Postoperative outcome and survival in relation to small intestinal involvement of total colonic aganglionosis.

BACKGROUND: The prognosis and treatment of total colonic aganglionosis (TCA) vary according to the presence and extent of small bowel involvement. METHODS: Medical records of TCA patients treated in Helsinki University Children's Hospital during 1984-2013 (n=21) were reviewed. RESULTS: The aganglionosis extended up to cecum or distal ileum (n=12), mid small bowel (n=4), or duodenojejunal flexure (n=5). Patients underwent resection of distal aganglionic bowel with ileoanal (IAA) or jejunoanal anastomosis (JAA) with (n=9) or without J-pouch (n=5), Lester-Martin pull-through (n=1), or were left with an end-jejunostomy (n=6). Further procedures included autologous intestinal reconstruction (n=3) and ITx/listing for ITx (n=2). Compared to distal ileum aganglionosis, patients with more proximal disease required parenteral nutrition (PN) more often (100% vs. 25%) and weaned off PN less frequently (p=0.001). At last follow-up 6.5 (interquartile range 2.5-14.5) years postoperatively, all patients with distal ileum aganglionosis were off PN and alive compared to 78% on PN (p<0.001) and 67% alive (p=0.063) of those with more proximal disease. All had normal plasma bilirubin and patients with preserved intestinal continuity (n=13) were continent. CONCLUSIONS: Outcomes following restorative proctocolectomy for aganglionosis extending up to mid small bowel are promising, whereas long-term outlook in proximal small intestinal disease is dismal without ITx.

Adult intussusception: diagnostic pitfalls, morbidity and mortality in a developing country.

OBJECTIVE: To study diagnostic pitfalls, morbidity and mortality of adult intussusception. PATIENTS AND METHODS: Retrospective study of adult patients records operated between 1979 and 2007 with the diagnosis of adult intussusception. RESULTS: We found 41 cases of adult intussusception. The mean age was 35.2 years (standard deviation (SD)=7.1). The delay between onset and medical consultation was 15 days. The diagnosis was made pre-operatively in 11 cases. Abdominal ultrasound showed an abdominal mass in 11 cases. Ileo-ileal intussusception was most frequent (16 cases). Intussusception was secondary in 24 cases. There were seven instances of intestinal necrosis. Intestinal resection was performed in 34 cases. Surgical site infection occurred in four patients, three patients died. CONCLUSION: The pre-operative diagnosis of acute intestinal intussusception is difficult. Morbidity and mortality rates are high. Improved diagnostic investigations in developing countries could improve the prognosis of this condition.

Cecal rupture in foals--7 cases (1996-2006).

The objective of this study was to identify risk factors and describe clinical signs in 7 foals with cecal rupture; none of the foals survived. Six foals had undergone general anesthesia; 5 for orthopedic procedures. Six of the foals were receiving nonsteriod anti-inflammatory drugs. Most foals started showing colic signs on day 2 after surgery, preceded in 3 cases by dullness. Cecal rupture occurred between 4 hours and 2 days after the first signs of colic were noticed. Intestinal motility was decreased or absent in all foals for which it was recorded.Foals undergoing general anesthesia should be closely monitored for any sign of dullness, prolonged recumbency, reduced fecal output, and signs of abdominal discomfort for 3 days postoperatively, especially in cases following orthopedic surgery. If any of the above occurs, cecal impaction should be considered as a differential diagnosis. A prompt exploratory laparotomy may be a reasonable diagnostic option before the cecum ruptures with fatal consequences.

Bone marrow stromal cells attenuate sepsis via prostaglandin E(2)-dependent reprogramming of host macrophages to increase their interleukin-10 production.

Sepsis causes over 200,000 deaths yearly in the US; better treatments are urgently needed. Administering bone marrow stromal cells (BMSCs -- also known as mesenchymal stem cells) to mice before or shortly after inducing sepsis by cecal ligation and puncture reduced mortality and improved organ function. The beneficial effect of BMSCs was eliminated by macrophage depletion or pretreatment with antibodies specific for interleukin-10 (IL-10) or IL-10 receptor. Monocytes and/or macrophages from septic lungs made more IL-10 when prepared from mice treated with BMSCs versus untreated mice. Lipopolysaccharide (LPS)-stimulated macrophages produced more IL-10 when cultured with BMSCs, but this effect was eliminated if the BMSCs lacked the genes encoding Toll-like receptor 4, myeloid differentiation primary response gene-88, tumor necrosis factor (TNF) receptor-1a or cyclooxygenase-2. Our results suggest that BMSCs (activated by LPS or TNF-alpha) reprogram macrophages by releasing prostaglandin E(2) that acts on the macrophages through the prostaglandin EP2 and EP4 receptors. Because BMSCs have been successfully given to humans and can easily be cultured and might be used without human leukocyte antigen matching, we suggest that cultured, banked human BMSCs may be effective in treating sepsis in high-risk patient groups.

Acute typhlitis in inmunocompromised patient: an eight year experience.

INTRODUCTION: Acute typhlitis is usually associated with severe immunosuppressive conditions. Initially described as closely associated with infantile myeloid leukaemia, its incidence increased along the last decade. DESIGN: retrospective review. PATIENTS: 12 immunodepressed patients affected of acute typhilis in our hospital between 1994 and 2001. Suspected diagnosis was established by clinical symptoms and abdominal CT findings, and was confirmed with pathological finding in the surgical specimen. Clinical and radiological diagnosis, treatment, complications and survival of patients are discussed. RESULTS: 3 patients with a previous diagnosis af acute myeloid leukemia, 2 patients with non-Hodgkin lymphoma, 2 patients with aplastic anaemia, one patient with AIDS, and 4 patients with kidney transplantation were included in our study. Prednisone, cyclosporine, Ara-C and vincristine were the most frequently involved drugs. Most frequent clinical findings included abdominal pain, fever, nausea-vomiting and abdominal distension. CT diagnosis revealed caecum and colic involvement with rarefaction of pericaecal fat. Medical treatment was successful in only 33% of all patients, the other patients requiring a surgical procedure including right hemicolectomy with or without intestinal anastomosis. Mortality reached 58.3 per cent, representing multiorganic sepsis the main cause of death. CONCLUSIONS: although early diagnosis of acute typhlitis bears a better prognosis, mortality rates are up 50 % in spite of an established treatment.

Colonic volvulus.

OBJECTIVE: To review the incidence of volvulations in our workplace, to study the procedures employed in its treatment, and to discuss our results during the last 20 years. MATERIAL AND METHODS: A series of colonic volvulus treated between 1978 and 1998 at one hospital is presented. RESULTS: We reviewed 41 cases. Volvulus locations are: sigmoid colon: 21, caecum: 17, transverse colon: 2, and splenic flexure: 1. Mortality rates according to the type of volvulus and type of operative procedure is analyzed. Four cases of volvulus recurrence (9%). CONCLUSIONS: Treatment guidelines for the approach to colonic volvulus are presented.

Management of appendiceal masses.

OBJECTIVE: To evaluate the outcome of patients treated for appendiceal abscess, and managed either conservatively or surgically, and to describe the short and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively. DESIGN: Retrospective study. SETTING: University hospital, Sweden. PATIENTS: Ninety-three patients with the diagnosis of appendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14-93) years. Mean (range) follow-up for patients operated on was 65 (11-135) and for those treated conservatively 66 (6-136) months. MAIN OUTCOME MEASURES: Course of acute disease, recorded complications, recurrence of appendicitis and incidence of interval appendicectomy during follow-up. RESULTS: The duration of pain before admission was 4 (0.5-82) days for those operated on and 7 (2-60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. 4 of the patients treated conservatively (8%) had an underlying tumour diagnosed at follow-up. CONCLUSIONS: Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.

Tiflitis neutropénica en niños / Neutropenic typhlitis in children

Introducción. La tiflitis es una colitis necrozante con inflamación del ciego en pacientes neutropénicos, usualmente diagnosticada en la autopsia. Material y métodos. identificamos 18 niños hospitalizados en el Hospital Infantil de México Federico Gómez en un período de 10 años, con presencia de fiebre, dolor e hipersensibilidad abdominal sugestiva de tiflitis neutropénica. Resultados. Ocho de los 18 pacientes tenían evidencia radiológica de tiflitis en las radiografías de abdomen. Todos los pacientes presentaron neutropenia al momento del diagnóstico y 9 tenían bacteriemia documentada. Los 18 pacientes fueron tratados con diversos antibióticos, 4 de ellos sometidos a cirugía y 1 a colonoscopia. Once pacientes murieron, 10 se mejoraron médicamente y 1 quirúrgicamente. En orden de frecuencia, la tiflitis fue identificada en 9 pacientes con leucemia aguda no linfoide, en 6 con leucemia aguda linfoide; en 1 con anemia aplásica, neutropenia cíclica y carcinoma renal, respectivamente. Sólo 4 pacientes recibieron factor estimulador de colonias de granulocitos; y en todos los pacientes que sobrevivieron se observó un aumento de leucocitos polimorfonucleares a más de 500/mm3 documentado entre el cuarto y el décimosexto día de manejo médico y/o quirúrgico. Conclusiones. Recomendamos que ante un paciente con fiebre y neutropenia, con dolor e hipersensibilidad abdominal, además de datos como diarrea hematemesis se debe plantear como diagnóstico tiflitis neutropénia e instaurarse el manejo general y específico que incluye la valoración quirúrgica

Retrospective analysis of the results of 151 exploratory laparotomies in horses with gastrointestinal disease.

Of 149 horses that underwent 151 exploratory laparotomies for gastrointestinal disorders from September 1987 to May 1991, 107 (72%) were discharged from the hospital: 100 (66%) survived for > 7 months, 94 of which returned to their intended use. Survival rate (64/80) for horses with caecum/large colon obstruction was significantly (P = 0.003) higher than for horses with small intestinal obstruction (33/64). Prolonged surgery was associated with significantly (P < 0.001) lower survival rates than short surgical time. In the large intestine, survival rate (15/29) for strangulated obstructions was significantly (P < 0.001) lower than for simple obstructions (52/58). Generalised septic peritonitis (9 horses) and bowel obstruction associated with adhesions (8 horses) were the most frequent fatal post-operative complications. The rate (6/44) of post-operative adhesions after small intestinal obstruction was significantly (P = 0.006) higher than that (2/68) following large intestinal obstruction. The rate (8/55) of post-operative adhesion formation in horses that required enterotomy/enterectomy was significantly (P = 0.003) higher than that (0/57) in horses that did not require gut wall incisions. Incisional suppuration developed in 42 horses and occurred with a significantly (P = 0.028) higher rate (32/72) after caecum/large colon lesions than after obstruction at other sites, (10/42) but was not associated with known contamination at the time of surgery (P = 0.806).

[Surgical mortality and long-term recurrence of ileocecal volvulus]. / Mortalidad operatoria y recurrencia a largo plazo por vólvulo ileocecal.

Acute ileocecal volvulus is a condition of the abdomen which requires emergency treatment and is currently managed by several methods with a mortality rate of 25%. Surgical options include detorsion, cecostomy for nongangrenous volvulus or resection when gangrene is present. We studied the mortality and recurrence rate of ileocecal volvulus. This retrospective analysis evaluated 16 patients who underwent operation at Belen Hospital, Trujillo, Peru, between January 1966 and August 1992. As of August 1992, median follow-up was 160 months for 13 surviving patients (range, 6 to 307 months). Eleven men and 5 women with a median age of 52.3 + 21.1 years (range, 9 months to 83 years) formed the study population. Sixty eight percent of cases were 41 to 80 years of age and all women were than 40 years of age. Most of them were from the Peruvian Andes (81.3%), were from Indian and Spanish extraction (93.7%), and farmers (50%). Twelve patients (75%) developed a chronic ileocecal volvulus and 4 (25%) had an acute presentation. The clinical picture presented as large bowel obstruction in all patients. An ileocecal volvulus was accurately diagnosed by plain films of the abdomen in only 2 patients (16%) pre-operatively. A variety of procedures were used: cecopexy (9 cases), right hemicolectomy (3 cases) simple detorsion (2 cases), Mickulics exteriorization-resection (1 case) and cecostomy (1 case). The operative mortality rate was 18.7%. There were no recurrences after cecopexy. The most frequent post-operative complications were bronchopneumonia (18.7%), and wound infection (18.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality causes of owl monkeys (Aotus nancymae and Aotus vociferans) in captivity.

To determine the main causes of death in "owl monkeys" (Aotus nancymae and A. vociferans) in captivity, 115 necropsies were performed. According to the macroscopic findings and clinical data, results are as follow: acute lobular pneumonia (25.2%), chronic nephropathy (10.4%), acute catarrhal enteritis (8.7%), acute hemorrhagic enteritis (7%), acute toxic hepatitis (5.2%), trauma (5.2%), and others.

Cecal pseudo-obstruction. Early therapy should be nonoperative.

This study was undertaken to ascertain the role of colonoscopy and surgery in patients with pseudo-obstruction of the cecum. Twenty-eight patients developed cecal pseudo-obstruction (cecal diameter ave., 13.6 cm +/- 2.0; range, 10-18 cm) and 25 of these 28 (89%) were hospitalized for nonabdominal problems. Significant comorbidities existed in all patients. Multimodal therapy was used in most: nasogastric (NG) suction (100%), rectal tube (64%), laxatives (64%), enemas (57%), Colonoscopy (57%), and surgery (25%). Twelve of 18 patients receiving rectal tubes, 14 of 18 receiving laxatives, 11 of 16 receiving enemas, and 12 of 16 (75%) undergoing colonoscopy avoided surgery; colonoscopy cured 44 per cent of the patients, was useless in 38 per cent, was detrimental in 6 per cent, and was temporizing in 12 per cent. Seven of the 28 patients (5 cecostomy, 2 right hemicolectomy) underwent surgery. Four of the seven patients (57%) had significant surgical complications such as wound infection, incisional hernia, cecal prolapse with infarction/death, and evisceration/death. Twenty-four patients of the 28 (86%) survived the index admission; Two of four patients died of the systemic problems that brought on cecal pseudo-obstruction and two of four patients died as a result of cecostomy complications. Pseudo-obstruction occurs in older, debilitated patients generally hospitalized because of nonabdominal problems. Treatment should be aimed at correcting the underlying cause; multimodalities often temporize until underlying problems are corrected and pseudo-obstruction resolves. Colonoscopy is often curative, occasionally helpful, and rarely harmful. Surgery is curative but carries significant risks. Uncomplicated cecal dilatation to 10-18 cm is tolerated; early operative intervention should not be dictated by cecal size alone.

Relationship between levels of Clostridium difficile toxin A and toxin B and cecal lesions in gnotobiotic mice.

Various Clostridium difficile strains were studied with respect to their pathogenicity in monoassociated mice in relation to levels of toxin A and toxin B in vivo and in vitro. Two strains which were the most potent toxin producers in vitro induced mortality (100%); mice monoassociated with these strains were found to have high levels of both toxins in their ceca and an intense cecal epithelial ulceration together with a severe inflammatory process. No mortality was observed with the other strains. Strains which were moderately toxinogenic in vitro induced inflammation of the cecum but no ulceration, and no toxin A was found. Inflammation intensity was not related to toxin B levels. After 3 weeks, ceca returned to normal in spite of a chronic cytotoxin production. When compared with in vitro results, which showed a good correlation between the levels of the two toxins, toxin A amounts in vivo were found to be lowered relative to toxin B levels. The lack of detectable toxin A levels in animals infected with all but the two most highly toxinogenic strains prevented death. This work points out the importance of investigation of toxin A for the understanding of C. difficile pathogenicity.

Volvulus of the colon. Incidence and mortality.

Between 1960 and 1980, 137 patients with colonic volvulus (52% cecal, 3% transverse colon, 2% splenic flexure, and 43% sigmoid) were seen at the Mayo Clinic. Among the 59 patients with sigmoid volvulus, four (7%) had colonic infarction. Total mortality with sigmoid volvulus was seven per cent. There were 71 patients with cecal volvulus. Colonoscopic decompression was accomplished in two of these patients; in 15 (21%), gangrenous colon developed and mortality was 33%. Total mortality for cecal volvulus patients was 17%. Mortality for all forms of volvulus in patients with viable colons was 11%. Mortality for all patients with volvulus was 14%.

Faecal peritonitis in the rat. An experimental model for evaluation of surgical and adjuvant therapies.

Wistar rats were equipped with two central venous catheters used for parenteral nutrition/antibiotics and blood sampling. The rats were conditioned in special cages and given a meat pellet diet to achieve a bowel flora more similar to man. When the animals after two weeks were adjusted to life in cages, meat pellets and indwelling non-functioning venous catheters, peritonitis was induced with a standardized 3 mm caecal perforation without any ligation or devascularization. Within few hours the animals were severe septic and blood cultures were positive in all with a mixed flora of gram-negative coliforms and anaerobic bacteroides. Important occurrence of circulating endotoxin was detected and found to increase gradually till death. Without any treatment this form of septic peritonitis gave a 100% mortality. Total parenteral nutrition (TPN) reduced mortality to 50%. Substitution of TPN with a simple saline/glucose solution gave the same survival rate demonstrating the importance of fluid supply and crystalloids during the early phase of septicaemia. Intravenously given antimicrobial agents active against anaerobes (tinidazole) and aerobes (cefotaxim) will in combination reduce mortality to less than 15%. The lethal effect of a 3 mm caecal perforation was almost abolished when TPN was added to this combination of antimicrobial agents. Continuous peritoneal irrigation did not increase survival rate.

Cecal volvulus. Low mortality at a city hospital.

The case records of 12 patients with cecal volvulus over a 20-year period were reviewed. The patients averaged 46.7 years old; 75 per cent were white and 67 per cent were male. Patients presented with signs and symptoms of intestinal obstruction. Pain and distention were present in more than half of the patients. X-rays assisted in making the diagnosis of cecal volvulus in only five of the patients. Diagnosis was made in the remainder at the time of surgical exploration. At operation, one cecum was necrotic and required resection. Five patients underwent cecostomy, two cecopexy, and four simple detorsion. Post-operatively, one patient developed a wound infection. There were no deaths. Follow-up for seven patients averaged 75 months each. One patient who had undergone simple detorsion developed another cecal volvulus. All who were contacted were alive and well. At St. Luke's Hospital, cecal volvulus generally occurs in middle-aged white males. Cecostomy or cecopexy adequately treats cecal volvulus when the cecum remains viable. This study demonstrates that prompt surgical intervention, before strangulation of the colon occurs, results in low mortality even in city hospital patients.

Continuous peritoneal lavage after experimental caecal perforation. Increase in survival prevented by lack of adhesion formation.

The effect of continuous peritoneal irrigation on adhesion formation and survival rate was investigated in rats with faecal peritonitis induced by a caecal perforation. When no treatment was thereafter given, extensive adhesion formation and covering of the perforation were found at autopsy. Continuous peritoneal lavage did not increase the survival rate, but at autopsy no adhesion formation was seen and the perforation was wide open, permitting continued soiling.

Responses to prolonged selection for resistance and susceptibility to acute cecal coccidiosis in the auburn strain single comb white leghorn.

Selection in the parental Auburn Strain Leghorn (A line) for resistance (R line, 13 filial generations) and susceptibility (S line, 7 filial generations) to acute cecal coccidiosis (ACC) caused by Eimeria tenella resulted in a sixfold difference in the ACC mortality rates of the two lines. Relaxation of selection for resistance in line RR, derived entirely from R line, resulted in gradual regression of the ACC mortality rate toward that of the parental A line nonselected control. Progress of selection in R line based on the same low dose of oocysts employed in S line neared a plateau of low mortality after six generations. Average ACC mortality in the first four generations of S line was 50% greater than that in A line. Before infection, chicks of S line were smaller than those of lines A, R, and RR. After infection, growth of S line survivors was inferior to that of survivors of the other lines. Uninfected controls of S line and A line grew at similar rates; those of R line grew at a significantly lower rate. In R line, large doses of oocysts caused high mortality. The largest dose caused mortality approaching 90% in both sexes; at lower doses, males died at higher rates than females. Among the survivors, growth rates of females were inferior to those of males; the difference increased with increasing dose. Large doses of oocysts resulted in spreading of the infection beyond the typical site. In R line, severe infection occurred in the necks of the cecal pouches and rectum with comparatively mild infection in the bulbar portion of the pouches. In contrast, the chief focus of infection remained in the bulbar pouches in S line. Selection for resistance seemingly disrupted the typical host tissue specificity of E. tenella. Thus, genes mediating the response of the host to ACC are possibly identical or complementary to genes controlling tissue specificity.