Corrigendum to "Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention".

[This corrects the article DOI: 10.1155/2015/531021.].

Management of gastrosplenic fistula in the emergency setting - A case report and review of the literature.

INTRODUCTION: A gastrosplenic fistula (GSF) is a very rare complication that arises mainly from a splenic or gastric large cell lymphoma. The proximity of the gastric fundus to the enlarged fragile spleen may facilitate the fistulisation. This complication can lead to massive bleeding, which, though uncommon, may be lethal. We present a patient with massive upper gastrointestinal bleeding secondary to a GSF. CASE PRESENTATION: We present a 48-year-old man with a refractory diffuse large B-cell lymphoma who was admitted to our hospital due to hematemesis. On arrival, he was in hemorrhagic shock, and was taken directly to the intensive care unit. The source of bleeding could not be identified on gastroscopy, the patient remained hemodynamically unstable and a laparotomy was performed.A fistula between a branch of the splenic artery and the stomach was identified. The stomach appeared to be involved in the malignant process. After subtotal gastrectomy and splenectomy, the bleeding was controlled. After stabilization, the patient was admitted to the intensive care unit, and 24 hours later was discharged in stable condition. DISCUSSION: We describe a fistula between a branch of the splenic artery and the stomach, which was accompanied by massive bleeding. An emergency laparotomy saved the patient's life. CONCLUSION: The purpose of this report is to alert physicians that surgical intervention can be lifesaving in this rare malignant condition. A literature review focusing on the presenting symptoms and the epidemiology of GSF is presented.

A Nearly Lethal Screw: An Unusual Cause of Recurrent Bradycardia and Asystole Episodes after Fixation of the Cervical Spine.

We present a case of a 51-year-old man who was injured in a bicycle accident. His main injury was an unstable fracture of the cervical and thoracic vertebral column. Several hours after his arrival to the hospital the patient underwent open reduction and internal fixation (ORIF) of the cervical and thoracic spine. The patient was hospitalized in our critical care unit for 99 days. During this time patient had several episodes of severe bradycardia and asystole; some were short with spontaneous return to sinus and some required pharmacological treatment and even Cardiopulmonary Resuscitation (CPR). Initially, these episodes were attributed to the high cervical spine injury, but, later on, CT scan suggested that a fixation screw abutted on the esophagus and activated the vagus nerve by direct pressure. After repositioning of the cervical fixation, the bradycardia and asystole episodes were no longer observed and the patient was released to a rehabilitation ward. This case is presented in order to alert practitioners to the possibility that, after operative fixation of cervical spine injuries, recurrent episodes of bradyarrhythmia can be caused by incorrect placement of the fixation screws and might be confused with the natural history of the high cervical cord injury.

Validation of a Cross-Infection Control Program in an Understaffed Intensive Care Unit.

BACKGROUND: The authors describe a multifaceted cross-infection control program that was implemented to contain an epidemic of multidrug-resistant microorganisms (MRO) (carbapenem resistant Pseudomonas aeruginosa and Acinetobacter baumannii; extended spectrum ß-lactamase producing Klebsiella pneumoniae, Escherichia coli, Enterobacter Cloacae, and Proteus mirabilis; and methicillin-resistant Staphylococcus aureus and Candida species). OBJECTIVES: To assess the effect of a control program on the incidence of cross-infection with MRO. METHODS: Clinical criteria triaged patients into a high-risk wing (HRW) or a low-risk wing (LRW). Strict infection control measures were enforced; violations led to group discussions (not recorded). Frequent cultures were obtained, and use of antibiotics was limited. Each quarter, the incidence of MRO isolation was reported to all staff members. RESULTS: Over a 6 year period, 1028 of 3113 patients were placed in the HRW. The incidence of MRO isolation within 48 hours of admission was 8.7% (HRW) vs. 1.91% (LRW) (P < 0.001). Acquired MRO infection density was 30.4 (HRW) vs. 15.6 (LRW) (P < 0.009). After the second year, the incidence of group discussions dropped from once or twice a month to once or twice a year. CONCLUSIONS: These measures contained epidemics. Clinical criteria successfully triaged HRW from LRW patients and reduced cross-infection between the medical center wings. The quarterly reports of culture data were associated with improved staff compliance. MRO epidemic control with limited resources is feasible.

Life Threatening Idiopathic Recurrent Angioedema Responding to Cannabis.

We present a case of a 27-year-old man with recurrent episodes of angioedema since he was 19, who responded well to treatment with medical grade cannabis. Initially, he responded to steroids and antihistamines, but several attempts to withdraw treatment resulted in recurrence. In the last few months before prescribing cannabis, the frequency and severity of the attacks worsened and included several presyncope events, associated with scrotal and neck swelling. No predisposing factors were identified, and extensive workup was negative. The patient reported that he was periodically using cannabis socially and that during these periods he was free of attacks. Recent data suggest that cannabis derivatives are involved in the control of mast cell activation. Consequently, we decided to try a course of inhaled cannabis as modulators of immune cell functions. The use of inhaled cannabis resulted in a complete response, and he has been free of symptoms for 2 years. An attempt to withhold the inhaled cannabis led to a recurrent attack within a week, and resuming cannabis maintained the remission, suggesting a cause and effect relationship.

Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention.

Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5-4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis.

Trans-oral anterior fundoplication: 5-year follow-up of pilot study.

BACKGROUND: This is a report of an IRB-approved pilot study of 13 patients who received a trans-oral anterior partial fundoplication for the treatment of GERD using an ultrasound-guided, flexible surgical stapler. All patients had a history of PPI use, objective evidence of GERD, and no significant comorbidity. Under general anesthesia, a flexible stapler was passed trans-orally into the stomach and placed two or three quintuplets of titanium staples approximately 3 cm above the gastroesophageal junction. The stapler contains an ultrasonic range finder, video camera, and illuminator. METHODS: Primary follow-up at 6 weeks included pH metrics, GERD-HRQL scores, and PPI use. The protocol allowed annual telephone interviews for the following 5 years to collect GERD-HRQL scores, PPI use, satisfaction with the procedure, and willingness to have the procedure again. RESULTS: At 6 weeks, mean total acid exposure was significantly reduced, and 12/13 patients reduced GERD-HRQL scores by ≥50%. Twelve of 13 patients had stopped daily GERD medications, and nine of 13 had stopped all GERD medications. Each year, 11 of the 13 patients could be reached with all 13 patients having at least 4-year follow-up. Throughout the follow-up period, GERD-HRQL scores were normal (<10) in all but one patient. All patients would agree to do the procedure again. The median satisfaction score is 8 (range 6-10) on a scale of 1-10. None reported dysphagia. At 1 year, 54% of respondents (6/11) had eliminated PPI use, with another 27% (3/11) taking a reduced dose. Combining respondents at 4 and 5 years to account for all patients, 54% (7/13) had eliminated and another 23% (3/13) reduced PPI use ≥50 %. CONCLUSION: At 5 years, the procedure remained effective as demonstrated by the improved quality of life and changes in PPI use. The results remained stable after the second year.

Endoscopic anterior fundoplication with the Medigus Ultrasonic Surgical Endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial.

BACKGROUND: Both long-term proton pump inhibitor (PPI) use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). This multi-center, prospective study evaluated the clinical experiences of 69 patients who received an alternative treatment: endoscopic anterior fundoplication with a video- and ultrasound-guided transoral surgical stapler. METHODS: Patients with well-categorized GERD were enrolled at six international sites. Efficacy data was compared at baseline and at 6 months post-procedure. The primary endpoint was a ≥ 50 % improvement in GERD health-related quality of life (HRQL) score. Secondary endpoints were elimination or ≥ 50 % reduction in dose of PPI medication and reduction of total acid exposure on esophageal pH probe monitoring. A safety evaluation was performed at time 0 and weeks 1, 4, 12, and 6 months. RESULTS: 66 patients completed follow-up. Six months after the procedure, the GERD-HRQL score improved by >50 % off PPI in 73 % (48/66) of patients (95 % CI 60-83 %). Forty-two patients (64.6 %) were no longer using daily PPI medication. Of the 23 patients who continued to take PPI following the procedure, 13 (56.5 %) reported a ≥ 50 % reduction in dose. The mean percent of total time with esophageal pH <4.0 decreased from baseline to 6 months (P < 0.001). Common adverse events were peri-operative chest discomfort and sore throat. Two severe adverse events requiring intervention occurred in the first 24 subjects, no further esophageal injury or leaks were reported in the remaining 48 enrolled subjects. CONCLUSIONS: The initial 6-month data reported in this study demonstrate safety and efficacy of this endoscopic plication device. Early experience with the device necessitated procedure and device changes to improve safety, with improved results in the later portion of the study. Continued assessment of durability and safety are ongoing in a three-year follow-up study of this patient group.

Preclinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gastroesophageal reflux disease.

BACKGROUND: Laparoscopic fundoplication provides good reflux control, but side-effects due to the surgical procedure are known. Different endoluminal techniques have been introduced, but all with disappointing results. OBJECTIVE: Evaluation of the feasibility and safety of a new device, which enables a totally endoluminal anterior fundoplication for the treatment of gastroesophageal reflux disease (GERD). MATERIAL: The device is a modified video gastroscope, which incorporates a surgical stapler (using standard 4.8 B-shaped surgical staples) and an ultrasonic sight. The cartridge is mounted on the shaft and the anvil is at the tip. This enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge. METHOD: Sixteen female swine of mixed breed were used in the study; 12 underwent the endoscopic procedure, and 4 were used a controls to monitor weight gain. The 12 study animals were sacrificed at 2, 4, and 8 weeks (4 pigs each time) and visually inspected for complications, healing, and fundoplication. The study was sponsored by MediGus Ltd. and monitored for compliance with good laboratory practice (GLP) regulations by an external company (Econ Inc.), which is GLP certified by the German Federal Government. It was conducted at the animal testing facility of the Charité Virchow Clinic in Berlin. RESULTS: The procedure went smoothly in all pigs; median procedure time was 12 min (range 9-35 min). At sacrifice, the stapled area had healed well, all animals had a satisfactory 180° anterolateral fundoplication, and there were no procedure-related complications. CONCLUSIONS: Creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. Proof of efficacy must await clinical trials, which are underway.

Early relaparoscopy for management of suspected postoperative complications.

BACKGROUND: Diagnosis of complications after laparoscopic surgery is difficult and sometimes late. METHODS: We compared the outcome of patients who had early (<48 h) relaparoscopy for suspected postoperative complication to those where relaparoscopy was delayed (>48 h). RESULTS: During the study period, 7726 patients underwent laparoscopic surgery on our service. Of these, 57 (0.7%) patients had relaparoscopy for suspected complication. The primary operations were elective in 48 patients and emergent in nine. Thirty-seven patients had early, 20 had delayed, secondary operations. The most common indication in the early group was excessive pain (46%) followed by peritoneal signs in 35%. In the delayed group, the most common indication was signs of systemic inflammatory response syndrome in 30% and peritoneal signs in 25%. Relaparoscopy was negative in 16 (28%) patients with no difference between groups. The identified complication was treated laparoscopically in 37(65%) patients, and the rest were converted. The patients in the delayed group had a significantly longer hospital stay (p < 0.003) and had a higher rate of complications (p < 0.05). They also had a higher mortality rate (10% vs. 2.7%), but the difference was not statistically significant. CONCLUSIONS: A policy of early relaparoscopy in patients with suspected complications enables timely management of identified complications with expedient resolution.

Use of the "Bogota bag" for temporary abdominal closure in patients with secondary peritonitis.

Various methods may be used for temporary closure of the abdomen. Use of the "Bogota bag" (BB) technique for abdominal closure has been reported primarily in the management of injuries. This review describes our experience using the BB technique in cases of secondary peritonitis. Abdomenal closure using BB was reviewed retrospectively in 152 patients with secondary peritonitis. Of the 152 cases of BB use reviewed, 79 patients had complications of previous abdominal operations, 57 had secondary peritonitis, 14 had complications of abdominal trauma, and 2 were cases of mesenteric events. The BB remained in situ from 1 to 19 days. Changes occurred between 1 and 11 times per patient (mean, 2.8). In nine patients, early diagnosis of leaking of small bowel content under the bag was noted, and 36 patients (24%) died from sepsis. In 12 patients, the resolution of abdominal sepsis permitted secondary closure 10 days later. In 16 patients, mesh repair was performed after 4 weeks. Musculocutaneal flap repair was used in one case, and 13 patients had skin grafts. Eleven patients eventually underwent ventral hernia repair. Early temporary closure of the abdominal wall using BB in patients with abdominal sepsis and planned re-explorations is simple, safe, inexpensive, and effective. This temporary abdominal cover provides good exposure of abdominal content between re-explorations and may prevent fistula formation. The development and subsequent repair of large hernias constitute one of the difficult postoperative problems requiring future solution.