Gastric perforation and subarachnoid hemorrhage secondary to intragastric balloon device.

Obesity is a major health problem worldwide that leads to high morbidity and mortality rates. Medical options for obesity treatment are multiple and invasive therapy may be classified as surgical and non-surgical. Intragastric balloon device placement is an invasive non-surgical option that may benefit some obese patients. Potential complications related to intragastric balloon placement are multiple and perforations at the esophagus or stomach are the most hazardous. Prompt surgical management is mandatory upon the diagnosis of gastric perforation secondary to intragastric balloon to avoid further complications and mortality. Here we report an unusual case of patient that suffered both a subarachnoid hemorrhage as well as a gastric perforation related to intragastric balloon in which early diagnosis and prompt surgical treatment lead to a successful outcome.

Ileocolic intussusception secondary to Hodgkin's lymphoma. Report of a case.

Intussusception is a rare condition in adults and represents 1% to 5% of the total cases of intestinal obstruction. Preoperative diagnosis occurs only in a few patients and most of the cases are diagnosed during surgery. A demonstrable etiology is found in 70% to 90% of cases in adult intussusceptions, and approximately 40% of them are caused by primary or secondary malignant tumors. We report the case of a 32 year old male patient with an ileocolic intussusception secondary to Hodgkin's lymphoma, as well as the surgical treatment, and outcome.

Acute epiploic appendagitis. Report of three cases.

Primary epiploic appendagitis is a very rare condition that results from acute inflammation of an epiploic appendix. Clinical presentation is non-specific, and many times can mimic acute abdomen. When the diagnosis of epiploic appendagitis is made, conservative treatment must be initiated to avoid unnecessary surgery. We report three cases of acute epiploic appendagitis which were diagnosed by imaging and were managed conservatively with good clinical outcome.

[Laparoscopic therapy of gastric volvulus associated with hiatal hernia in the elderly patient]. / Tratamiento laparoscópico del vólvulo gástrico asociado a hernia hiatal en el paciente de edad avanzada.

Gastric volvulus is an abnormal rotation of one portion of the stomach around itself that may lead to gastric obstruction or an impairment of the vascular supply to the stomach leading to strangulation. This may present acutely or with chronic intermittent symptoms. Acute gastric volvulus is an emergency situation in which there is a closed loop obstruction and vascular compromise that requires urgent treatment. In the chronic type, unspecific abdominal pain is common. Chronic gastric volvulus must be treated to avoid complications, but there is not a standard treatment for this condition. Minimally invasion techniques, either endoscopic or laparoscopic offer the best option for treatment reducing morbidity and mortality rates. We report two cases of chronic gastric volvulus treated laparoscopically in the elderly.

Toxic megacolon secondary to Clostridium difficile colitis. Case report.

The incidence and severity of Clostridium difficile colitis has markedly increased in recent years. The spectrum of Clostridium difficile infection ranges from asymptomatic colonization to fulminant colitis requiring immediate surgery. Medical therapy failure and the presence of toxic megacolon dictate urgent surgical treatment with unfortunate high mortality rates (35% to 57%). We broach herein a case of toxic megacolon secondary to colitis due to Clostridium difficile infection in which early diagnosis and prompt surgical treatment led to a successful outcome.

[Left paraduodenal hernia: an unusual cause of intestinal obstruction.]. / Hernia paraduodenal izquierda:una causa inusual de obstrucción intestinal.

Paraduodenal hernias are an unusual cause of small bowel obstruction. The clinical spectrum varies from episodes of partial, intermittent,small bowel obstruction, to those of acute, complete small bowel obstruction, with the potential risk of complications such as intestinal ischemia,perforation and abdominal sepsis. Reported here in is the case of a 53 year old man with complete small bowel obstruction secondary to a left paraduodenal hernia, in whom operative treatment consisted of reduction of the hernia content, small bowel decompression and closure of the hernia ring. The operation successfully resolved the acute event and has prevented recurrences during a 4 year follow-up.

Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn's disease.

PURPOSE: Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis METHOD: A case-control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed. RESULTS: A total of 138 patients with Crohn's disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P = 0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P = 0.017; log-rank test) for the wide-lumen stapled anastomosis group. CONCLUSION: Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.

Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: report of two cases.

PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 10 percent of patients who undergo ileal pouch-anal anastomosis for ulcerative colitis. Specific infection of the ileal pouch-anal anastomosis with cytomegalovirus has not been reported. AIM: We report two patients with specific cytomegalovirus infection of the ileal pouch-anal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had ileal pouch-anal anastomosis for ulcerative colitis. Three years later she had diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consistent with pouchitis. She had no response to medical therapy. Repeat endoscopy showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were negative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for ulcerative colitis. Nine years later she had resection of obstructing stricture at previous loop ileostomy site. She underwent reoperation with ileostomy and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with biopsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclonal immunofluorescent stain showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 days. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: Specific cytomegalovirus infection of the ileal pouch-anal anastomosis may be misdiagnosed as idiopathic refractory chronic pouchitis. Cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients.

Vena caval impalement: an unusual lawn mower injury in a child.

Penetrating injury to the vena cava is a potentially life threatening condition that necessitates prompt recognition and immediate treatment. Herein we describe a unique lawn mower-related injury in a 4-year-old boy, resulting in the impalement of the inferior vena cava by a foreign body projectile. Relevant concepts in the management of children with lawn mower injuries are discussed, with emphasis on penetrating injury to the inferior vena cava.

[Ileoanal reservoir: new concepts and current results]. / El reservorio ileoanal: nuevos conceptos y resultados actuales.

More than 1,800 ileoanal pouches have been performed at the Mayo Clinic since 1981 and results have been satisfactory in more than 90% of the patients. However, we continue to search for alternatives to improve postoperative results and avoid the complications that currently occur in a minority of patients. During the last two years new concepts and surgical techniques for the construction of the ileoanal reservoir have been described. Herein we present those innovations and compare them to our current institutional practice.

[Current concepts in the treatment of hemorrhoids]. / Actualidades en el tratamiento de la enfermedad hemorroidal.

Hemorrhoidal disease is a common problem that affects a large number of patients. Usually multiple remedies are used by those patients without medical advise and for several reasons consultation with a specialist is often delayed. The large prevalence of popular misconception adds to this and occasionally makes adequate treatment difficult. Herein we present a brief and useful review of current relevant concepts in the management of patients with hemorrhoidal disease.

[Sclerosing mesenteritis: a disease of malignant appearance]. / Mesenteritis esclerosante: una enfermedad de apariencia maligna.

Sclerosing mesenteritis is a rare benign disorder of unknown etiology that often resembles a neoplasm. Numerous terms have been used in the past to describe this entity which has a variable clinical presentation and is characterized by thickening of the intestinal mesentery. Accurate information regarding the epidemiology, natural course and therapeutic response of the disease is sparse. Herein we present a review of the literature and a brief discussion of relevant concepts for the diagnosis and treatment of patients with sclerosing mesenteritis.

Intraabdominal hemorrhage complicating surgical management of necrotizing pancreatitis.

Surgical management of necrotizing pancreatitis (NP) may result in significant intraabdominal hemorrhage requiring intervention. To determine the incidence and management of hemorrhage complicating operative management of NP, we analyzed retrospectively all patients undergoing operative treatment of NP between 1985 and 1994. Thirteen of 61 patients (21%) developed intraabdominal hemorrhage requiring intervention. The five patients (38%) who experienced more than one bleeding episode had undergone more prior operative debridements (mean of 5.6 vs. 3.8), had had higher transfusion requirements during the first bleeding episode (mean of 27.4 vs. 11.3 U of packed red blood cells), and had a higher hospital mortality (60 vs. 38%) compared to patients with only one bleeding episode. Coexistence of pancreatic and/or gastrointestinal fistula was more common in patients who developed bleeding (36 vs. 11%). Seventeen bleeding sites (eight venous, seven arterial, two generalized oozing) were identified. Angiography was successful in one of two patients in whom it was employed. Surgical control was effective in the other 12 patients. There was no acute mortality related to hemorrhage, but the hospital mortality was greater than in those without hemorrhage (46 vs. 21%). We conclude that significant hemorrhage complicates the surgical management of NP in approximately 20% of patients; while it can be effectively controlled surgically and does not lead to immediate mortality, it may predict worse prognosis.