeding time was shortened and MDA- and NO-levels remained normal. L-NAME: reduced vessel presentation but not more than the control, did not change defect and shortened bleeding. L-arginine: exhibited less vessel reduction, did not change the defect and prolonged bleeding. In combination, mutual counteraction occurred (L-NAME + L-arginine) or the presentation was similar to that of BPC 157 rats (BPC 157 + L-NAME; BPC 157 + L-arginine; BPC 157 + L-NAME + L-arginine), except the defect did not change. Thereby at day 1 and 7, saline, L-NAME, L-arginine and L-NAME + L-arginine failed (defect was still open and large adhesions present).

CONCLUSION

The therapeutic effect was achieved with BPC 157 alone or in combination with L-NAME and L-arginine as it was able to consolidate the stimulating and inhibiting effects of the NO-system towards more effective healing recruiting vessels.

Successful Treatment of IgA Vasculitis Complicated with Bowel Perforation and Crescentic Glomerulonephritis by Combination Therapy of Glucocorticoid, Cyclosporine and Factor XIII Replacement

We report the findings of an 18-year-old boy with immunoglobulin A vasculitis (IgAV) complicated with bowel perforation and nephritis. He presented with abdominal pain, arthralgia and palpable purpura. Massive proteinuria developed during his clinical course. The patient was treated successfully using combination therapy of glucocorticoid (GC), cyclosporine (CYA) and factor XIII (F XIII) replacement. A standard treatment strategy for severe IgAV patients has not been established due to its rarity. Combination therapy using GC, CYA and F XIII replacement should be considered for severe IgAV patients.

Effect of coenzyme Q10 on organ damage in sepsis

OBJECTIVE

Investigating the effects of coenzyme Q10 on organ damage and survival on mice in cecal ligation perforation (CLP) model in sepsis.

BACKGROUND

Coenzyme Q10 is an antioxidant molecule playing an important role in mitochondria. Mitochondrial dysfunction is an important mechanism in sepsis pathophysiology.

METHODS

Nintyfour Swiss Albino male mice were divided into 8 groups. CLP was performed in Group I. Coenzyme Q10, 100 mg/kg subcutaneously, was given 5 hours after CLP to Group II and 20 hours after CLP to Group III. Sham operation was performed in Group IV, 100 mg/kg coenzyme Q10 subcutaneously was given 5 hours after sham operation to Group V and 20 hours after sham operation to Group VI. No operation was performed in Group VII; coenzyme Q10, 100 mg/kg subcutaneously, was given to Group VIII. Antibiotics and fluid replacement were applied for 3 days. The mice still living were sacrificed at 576th hour. The organ damages were scored under light microscopy.

RESULTS

The survival of Group I and Group II was lower than that of the control groups, but the survival in the Group III was similar to control groups. It was established that spleen, kidney, heart damage and total organ damage were decreased when compared to CLP group.

CONCLUSIONS

Coenzyme Q10 is effective in decreasing histological organ damage in sepsis (Tab. 3. Fig. 1, Ref. 30).

Spontaneous perforation of primary gastric malignant lymphoma: a case report and review of the literature

BACKGROUND AND AIMS

Spontaneous gastric perforation in the absence of chemotherapy is extremely rare. The authors encountered a case of spontaneous perforation of primary gastric lymphoma.

CASE PRESENTATION

A 58-year-old man visited the authors' hospital with acute severe epigastralgia. A large amount of free gas and a fluid collection around the stomach were noted on an abdominal computed tomography scan. The results of imaging studies indicated a perforated gastric ulcer, and a distal gastrectomy was performed. There was a large perforation about 50 mm in diameter in the anterior wall of the middle part of the stomach body. Microscopically, the full thickness of the gastric wall was diffusely infiltrated by a population of large atypical lymphoid cells. The lymphoid nature of these cells was indicated by the strongly positive immunohistochemical staining for CD20 and CD10. This confirmed the diagnosis of a germinal center B-cell-like type of diffuse large B cell lymphoma. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone were administered after the operation.

RESULTS AND CONCLUSION

Gastrectomy should be considered if a giant ulcer with necrotic matter on the ulcer floor is seen on upper gastrointestinal endoscopy because of the possibility of gastric perforation. If upper gastrointestinal endoscopy shows a finding similar to the abovementioned one during chemotherapy, dose reduction of chemotherapy or gastrectomy should be considered.

Non-operative successful management of a perforated small bowel diverticulum

Jejunoileal diverticula are rare and generally asymptomatic. In the few cases of patients who develop complications such as diverticulitis, perforation, obstruction, and/or hemorrhage, conventional treatment consists of surgical resection. We describe a case of perforated jejunoileal diverticulum with localized abscess and highlight the merits of surgical vs medical management. The patient is a 77-year-old male who presented with sharp, constant abdominal pain just inferior to the umbilicus. Administration of intravenous antibiotics results in complete and long-term resolution of the patient’s symptoms. In this report, we establish a framework for safely treating perforated small bowel diverticulum without surgical exploration.

[Successful conservative treatment of coecal perforation in a patient with Ogilvie's syndrome]

The case report describes a 37-year-old woman who was diagnosed with Ogilvie's syndrome after caesarean section. Conservative treatment was initiated with minimal effect, and the patient was subsequently treated with IV neostigmine. A computed tomography of the abdomen revealed enlarged peritoneal cavity. However the patient was clinically unaffected without fever or signs of peritonitis. The perforation was managed with a conservative approach including antibiotics and close observation of the patient. After nine days the patient was discharged with normal gastrointestinal function and without further reported complications.

[Digestive tract perforations at Point G Teaching Hospital in Bamako, Mali]

AIMS

To determine the most frequent causes of the digestive perforations and to evaluate the surgical procedures, the morbidity and mortality.

PATIENTS AND METHODS

It was about a retrospective descriptive study, over 5 year's period in a visceral service of CHU du Point G, Bamako. Were included in the study all the patients operated for digestive perforation and hospitalized in the service of surgery "A". Were not included in the study patient operated not presenting a digestive perforation. Per operational etiologies of the perforations and their frequency were determined, as well as the morbidity and morbidity and mortality.

RESULTS

Files of 202 patients were collected. The average age of the patients was 28.3 ± 15.5 years with extremes of 6 and 71 years. The frequency of digestive perforations was higher in the age from 11 to 20 years (29.7%). The average time of consultation was of 7± 6 days. Abdominal pains, nauseas and vomiting, matter and gas stop (48.5%) were the most current functional signs. A "wood belly" abdomen was found in 72,3% of the cases. The radiography of abdomen without preparation found a diffuse greyness (64.7%), a pneumoperitoine (30.7%). A double antibiotic therapy was made in all the cases. A median laparotomy was practiced in 98,5%, and laparoscopy in 3 cases (1.5%). A single perforation was found among 172 patients (85,1%). Morbidity, all confused causes, was made of 30 cases of parietal suppurations (14.8%). Total mortality was 74%. According to aetiologies it was 10.3% in the typhic perforations, 4.6% in the appendicular perforations and 4.9% in the perforations of gastroduodenal ulcers.

CONCLUSION

The most frequent aetiologies of digestive perforation in our context were the typhoid fever, acute appendicitis and the gastroduodenal ulcer. The résection - joining and peritoneal toilet were the most practised procedure. The main factor of bad outcome remains the diagnostic delay burdening morbidity and mortality.

Intestinal perforation due to concomitant cytomegalovirus infection during treatment for Pneumocystis jirovecii pneumonia in a patient with rheumatoid arthritis

A 78-year-old woman with rheumatoid arthritis treated with methotrexate and corticosteroid was admitted to our hospital for dry cough and dyspnea. She was diagnosed as having Pneumocystis pneumonia based on elevated beta-D-glucan and positive PCR analysis of bronchoalveolar lavage fluid for Pneumocystis jirovecii. We started trimethoprim-sulfamethoxazole and high-dose corticosteroid therapy. Her pulmonary lesions gradually improved; however, she developed perforation of the ileum and subsequently died from sepsis. Histology of the perforated site was compatible with cytomegalovirus enterocolitis.

Effect of Bioactive Polypeptides on Leaking Large Bowel Anastomosis and Intestines in the Rat

Anastomotic leakage and postoperative adhesions represent major complications after colorectal surgery. We have previously shown a positive effect on both anastomotic strength and abdominal adhesions by the use of differently charged bioactive polypeptides. The present study aimed to investigate the effect of the same polypeptides on the healing of an insufficient intestinal anastomosis, as well as on accidental intestinal injury, in addition to measuring the preventive effect against the development of abdominal adhesions. An insufficient, and thereby potentially leaking, intestinal anastomosis and punctures of the intestine ("accidental intestinal injury model") were performed in rats. The treatment groups received intraperitoneal administration of poly-L-lysine and poly-L-glutamate, while controls received sodium chloride. Burst pressure, extent of abdominal adhesions, and postoperative complications were analyzed in both experimental models. A significant decrease of adhesions was seen in all animals treated with polypeptides (p < .05). Burst pressure was significantly higher (p < .001) in animals with intestinal perforation as seen on day 1 and then decreasing. A significant decrease in the incidence of peritonitis was also noted early (day 1) in this model (p = .002). The mortality and complications were high in the intestinal anastomosis model, though not affected by treatment with polypeptides. Intraabdominal adhesions were significantly reduced using polypeptides in this study, with no observed effect on other postsurgical complications. There were signs of less infectious complications in polypeptide treated animals. In animals with accidental intestinal injury, a higher burst pressure was noted in treated animals.

[Multiple intestinal perforations due to tuberculosis: a case report and review of the literature]

The incidence of tuberculosis in Italy steadily decreased until two decades ago, but the infection is now frequently diagnosed in common clinical practice. The Authors describe a rare acute abdominal presentation of the disease featuring a double intestinal perforation in a subject affected by pulmonary, renal and gastrointestinal miliary tuberculosis. A review of the literature is also presented. Intestinal resection is the treatment of choice in such cases, even if it leads to frequent, major complications, but the authors stress that there may be a possibility for a less radical form of management of these patients.

[Acute abdomen for perforated gastrointestinal stromal tumor (GIST). A case report]

The authors report on a case of voluminous perforated gastrointestinal stromal tumor (GIST) of small intestine and make a review to the light of most recent clinicopathologic advancements. The first clinical manifestation as acute abdomen due to their perforation extremely rare. Gastrointestinal stromal tumor (GIST) represent a rare group of multiform tumors with various biological behaviour. Were identified in the past as leiomyomas, leiomyosarcomas or leiomyoblastomas, has been reclassified on immunochemical features, with a positive expression of Kit (CD117 antigen). Traditionally the prognostic factors of these tumour are: mitotic rate, tumor size and anatomic site. The complete surgical resection and use of imatinib mesylate (Gleevec) are the best available approach.

Effect of basic fibroblast growth factor, trafermin, on entero-related fistulae, report of two cases

Entero-related fistulae are often intractable. Recently, growth factors were generally in sight with the development of regenerative medicine. Basic fibroblast growth factor (bFGF) possesses potent angiogenic activity. In Japan, recombinant bFGF, also known as Trafermin, has been administered for intractable skin ulcer for its strong effect on tissue granulation. Here, we report the effect of bFGF for entero-related fistulae. Two intractable cases were treated by applying bFGF in the fistulae after performing the enterostomy. Case 1: Postoperative intractable vesicorectal fistula was treated by bFGF. 82 days later, fistula was closed. Case 2: Colonic perforation due to ischemic colitis was treated. 37 days after treatment, fistula was closed. In conclusion, in the treatment of the intractable entero-related fistulae, Trafermin was useful for healing the fistulae.

Bilateral ureteral stenosis and duodenal perforation in a patient with dermatomyositis

We report the case of a 19-year-old man with dermatomyositis who developed abdominal pain and anuria. The examination revealed bilateral ureteral stenosis. The patient also developed multiple ulcerations of the duodenum with perforations. The clinical feature was considered to represent that of juvenile dermatomyositis, which is characterized by systemic necrotizing vasculitis. Rheumatologists should be alerted about this serious complication in patients with childhood or young adult dermatomyositis presenting with abdominal complaints.

Severity Scoring Systems for Prognosis and Efficacy of Polymyxin B-Immobilized Fiber Treatment for Colonic Perforation

PURPOSE

There is no established system for predicting prognosis and evaluating the efficacy of antiseptic treatments such as polymyxin B-immobilized fiber (PMX) according to the severity of peritonitis in patients with colonic perforation. We investigated the predictive value of various severity scoring systems for survival and for the efficacy of antiseptic treatments, to identify high-risk patients.

METHODS

We reviewed 26 consecutive patients who underwent emergency operations between 1996 and 2003 for colorectal perforation not caused by trauma or iatrogenic disease. Several severity scores, i.e., Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Mannheim Peritonitis Index (MPI), and Multiple Organ Failure (MOF) were calculated and analyzed as predictive scoring systems for prognosis, survival and efficacy of PMX treatment.

RESULTS

An APACHE II score of 19, a SOFA score of 8, an MPI score of 30, and an MOF score of 7 or more were significantly related to a poor prognosis. With or without PMX treatment, an APACHE II score of 15 or less, a SOFA score of 7 or less, an MPI score of 27 or less, and an MOF score of 7 or less were all related to a good prognosis. Conversely, all patients died when the severity scoring points were higher than 20 in APACHE II, higher than 12 in SOFA, and higher than 39 in MPI. When PMX treatment was given to patients with an intermediate score, no correlation between survival and its efficacy was found, except in the MOF scoring system.

CONCLUSION

These severity scoring systems can assist with the prediction of prognosis. They may also be useful for determining if PMX treatment would be unnecessary or ineffective in certain patients. However, the optimal application of PMX treatment in selected patients according to the severity scoring systems needs further investigation.

Sickle cell 'girdle syndrome' progressing to ischaemic colitis and colonic perforation

Abdominal pain of presumed vasocclusive origin, often termed 'girdle syndrome' because of the circumferential distribution of the pain, is common in sickle cell anaemia (SCA). Evidence of progression to bowel infarction is rare. A 27-year-old man with SCA developed chest and abdominal pain unresponsive to opiate analgesia. Abdominal X-ray showed dilated bowel loops because of partial obstruction. Despite reduction of HbS to 23% by automated red cell exchange, abdominal pain worsened. A CT scan was the most informative investigation and showed free peritoneal air. He underwent emergency hemicolectomy and reversible ileostomy formation. Histology of the resected colon was consistent with acute ischaemic colitis. Early surgical intervention remains essential in SCA when abdominal pain does not respond to maximal therapy including red cell exchange: as this case illustrates, sickle girdle syndrome has the capacity to progress to irreversible ischaemic colitis and necrotic perforation of the bowel wall.

[Leukemoid reaction with uncommonly high leucocytosis in the course of serious infection]

We present a case of 51-year old female patient with gastrointestinal perforation and septic shock leading to leukemoid reaction with WBC 155 x 109/l. Leukemoid reaction in neoplasms and infections can mimic chronic myelogenous leukaemia and is an important diagnostic problem.

Treatment of recurrent perforating intestinal ulcers with thalidomide in Behçet's disease

OBJECTIVE

To report the beneficial effects of thalidomide on recurrent perforating intestinal ulcers in a patient with Behçet's disease (BD).

CASE SUMMARY

A 24-year-old Turkish woman with BD was admitted to our hospital because of severe abdominal pain and vomiting. She had been receiving colchicine 1.5 mg/day and azathioprine 150 mg/day for treatment of BD for 2 years. During emergency laparatomy, 2 perforating ulcers were detected in the anterior cecum, which were treated with debridement and primary repair. She experienced 2 more episodes of intestinal perforations during the second and fifth weeks despite intense immunosuppressive treatment with methylprednisolone and cyclophosphamide. New intestinal perforations were found in the posterolateral cecum and transverse colon during the second operation and in the terminal ileum during the third one. Thalidomide 100 mg/day was then started, and the symptoms disappeared within 2 weeks. The woman experienced no other intestinal perforation during the follow-up period of 4 months.

DISCUSSION

The mode of action of thalidomide in BD is still unclear. In BD, various cytokines have been shown to be abnormally expressed and neutrophils are overactive. This is a possible mechanism of action with thalidomide reducing both tumor necrosis factor and the neutrophil migration.

CONCLUSIONS

Thalidomide may be an effective alternative treatment for BD patients with recurrent and perforating intestinal ulcers despite intense immunosuppressive therapy.

Effects of age on mortality and antibiotic efficacy in cecal ligation and puncture

The incidence and mortality of sepsis increase with age, consequently, 80% of the clinical mortality from sepsis occurs in patients over age 65. Despite this aged clinical population, most research models of sepsis use 6- to 16-week-old mice as patient surrogates. This age range of mice corresponds to human ages 10 to 17 years. To assess the influence of age on rodent CLP and on antibiotic therapy, we studied young (4 month), mature (12 month), and aged (24 month) mice. Male C57BL/6 mice (n = 27-30 in each age group) were subjected to cecal ligation and puncture (CLP), two punctures with a 25-gauge needle. Mice were observed untreated for 10 days. Young mice had 20% mortality, mature mice had 70% mortality (P = 0.0013 vs. young), and aged mice had 75% mortality (P = 0.0001 vs. young). To assess the effects of age on antibiotic therapy, mice were subjected to CLP as above (n = 38-40 in each age group). Mice were then randomized to treatment with intraperitoneal injections of ceftriaxone and metronidazole or normal saline. Therapy was initiated 12 h after CLP, and injections were repeated every 12 h for 7 days. Young mice saw a 56% decrease in mortality from CLP with antibiotic therapy (P = 0.001), and mature mice had a 30% decrease in mortality (P = 0.06). Aged mice saw no benefit from antibiotic therapy. We also compared plasma cytokine levels between young and aged mice after CLP. When compared with young mice, aged mice had higher levels of IL-6 and TNF-alpha 24 h after CLP. However, high IL-6 was predictive of mortality at any age. Mice appear to have age-dependent responses to intra-abdominal sepsis and to appropriate therapy.

Current practice patterns in the treatment of perforated appendicitis in children

BACKGROUND

The treatment of perforated appendicitis in children often involves a combination of surgical and medical therapy. The aim of this study was to document the degree of consensus in the current management of perforated appendicitis in children.

STUDY DESIGN

A survey was sent to all practicing pediatric surgeons in North America in April 2000 who were members of the American Pediatric Surgical Association for 1999-2000. Survey questions pertained to preoperative, perioperative, and postoperative practice patterns, particularly those issues related to use of antibiotic therapy.

RESULTS

Among eligible surgeons, 80.2% completed the survey. Although more than 80% of respondents practiced in an academic setting, only 17% of surgeons used a formal clinical practice guideline to direct care. Responses varied substantially in the duration of postoperative antibiotic therapy, the use of intravenous or oral agents or both, and the duration of hospitalization. A considerable number of patients are receiving a portion of their intravenous antibiotic therapy as outpatients.

CONCLUSIONS

There is little apparent consensus in the many aspects of perioperative and postoperative care of perforated appendicitis in children across North America. Only a fraction of surgeons currently uses a formal clinical practice guideline for treatment of perforated appendicitis, although increased pressures to develop more cost-effective therapeutic strategies can encourage development of additional guidelines. Definitive evidence to inform development of such guidelines and enhance consensus is lacking. Further studies are needed across institutions to better inform clinical decisions in light of a changing practice environment and treatment alternatives.

Results of a prospective, randomized, double blind comparison of the efficacy and the safety of sequential ciprofloxacin (intravenous/oral)+metronidazole (intravenous/oral) with ceftriaxone (intravenous)+metronidazole (intravenous/oral) for the treatment of intra-abdominal infections

The efficacy and the safety of sequential intravenous/oral (i.v./p.o.) ciprofloxacin (CIPX) plus i.v./p.o. metronidazole (MTR) was compared with i.v. ceftriaxone (CTRX) plus i.v./p.o. MTR in the treatment of complicated intra-abdominal infections. One hundred and forty two patients received study medications. Of these, 135 could be studied. Sixty-nine patients were randomized in the CIPX arm of the study and 66 in the CTRX arm. In the CIPX group 58 patients were switched to oral treatment and 11 patients remained in the intravenous arm. In the CTRX group 57 patients switched to oral MTR continuing i.v. CTRX and 9 patients remained in the i.v. branch. Success rates at the end of treatment in patients who switched to oral were 100% in both the CIPX group and the CTRX group. For validated patients continuing on oral, the success rates at the end of treatment were 63.6 and 33.3% in the CIPX and CTRX groups respectively. Overall success rates at the end of treatment and follow-up in all patients were 94.2% in the CIPX group and 89.4% in the CTRX group. Overall success rates at the end of treatment in patients with proven bacterial infection were 92.9% in the CIPX group and 88.3% in the CTRX group. Duration of hospitalization (days) for studied patients was 22.7+/-8.2 in the CIPX and 19.6+/-14.5 in the CTRX group. There was no statistical difference between the CIPX and CTRX groups in both the intent to treat and in the modified intent to treat populations. Conversion to oral therapy with CIPX/MTR was as effective as continued intravenous therapy with CTRX and oral MTR in those patients able to tolerate oral feeding.

[A questionnaire survey on antimicrobial chemotherapy for acute peritonitis]

A questionnaire survey on antimicrobial chemotherapy for acute peritonitis was conducted to obtain the consensus among abdominal surgeons in Japan in the period from January to March 2002. Forty-one of the 58 surgeons replied, and the following consensus was obtained. Antibiotics should be given as soon as possible the diagnosis of infection in the abdominal cavity is established. When the perforated viscus is demonstrated at operation, giving antibiotic should be reconfirmed whether it covers organisms in the perforated site or not. The ascites obtained at operation should be sent for bacterial culture. When postoperative course is eventful, considering WBC, body temperature and CRP, the drainage fluid should be sent for culture on 4 to 7 days postoperatively. Most commonly used antibiotic for perforation of duodenal ulcer is cefotiam, and it is given 4.1 +/- 1.2 days postoperatively. Target organisms at the perforation of the lower digestive tract were E. coli, Bacteroides spp., Klebsiella pneumoniae and Enterobacter spp. Carbapenems were likely given agents for the perforation of the colon, and they were given 5.0 +/- 1.4 days postoperatively.

Ileal perforation caused by cytomegalovirus infection in an immunocompetent adult

A 71-year-old woman developed a small bowel perforation due to cytomegalovirus infection. She did not taken any immunosuppressive medication and her cellular immunity was normal. Surgical resection and antiviral therapy with ganciclovir led to complete recovery. As far as we know, this paper reports the first case of small bowel perforation due to cytomegalovirus infection in a non-immunocompromised patient. Nevertheless the patient was known with diabetes mellitus. It should be emphasised that elderly patients have impaired immune defences and may be unsuspected hosts of opportunistic infections.

Piperacillin/Tazobactam versus cefotaxime plus metronidazole for treatment of children with intra-abdominal infections requiring surgery

The efficacy of piperacillin/tazobactam at 100/12.5 mg/kg every 8 h (35 patients) was compared to cefotaxime plus metronidazole at 50/7.5 mg/kg every 8 h (35 patients) in 70 children with intra-abdominal infections requiring surgery. Diagnoses were gangrenous or perforated appendicitis (n =56), peritonitis (n =12), and abscess (n =2). Clinical cure was observed in 35 of 35 evaluable patients treated with piperacilin/tazobactam and in 34 of 34 evaluable patients treated with cefotaxime plus metronidazole. Presumed bacteriological eradication was noted in 29 of 30 evaluable patients in the piperacillin/tazobactam group and in 31 of 31 evaluable patients in the cefotaxime plus metronidazole group. In this study, piperacillin/tazobactam was as effective as cefotaxime plus metronidazole for treating children with intra-abdominal infections requiring surgery.

[Postoperative complications following kidney transplantation]

Despite the remarkable development of kidney transplantation techniques, surgical complications are still a very important factor affecting the final outcome of kidney transplantation. After 92 kidney transplantations (22 from cadaver donors and 70 from living donors) performed at Skopje hospital (Macedonia), we observed the following complications: nine (10%) urinary fistula, five (5%) graft ruptures, seven (8%) lymphoceles, two (2%) urinary calculosis, two (2%) intestinal perforations, four (4%) renal artery stenoses, one (1%) renal artery thrombosis, and seven (8%) early complications following surgical incision. Complications were detected by either ultrasonography, intravenous pyelography, percutaneous nephrostomy with anterograde pyelography, computerized tomography, and intravenous digital angiography. They were subsequently treated by application of modern surgical procedures: use of the ureter (termino-terminal or uretero-pyelic anastomosis) for treatment of urinary fistulas; conservative surgery using tissue glue and external compression with polyglactin 910 (Vicryl) mesh for graft ruptures; drainage and application of sclerosants under ultrasound control and intraperitoneal marsupialization for the clinically relevant lymphoceles; transluminal angioplasty with balloon dilatation in case of significant arterial stenosis; extracorporeal shock wave lithotripsy and surgery for urinary calculi. Intestinal perforations and problems relating to parietal tissue were quickly solved using standard surgical techniques. On total, rejection of the graft occurred in four (4%) cases following surgical complications, while one death was encountered due to septic peritonitis. We consider the percentage of surgical complications acceptable, as this work consists of a pioneering effort in this Balkan region.

Comparison of two antibiotic regimens in the treatment of perforated appendicitis in pediatric patients

BACKGROUND AND PURPOSE

An increased incidence of post-surgical infectious complications in children admitted with a diagnosis of perforated appendicitis led to development of a disease-specific antibiogram and modification of our post-operative antibiotic regimen.

METHODS

A historical control group comprised of 32 pediatric patients receiving ampicillin, gentamicin, and clindamycin (group AGC) was compared to a cohort of 32 children receiving ticarcillin/clavulanate plus gentamicin (group TG). The surgical procedure, peri-operative management, and inclusion, exclusion and discharge criteria were the same for each group. Outcome measures including length of stay, time to defervesce, incidence of infectious complications, and clinical failures to the antibiotic regimen were compared.

RESULTS

The groups were similar with respect to gender, age, weight, surgical time, pre-operative leukocytes, and number of intra-operative bacterial isolates cultured per patient. Length of stay was 10.1 days in group TG and 12.5 days for group AGC (p = 0.0197). The number of clinical failures was reduced from 9 (28.1%) to 2 (6.3%) in group TG (p = 0.02). The time to defervesce was decreased by 1.4 days, and the number of infectious complications was reduced to 2.5-fold in group TG patients.

CONCLUSIONS

Ticarcillin/clavulanate plus gentamicin was clinically more effective than ampicillin, gentamicin, and clindamycin combination therapy in the management of perforated appendicitis in our pediatric population.

Complicated appendicitis: is there a minimum intravenous antibiotic requirement? A prospective randomized trial

The proper duration of postoperative intravenous (IV) antibiotics in patients suffering complicated (perforated or gangrenous) appendicitis is debatable. Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient's clinical course regardless of the length of therapy. Our objective was to determine whether there are differences in morbidity and resource utilization between the two treatment methodologies. Ninety-four patients with intraoperative findings of complicated appendicitis were included. In all patients IV antibiotics were discontinued on the basis of clinical factors. However, Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement. Group 1 patients received more IV antibiotics than Group 2 patients did (5.9 vs 4.3 days; P = 0.014). Infectious complications were not statistically different between the two groups (13.0% in Group 1 and 12.5% in Group 2). Average hospital stay was also not statistically different between the two groups. The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity. Furthermore, the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay.

Treatment of perforated appendicitis: an analysis of 362 patients treated during 8 years

BACKGROUND AND METHOD

In a retrospective study 2,351 records from patients who underwent surgery for acute appendicitis during 1986-1993 were analysed. During this period, there were 362 patients with perforated appendicitis. The aim of this study was to analyse the complication rate, the period of antibiotic treatment and whether the complication rate decreased when intravenous treatment was followed by oral antibiotic treatment.

RESULTS

The complication frequency was 18% which was significantly higher than that for non-perforated appendicitis of 10%. The complication rate was 15% in the group receiving additional oral antibiotics compared to 19% in the group receiving only intravenous antibiotics. This difference is not significant.

CONCLUSION

Perforated appendicitis is however still associated with increased mortality and morbidity.

Determining duration of antibiotic use in children with complicated appendicitis

BACKGROUND

The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician.

AIM

This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued.

METHODS

Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms).

RESULTS

Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1).

CONCLUSION

Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.

The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis

BACKGROUND

Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data.

METHODS

The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation.

RESULTS

Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%).

CONCLUSION

These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.

Ticarcillin/clavulanate versus imipenem/cilistatin for the treatment of infections associated with gangrenous and perforated appendicitis

The objective of this study was to compare ticarcillin/clavulanate given at 3.1 g every 6 hours with imipenem/cilistatin given at 500 mg every 6 hours for the treatment of infections associated with gangrenous or perforated appendicitis. One hundred thirty-seven patients were found to have gangrenous or perforated appendicitis and received the study medication for 3 to 5 days in a double-blinded, randomized manner. Clinical success was similar for the two treatment groups, 96.9 and 95.9 per cent in the ticarcillin/clavulanate and imipenem/cilistatin groups, respectively (P=0.99; 95% confidence interval for the difference was -5.6% to 7.6%). Bacteriologic success at the end of therapy was similar in the two groups, 100 and 98.4 per cent in the ticarcillin/clavulanate and imipenem/ cilistatin groups, respectively (P=0.99; 95% confidence interval for the difference was -1.8% to 4.7%). The occurrence of adverse events related to treatment was similar for the two groups (P=0.31) and led to study withdrawal for four patients (one with ticarcillin/clavulanate and three with imipenem/ cilistatin). Ticarcillin/clavulanate given at 3.1 g every 6 hours is as effective and as safe as imipenem/ cilistatin given at 500 mg every 6 hours for treatment of gangrenous or perforated appendicitis.

Conservative treatment of recognized laparoscopic colonic injury

Injuries associated with insufflation needles and trocar insertion have been reported extensively in the literature. Two millimeter laparoscopy is a more recent technique that has been used for laparoscopic cholecystectomy. This case illustrates a 2 mm trocar colonic injury, recognized during a routine laparoscopic cholecystectomy; management was non-operative and ambulatory, with a successful outcome.

Inflammatory bowel disease

The vast majority of patients with inflammatory bowel disease experience chronic symptoms punctuated by periodic exacerbations requiring adjustments in medical therapy or surgery. True emergencies are fortunately uncommon but have been associated with high rates of morbidity and mortality. Patients presenting with fulminant colitis, toxic megacolon, or perforation require prompt identification as well as intensive medical therapy and monitoring by physicians and surgeons experienced in the care of such patients. Recent advances in the evaluation and treatment of these complicated patients are reviewed.

Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice

BACKGROUND

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk for hospitalization and death from gastrointestinal bleeding and perforation.

OBJECTIVES

To 1) estimate the extent to which NSAIDs are prescribed unnecessarily and NSAID-related side effects are inaccurately diagnosed and inappropriately managed and 2) identify the physician and visit characteristics associated with suboptimal use of NSAIDs.

DESIGN

Prospective cohort study.

SETTING

Montreal, Canada.

PARTICIPANTS

112 physicians representing academically affilliated general practitioners, community-based general practitioners, and residents in family medicine and internal medicine.

INTERVENTIONS

Blinded, office-based assessment of the management of two clinical cases (chronic hip pain due to early osteoarthritis and NSAID-related gastropathy) using elderly standardized patients.

MEASUREMENTS

Quality of drug management and potential predictors of suboptimal drug management.

RESULTS

Unnecessary prescriptions for NSAIDs or other drugs were written during 41.7% of visits. Gastropathy related to NSAID use was correctly diagnosed in 93.4% of visits and was acceptably managed in 77.4% of visits. The risk for an unnecessary NSAID prescription was greater when the contraindications to NSAID therapy were incompletely assessed (odds ratio, 2.3 [95% CI, 1.0 to 5.2]) and when the case was managed by residents in internal medicine (odds ratio, 4.1 [CI, 1.2 to 14.7]). The risk for suboptimal management of NSAID-related side effects was increased by incorrect diagnosis (odds ratio, 16.6 [CI, 3.6 to 76.5]) and shorter visits.

CONCLUSIONS

Unnecessary NSAID prescribing and suboptimal management of NSAID-related side effects were sufficiently common to raise questions about the appropriateness of NSAID use in the general population. If these results reflect current practice, prescribing patterns may contribute to avoidable gastrointestinal morbidity in elderly persons.

A patient with acquired immunodeficiency syndrome and untreated Encephalitozoon (Septata) intestinalis microsporidiosis leading to small bowel perforation. Response to albendazole

BACKGROUND

Encephalitozoon (Septata) intestinalis is a common disseminating opportunistic intestinal microsporidian affecting patients with acquired immunodeficiency syndrome. This microsporidian does respond to albendazole therapy. A patient with acquired immunodeficiency syndrome and chronic diarrhea presented to George Washington University Hospital in January of 1996. Despite appropriate surgical specimens, no etiology had been found to explain his cholecystitis, cystitis, and enteritis 3 months previously at another hospital.

DESIGN

Tissue specimens were analyzed by light microscopy, using hematoxylin-eosin and the Armed Forces Institute of Pathology Brown-Brenn microsporidia stain, and by transmission electron microscopy. Urine and stool specimens were analyzed by modified chromotrope 2R trichrome and chitin fluorochrome stains and by transmission electron microscopy.

RESULTS

At George Washington University Hospital, disseminated E intestinalis was diagnosed from duodenal biopsy, urine, and stool specimens. On the 14th day of oral albendazole therapy, a partial small bowel resection was performed to correct a perforation (air under the diaphragm). There was no enterocyte microsporidian infection at that time, only spores undergoing macrophage digestion. Review of previous specimens showed severe E intestinalis cholecystitis, cystitis, and enteritis. Albendazole was restarted and, after 2 weeks, the patient had negative stool and urine specimens.

CONCLUSIONS

Encephalitozoon intestinalis symptomatically targets many organs, including the urinary bladder. To our knowledge, this is the first tissue-documented case of cystitis. Left untreated with albendazole, small bowel infection can lead to perforation and peritonitis.

Comparative trial of four antibiotic combinations for perforated appendicitis in children

OBJECTIVE

To compare the therapeutic efficacy of four antibiotic regimens: penicillin, tobramycin, and clindamycin; penicillin, tobramycin, and ornidazole; piperacillin alone; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis.

DESIGN

Prospective randomised study.

SETTING

Teaching hospital, Turkey.

SUBJECTS

200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were randomly assigned to one of four groups each consisting of 50 patients.

INTERVENTIONS

Preoperative antibiotics given intravenously, peritoneal drainage by Penrose drains without irrigation, appendicectomy with the inversion of the stump by a purse string, taking peritoneal swabs, and primary skin closure.

MAIN OUTCOME MEASURES

Comparability of the groups, duration of fever, leucocytosis, antibiotic treatment, stay in hospital, nasogastric intubation, and drainage, as well as results of cultures and complications.

RESULTS

There were no significant differences between the groups for any variable studied. The predominant bacterial species were Escherichia coli, Klebsiella spp, Pseudomonas spp, Fusobacteria, and Peptostreptococci which were appropriately covered by all the antibiotic regimens. Fourteen patients had complications including wound infections (n = 10), prolonged ileus (n = 2) and intra-abdominal abscess (n = 2) all of which were treated conservatively. There was no mortality and no major complications. All regimens had the same clinical and bacteriological efficacy.

CONCLUSION

There is no gold standard for antimicrobial chemotherapy in perforated appendicitis. Different antibiotic combinations or a single broad spectrum antibiotic, which include both aerobic and anaerobic coverage, can safely be used in children with perforated appendicitis.

Is interval appendectomy necessary after rupture of an appendiceal mass?

Since 1980, the authors have not routinely removed an appendix on an interval basis after treatment of a ruptured appendiceal mass (phlegmon and/or abscess). In the present group of patients, there were eight boys and two girls, two to 15 years of age (mean, 8.5 years). All presented with symptoms and signs typical of ruptured appendix, with a mass suspected by history and examination, and proven by radiological means (usually ultrasonography). The patients were treated for at least 1 week with intravenous triple antibiotics; three required drainage of their abscess (2 radiological, 1 surgical). The follow-up has been both clinical and sonographic. In all cases the inflammation disappeared with 1 month. One child (2 years old) returned in 2 months with symptoms and signs of a ruptured appendix, and appendectomy was performed. The other nine have remained well, for 6 months to 13 years. From this experience and a review of the literature, only a relatively small number of patients with a properly treated ruptured appendiceal mass (phlegmon and/or abscess) will return with a flareup (recurrence) of appendicitis (requiring appendectomy); the rest live a normal life, with their asymptomatic appendix intact.

Meropenem versus tobramycin with clindamycin in the antibiotic management of patients with advanced appendicitis

BACKGROUND

Meropenem (MP), a new carbapenem antibiotic, has excellent antimicrobial activity against the enteric flora commonly encountered in acute appendicitis. Although similar to imipenem, it may have clinical advantages.

STUDY DESIGN

We compared patients with advanced appendicitis (gangrenous or perforated) treated with 1,000 mg MP every eight hours with those given the combination of tobramycin 5 mg/kg/day at eight hour intervals and clindamycin 900 mg every eight hours. Both treatments were given intravenously. Patients were randomized to either group of the double-blind study.

RESULTS

Of 129 evaluable cases, 63 received MP and 66 received both tobramycin and clindamycin (T/C). The two groups were similar in age, sex, and severity of disease. The mean number of days of postoperative fever (MP = 3.1 +/- 1.7 SD compared to T/C = 4.4 +/- 2.2 SD, p < or = 0.01), days of antibiotic therapy (MP = 6.1 +/- 1.6 SD compared to T/C = 7.3 +/- 2.2 SD, p = 0.01), and therefore hospital stay (MP = 8.0 +/- 3.5 SD compared to T/C = 9.4 +/- 2.6 SD, p < 0.01) were significantly better for patients treated with MP. No difference was found between the numbers of failures in each group (MP = 5 compared to T/C = 6).

CONCLUSIONS

This study demonstrates a small but significant reduction (approximately one day) in post-operative fever, duration of antibiotic treatment, and hospital stay for patients treated with MP compared to those treated with T/C.

Typhoid perforation treated with and without metronidazole along with chloramphenicol, gentamycin

Forty cases of typhoid ileal perforation were treated surgically in three years. Chloramphenicol and gentamycin were given to 20 patients, while the remaining 20, received Metronidazole additionally. The mortality rate was 60 percent in the first and 40 percent in the second group.

Rectal perforation after retropubic radical prostatectomy: occurrence and management

OBJECTIVES

A surgical audit of the management of rectal perforations during retropubic radical prostatectomy. Assessment of incidence, risk factors, management and outcome.

METHODS

All 10 cases (3.6%) sustaining a rectal injury of a total series of 270, while undergoing retropubic radical prostatectomy at our 2 institutions were reviewed. In all cases, the injury was immediately recognized and treated by primary suture, anal dilatation and antibiotics. In 1 case, a temporary colostomy was performed.

RESULTS

Recovery was uneventful in all cases, and the postoperative hospitalization was only slightly longer than usual in the 9 cases without fecal diversion. No fistulae or wound infections occurred, but closure of 1 colostomy was complicated.

CONCLUSION

Provided that the injury is promptly recognized and properly sutured, a rectal perforation at radical prostatectomy is not of great significance and should not deter from an adequate preoperative investigation by multiple transrectal core biopsies or neoadjuvant hormonal treatment. The use of preoperative bowel preparation, routine antibiotic prophylaxis, omental interposition or a proximal colostomy does not appear to be necessary in order to achieve immediate safe repair.