Intravascular placement and migration of a colonic stent into the inferior mesenteric vein.

Colonic self-expanding metal stents (SEMSs) are commonly used to treat large bowel obstruction due to gastrointestinal malignancy with great success. While mortality is negligible, morbidity from both early and late complications can be significant. Stent perforation, erosion and migration are the most feared complications. We present the first reported case of wire-associated colon perforation with placement and migration of an SEMS into the inferior mesenteric vein (IMV). A man in his early 60s presented with a large bowel obstruction due to a colorectal mass. He underwent endoscopic colonic SEMS placement for colonic decompression. The stent was later found to be within the IMV, requiring a colon resection and retrieval of the stent.

Perioperative hypothermia during colectomy: when do patients get cold?

BACKGROUND: Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation. METHODS: Temperature data were collected from 105 consecutive patients undergoing elective colectomy at a single institution. RESULTS: The study population consisted of 105 patients; 67(64%) male, median age 59 years (range 17-95 years), median body mass index 27 kg/m2 (range 15-48 kg/m2). Median preoperative temperature was 36.7 °C (range 35.2-39.2 °C), dropping to 35.7 °C (range 34.0-37.3 °C) immediately following intubation and then rising to 36.2 °C (range 34.0-38.0 °C) prior to leaving the operating room. The median first postoperative temperature was 36.3 °C (range 34.4-37.7 °C). Temperatures were significantly different from one another (p < 0.05, ANOVA), except for the last operative and first postoperative temperature. A first postoperative temperature of ≥ 36.0 °C (meeting Surgical Care Improvement criteria Inf-10) was achieved in 78 (74%) of patients. A preoperative temperature of ≥ 36.5 °C was associated with a first postoperative temperature of ≥ 36.0 °C, but operative approach (laparoscopic versus open) was not. CONCLUSIONS: Most temperature loss occurs prior to operation in patients undergoing colectomy. Patients are rewarmed during the operative procedure. The time period prior to operation should be the focus of efforts designed to ensure normothermia.

Bowel Sounds Are Not Associated With Flatus, Bowel Movement, or Tolerance of Oral Intake in Patients After Major Abdominal Surgery.

BACKGROUND: Auscultation for bowel sounds has been advocated by some clinicians as a method to determine the resolution of postoperative ileus. OBJECTIVE: Our primary aim was to prospectively evaluate the relationships between bowel sounds and the ability to tolerate oral intake in patients after major abdominal surgery. Secondarily we aimed to evaluate relationships among bowel sounds, flatus and bowel movement, and oral intake. DESIGN: This was a prospective, blinded observational study. SETTINGS: The study was conducted at Western Pennsylvania Hospital. PATIENTS: A total of 124 adult patients undergoing major abdominal surgery were included. MAIN OUTCOME MEASURES: Data were collected by medical students blinded to the purpose of the study for 10 days postoperatively or until discharge, including the presence of bowel sounds (auscultation for 1 minute), flatus, bowel movement, and tolerance of oral intake (defined as ingestion of ≥1000 mL/24 h and each subsequent day without vomiting). Associations between paired variables were determined using ϕ coefficient testing. RESULTS: The study population consisted of 51 men and 73 women, with a mean age of 64 years (range, 20-92 y). The majority of patients (78/124 (63%)) underwent colorectal resection. The median length of hospital was 6 days. Bowel sounds were not associated with flatus, bowel movement, or tolerance of oral intake throughout the study period. The positive predictive value of bowel sounds in predicting flatus and bowel movement was low in the early postoperative period and remained <25% in predicting tolerance of oral intake throughout the study period. The analysis was repeated, including only those patients undergoing colorectal procedures, and was essentially unchanged. Flatus correlated with bowel movement in the first 6 days postoperation, but neither flatus nor bowel movement was associated with tolerance of oral intake. LIMITATIONS: The rate of tolerance of oral intake was relatively modest throughout the study period. CONCLUSIONS: Bowel sounds are not associated with flatus, bowel movement, or tolerance of oral intake after major abdominal surgery.

Laparoscopic colectomy for apparently benign colorectal neoplasia: A word of caution.

PURPOSE: Endoscopically unresectable apparently benign colorectal polyps are considered by some surgeons as ideal for their early laparoscopic colectomy experience. Our hypotheses were: (1) a substantial fraction of patients undergoing laparoscopic colectomy for apparently benign colorectal neoplasia will have adenocarcinoma on final pathology; and (2) in our practice, we perform an adequate laparoscopic oncological resection for apparently benign polyps as evidenced by margin status and nodal retrieval. METHODS: Data from a consecutive series of patients undergoing laparoscopic colectomy (on an intention-to-treat basis) for endoscopically unresectable neoplasms with benign preoperative histology were retrieved from a prospective database and supplemented by chart review. RESULTS: The study population consisted of 63 patients (mean age 67, mean body mass index 29). Two out of 63 cases (3%) were converted to laparotomy because of extensive adhesions (n = 1) and equipment failure (n = 1). Colectomy type: right/transverse (n = 49, 78%); left/anterior resection (n = 10, 16%); subtotal (n = 4, 6%). Invasive adenocarcinoma was found on histological analysis of the colectomy specimen in 14 out of 63 cases (22%), standard error of the proportion 0.052. Staging of the 14 cancers were I (n = 6, 43%), II (n = 3, 21%), III ( = 4, 29%), and IV (n = 1, 7%). The median nodal harvest was 12 and all resection margins were free of neoplasm. Neither dysplasia on endoscopic biopsy nor lesion diameter was predictive of adenocarcinoma. Eight out of 23 (35%) patients with dysplasia on endoscopic biopsy had adenocarcinoma on final pathology versus 6/40 (15%) with no dysplasia (p = 0.114, Fisher's exact test). Mean diameter of benign tumors was 3.2 cm (range 0.5-10.0cm) versus 3.9cm (range 1.5-7.5cm) for adenocarcinomas (p = 0.189, t - test). CONCLUSION: A substantial fraction of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy will harbor invasive adenocarcinoma, some of advanced stage. This finding supports the practice of performing oncological resection for all patients with endoscopically unresectable neoplasms of the colorectum. The inexperienced laparoscopic colectomist should approach these cases with caution.

Ileal perforation secondary to Clostridium difficile enteritis: report of 2 cases.

Two cases of small-bowel perforation secondary to Clostridium difficile enteritis are described and compared with the 8 cases of C difficile enteritis reported in the medical literature. The cause of small-bowel involvement with C difficile is unknown, but prior antibiotic use, prior colectomy, chronic alterations in small-bowel flora, and other host factors are discussed.

The biomechanical properties of the finger metacarpophalangeal joints to varus and valgus stress.

PURPOSE: The purpose of this study was to determine the normal biomechanical properties of the passive capsuloligamentous structures about the finger metacarpophalangeal (MCP) joints subjected to dynamic varus/valgus loading and to equate these findings to the clinical situation. METHODS: The finger MCP joints from 9 fresh-frozen cadaver hands were tested in a custom-designed testing apparatus that applied a varus/valgus force in each direction. Testing was performed at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of MCP joint flexion. Load-displacement curves were generated for each specimen. A nonlinear hysteresis curve was apparent on loading and unloading. A region of collateral ligament laxity was identified whereby minimal torque (< 0.5 Nm) caused progressive joint angulation. Subsequently incremental load was required to produce further joint angulation. The slope of this region was used to calculate early and late collateral ligament stiffness. RESULTS: The index and long fingers showed a significant decrease in the region of collateral ligament laxity between 0 degrees and 90 degrees. The long finger collateral ligament laxity also diminished significantly between 30 degrees and 90 degrees. The collateral ligament laxity did not significantly change in the ring and small digits throughout MCP joint flexion. The early or late phase of collateral ligament stiffness was not affected by the amount of MCP joint flexion across any of the digits, except in late radial collateral ligament stiffness of the long finger between 0 degrees and 60 degrees. CONCLUSIONS: The additional stability and clinical observation of tightening of the MCP in flexion appears related to the decreased laxity of the collateral ligaments and not to alterations in the biomechanical properties of the collateral ligaments.