A multicentre case control study on complicated coeliac disease: two different patterns of natural history, two different prognoses.

BACKGROUND: Coeliac disease is a common enteropathy characterized by an increased mortality mainly due to its complications. The natural history of complicated coeliac disease is characterised by two different types of course: patients with a new diagnosis of coeliac disease that do not improve despite a strict gluten-free diet (type A cases) and previously diagnosed coeliac patients that initially improved on a gluten-free diet but then relapsed despite a strict diet (type B cases). Our aim was to study the prognosis and survival of A and B cases. METHODS: Clinical and laboratory data from coeliac patients who later developed complications (A and B cases) and sex- and age-matched coeliac patients who normally responded to a gluten-free diet (controls) were collected among 11 Italian centres. RESULTS: 87 cases and 136 controls were enrolled. Complications tended to occur rapidly after the diagnosis of coeliac disease and cumulative survival dropped in the first months after diagnosis of complicated coeliac disease. Thirty-seven cases died (30/59 in group A, 7/28 in group B). Type B cases presented an increased survival rate compared to A cases. CONCLUSIONS: Complicated coeliac disease is an extremely serious condition with a high mortality and a short survival. Survival depends on the type of natural history.

SEMS vs cSEMS in duodenal and small bowel obstruction: high risk of migration in the covered stent group.

AIM: To compare clinical success and complications of uncovered self-expanding metal stents (SEMS) vs covered SEMS (cSEMS) in obstruction of the small bowel. METHODS: Technical success, complications and outcome of endoscopic SEMS or cSEMS placement in tumor related obstruction of the duodenum or jejunum were retrospectively assessed. The primary end points were rates of stent migration and overgrowth. Secondary end points were the effect of concomitant biliary drainage on migration rate and overall survival. The data was analyzed according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Thirty-two SEMS were implanted in 20 patients. In all patients, endoscopic stent implantation was successful. Stent migration was observed in 9 of 16 cSEMS (56%) in comparison to 0/16 SEMS (0%) implantations (P = 0.002). Stent overgrowth did not significantly differ between the two stent types (SEMS: 3/16, 19%; cSEMS: 2/16, 13%). One cSEMS dislodged and had to be recovered from the jejunum by way of laparotomy. Time until migration between SEMS and cSEMS in patients with and without concomitant biliary stents did not significantly differ (HR = 1.530, 95%CI 0.731-6.306; P = 0.556). The mean follow-up was 57 ± 71 d (range: 1-275 d). CONCLUSION: SEMS and cSEMS placement is safe in small bowel tumor obstruction. However, cSEMS is accompanied with a high rate of migration in comparison to uncovered SEMS.

Surgical findings and outcome for dairy cattle with jejunal hemorrhage syndrome: 31 cases (2000-2007).

OBJECTIVE: To describe signalment; surgical findings; short-, medium-, and long-term outcome; and recurrence rate for cattle undergoing celiotomy because of jejunal hemorrhage syndrome (JHS) and to analyze risk factors associated with outcome and recurrence. DESIGN: Retrospective case series. ANIMALS: 31 dairy cattle with JHS. PROCEDURES: Medical records were analyzed. Follow-up information was obtained from owners of cattle surviving until discharge. RESULTS: 18 of 31 (58%) cattle undergoing celiotomy survived to initial discharge. Fifteen (48%) and 13 (42%) were alive 6 and 12 months after discharge, respectively. All 5 deaths within 12 months after discharge were attributed to JHS recurrence. Survival time was 12 to 85 months for the 13 long-term survivors. Six of 7 that died > 12 months after celiotomy did so for reasons unrelated to JHS. Recurrence rate among short-term survivors was 7 of 18; 1 of these survived long-term. A significant proportion of affected cattle were Brown Swiss, compared with proportions for other breeds. Manual massage of the bowel to break down clots was associated with a significantly higher short-term survival rate than was enterectomy or enterotomy. Medium- and long-term survival rate was higher in cattle referred 24 to 48 hours after onset of signs. Length of obstructing blood clots was not associated with outcome. Other factors were not significantly associated with recurrence. CONCLUSIONS AND CLINICAL RELEVANCE: Survival rates were higher than those in other reports. Prompt celiotomy and resolution by use of manual massage were associated with higher survival rates. In this population, JHS recurred in 7 of 18 short-term survivors.

Complications and survival associated with surgical compared with medical management of horses with duodenitis-proximal jejunitis.

REASONS FOR PERFORMING STUDY: Based on clinical observation, it is hypothesised that horses with duodenitis-proximal jejunitis (DPJ) that are treated surgically have a shorter duration, smaller volume, and slower rate of nasogastric reflux (NGR) compared to horses treated medically, are more likely to develop diarrhoea than medically managed cases, and have a higher incisional infection rate than a sample population of horses undergoing abdominal exploration for gastrointestinal disease other than DPJ. OBJECTIVES: To compare: 1) duration, volume and rate of NGR and the percentage of horses with diarrhoea between medically and surgically treated DPJ cases; and 2) incisional infection rate in horses with DPJ undergoing abdominal exploration to a sample population of horses undergoing abdominal exploration for gastrointestinal disease other than DPJ. METHODS: Medical records of cases with DPJ diagnosed 1995-2006 were reviewed. Information obtained included subject details, presenting clinical findings, treatment category (medical/surgical), complications (diarrhoea, incisional infection), and outcome (survival/nonsurvival). Data were analysed using a Chi-squared test and a mixed model analysis of variance. Level of significance was P<0.05. RESULTS: Compared to medical cases, surgical cases had significantly decreased survival, a longer duration and larger total volume of NGR, and were more likely to develop diarrhoea. The incisional infection rate for horses with DPJ undergoing abdominal exploration was 16% compared to 7% for the sample population of horses. CONCLUSIONS: Surgical treatment of horses with DPJ did not lead to resolution of NGR faster than medical treatment. Surgical cases were more likely to develop diarrhoea and did not have a significantly higher incisional infection rate than the sample population.

[Diagnosis and treatment of acute intestinal obstruction due to gall-stone].

Results of treatment of 43 patients with acute intestinal obstruction due to gall-stones are analyzed. Forty patients were operated, 3 patients were not because of extremely severe state. Enterolythotomy was performed in 27 cases, incision of intestinal wall was carried out directly above the stones (14 cases, group 1), above or below it (13 cases, group 2). Insufficiency of enteral suture was seen in 4 patients of group 1 that required repeated surgery. Lethality in group 1 was 21.4%, in group 2-7.1%. Intestinal resection was performed in 12 patients of group 3, there were no cases of suture insufficiency, and lethality was 8.3%. It is concluded that enterotomy should be performed above or below strangulated stone. Intestinal resection should be performed when concrement is immovable or in cases of intestinal necrosis.

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series.

BACKGROUND: Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting. METHODS: Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement. RESULTS: A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression. CONCLUSIONS: Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.

[Undeveloped high intestinal fistulas as an urgent problem of modern surgery]. / Nesformirovavshiesia vysokie kishechnye svishchi kak aktual'naia problema sovremennoi khirurgii.

Eighty-two cases of un formed high intestinal fistulas are analyzed. Degree of non-formation and volume of chymus loss are the main criteria determining treatment policy. Early surgery (one or two-sided switching of fistulas zone) is indicated in intestinal loss more then 600-700 ml per day or in complete fistula. Mezonnes surgery was un effective in the majority of cases. Special policy including trunk vagotomy, antrumectomy and plastic repair of the duodenal bulb permitted in the last years to avoid duodenal fistulas in the treatment of ulcer disease.

[Perforation of the small intestine]. / Le perforazioni dell'intestino tenue.

BACKGROUND: Small bowel perforation is a major problem in abdominal typhi disease, but is seldom observed in Italy, as Salmonella typhi infections are rare in this Nation. The cause of perforation varies greatly. The reported mortality is high and varies from 23 up to 42%. A retrospective study has been performed in order to find how to improve the outcome. METHODS: A series spanning 10 years is reviewed, from January 1, 1987 to December 31, 1997, comprising 60 patients with small bowel perforation, operated in a urgency setting in the Operating Room of the Emergency Department of the Molinette Hospital in Torino. Resection and primary anastomosis were utilized in 33 patients, 27 underwent oversewing. In 3 patients a colostomy was felt necessary because of a concomitant damage of the colon. RESULTS: No leakages occurred. Hospital stay varies from 1 day to 76 days (24 days mean). Mortality is consistent with literature: 20 patients (33%) but the cause is related to the primary diseases of the patients. Delay in diagnosis did not affect the patient's outcome. CONCLUSIONS: In conclusion, it is confirmed the one-time surgery as the choice treatment in small bowel perforations from causes other then S. typhi infection. Mortality is not directly related to the consequences of surgical repair.

[Postoperative fistulas after gastrectomy: risk factors in relation to incidence and mortality]. / Fistole postoperatorie dopo gastrectomia: fattori di rischio in relazione ad incidenza e mortalità.

The relations between incidence and prognosis of postoperative fistulas after gastrectomy and some different variables were analysed in the present retrospective study. Thirteen digestive fistulas of 113 patients (11.9%) submitted to gastrectomy during the period 1989-1994 represent the study population. The incidence of postoperative fistulas was compared to the kind of gastric pathology, to the extension of gastrectomy, to different nutritional (serum haemoglobin, albumin and transferrin level, weight loss) and immunological factors (serum lymphocytes) and, for oncological patients, to the stage of the disease. Incidence was directly related to the extension of gastrectomy, to serum albumin and haemoglobin level, and to weight loss rate. The results were not statistically significant at Kruskal-Wallis and ANOVA tests. No relation was found between incidence of fistulas and serum transferrin level, number of lymphocytes and adoption of early postoperative enteral nutrition. Six patients had spontaneous closure of the fistula with conservative therapy. Seven patients required reoperation because of abdominal sepsis (53.8%). Three patients died (23%). Although spontaneous closure, reoperation and mortality were related to nutritional and immunological state, no examined variables showed a statistically significative relation. The adoption of early postoperative enteral nutrition was not related to the prognosis, unlike the stage of the disease: patients submitted to reoperation had a TNM III or IV stage; dead patients had a TNM IV stage. Treatment of metabolic-nutritional unbalance can prevent anastomotic failure and fistula after gastrectomy and improve the prognosis. The relation between early postoperative enteral nutrition and incidence and prognosis of postoperative fistulas remains unclear.

Perforated jejunal diverticula.

Jejunal diverticular (JD) perforation is an uncommon cause of acute abdominal pain in the elderly. From 1971 to 1994 we treated 13 such patients, 9 men and 4 women, with a mean age of 68 years. All patients experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis (range of white blood cell counts, 14,000-21,000). On physical examination, three patients had localized peritonitis, were thought to have appendicitis, and underwent immediate laparotomy and segmental jejunal resection for perforated JD. The remaining 10 patients had abdominal tenderness without peritoneal signs. They were hospitalized and managed expectantly. All experienced worsening signs and symptoms and underwent exploratory laparotomy and resection of the involved jejunal segment 13 hours to 8 days after admission. Although 6 of 13 patients had had JD documented previously, in only 2 patients was perforated JD diagnosed preoperatively. In 8 of 13 patients peritoneal contamination was minimal and was contained within the leaves of the mesentery. Soilage was severe with abscess formation in 5 patients. The longer the delay in operative intervention, the greater the peritoneal soilage. The 3 patients undergoing immediate surgery had minimal contamination. Of the 10 patients initially observed, the mean interval before operation was 74 hours in the 5 patients with severe soilage versus 21 hours in those with minimal contamination. The postoperative course was uneventful in 11 patients. Two patients died. Surgical consultation was delayed (8 days, 12 days) in both patients, who had severe peritoneal contamination and died of sepsis. In conclusion, JD perforation is an uncommon and frequently overlooked cause of acute abdominal pain in elderly patients. Timely operative intervention and resection of the involved jejunum are the keys to a successful outcome. Because the presentation and physical findings of perforated JD can be highly variable, a history of preexisting JD should arouse suspicion for JD perforation as the etiology of acute abdominal pain in the elderly.

Prognostic indicators for horses with duodenitis-proximal jejunitis. 75 horses (1985-1989).

The medical records of 75 horses with duodenitis-proximal jejunitis (DPJ) were reviewed. Ages, physical parameters, laboratory values, and treatment data were compared between horses surviving DPJ and horses not surviving DPJ (Table 1). Fifty of 75 horses (66.6%) survived. Sixty-six horses (88.0%) were managed with medical treatment alone and nine horses (12.0%) were managed with medical treatment plus surgical intervention. Using a logistic regression model, the association of each of the 19 physical and laboratory parameters with death was evaluated retrospectively in the 75 horses. Three parameters (anion gap, abdominal fluid total protein concentration, and volume of gastric fluid for the first 24 hours of hospitalization) were significantly associated with death by univariate analysis. Using a stepwise multiple logistic regression, two parameters remained significantly associated with death (P < 0.05), anion gap and abdominal fluid total protein concentration.

Improvement in survival of mice with proximal small bowel obstruction treated with octreotide.

Small bowel obstruction is a common disorder in surgical practice. The major morbidity of bowel obstruction relates to intestinal distension and ischemia. We hypothesized that octreotide, a potent inhibitor of gut secretion, would reduce mortality in a mouse model of lethal small bowel obstruction. C57 mice were anesthetized with urethane and prepared with either proximal jejunal or distal ileal obstruction. After 8 hours, surviving mice were randomized to receive either octreotide (100 micrograms/kg) or saline subcutaneously every 8 hours. Octreotide significantly improved survival in mice with proximal obstruction by life table analysis. Mean survival increased from 31 +/- 3 to 41 +/- 4 hours. In distal obstruction, octreotide treatment resulted in a trend towards improved survival; however, this trend failed to reach statistical significance by life table analysis. The improvement in survival in this mouse model suggests that octreotide may be a valuable adjunct in the treatment of patients with small bowel obstruction.

[Predisposing factors, clinical picture and mortality in volvulus of the small intestine]. / Factores predisponentes, cuadro clínico y mortalidad en vólvulo de intestino delgado.

This retrospective study evaluated predisposing factors, clinical picture and the methods of treatment related to morbidity and mortality of 19 small bowel volvulus (SBV) who underwent operation at Belen Hospital (Trujillo-Peru) during the last 26 years (1966-1992). The SBV was 1.6% of all cases of intestinal obstruction in this period and 10.8% of all intestinal volvulus. The median age was of 43 +/- 20.5 years (range, 6 to 78 years) and the majority of them were between 41 and 60 years. Sixteen cases (84.2%) were men from Indian and Spanish extraction and most of them were farmers and came from the Sierra of the Department of La Libertad. Two cases (10.5%) had non-related antecedents previous surgery. In six patients (31.6%) the volvulus was less than seven day's duration and in thirty (68.4%) it was more eight day's duration with previous attacks of obstruction (median: 19.3 days, range: 17 hours to 94 days). Pain, vomiting and distention were present in almost all of these cases. The most frequent abdominal finding was distention. The location of the volvulus was: ileum, 12 cases (63.2%), root of mesentery, 4 cases (21%) and jejunum, 3 cases (15.8%). Gangrenous bowel was present in six patients (31.5) and gangrenous intestine with perforation in two cases (10.5%) who underwent resection of the involved segment with primary anastomosis. In this group one patient (5.2%) died of sepsis and the wound infection rate was of 37.5%. There was no statistically significant correlation with the duration of illness and the presence of gangrenous loops or the mortality rate (p > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary conservative management of external small-bowel fistulas. Changing composition of fistula series?

A primary conservative approach was used in treatment of 42 patients with 45 external small-bowel fistulas. Closure of fistula was achieved in 29 patients but failed in 13 (10 died and 3 discharged with open fistula). There was no time-related improvement in closure rate or mortality, probably because of a general shift towards more serious cases. To evaluate this concept more specifically, groups of simple (19) or complicated (23) fistula were distinguished. The 23 patients with complicated fistula were more severely ill, had more sepsis, e.g. intra-abdominal abscess, and were more often treated in the intensive care unit (p less than 0.01) than the 19 with simple fistula. The respective mortality rates were 7/23 and 3/19. All six patients who died of sepsis had complicated fistula. Mortality in the simple fistula group was related to the primary disease. Especially in cases of complicated fistula, further improvements in management of septic complications should be aimed for, to permit success in delayed definitive surgery.

Nonspecific jejunitis--a challenging problem in children.

An acute enteric infection with the pathological feature of a severe necrotising jejunitis is an uncommon condition which mainly affects young people. It is characterized by severe abdominal pain of acute onset, copious bilious vomiting, and foul smelling loose stools containing blood. Exploration revealed varying degree of ischemic changes in the small bowel (mainly the upper jejunum) ranging from mucosal ulceration to frank gangrene of the bowel. The exact etiology is not known; the condition may be due to toxins produced by gram-negative bacilli or due to a localized allergic reaction. The disease had a progressive but self-limiting course. Mortality is around 40% and considerable morbidity continuing for 2-3 wk. Presentation bears similarity to Darmbrand of Germany, Pig-bel of New Guinea, and ischemic enteritis of Thailand.

[Ways of reducing mortality in patients with gastric and small and large intestine fistulas]. / Puti snizheniia letal'nosti bol'nykh zheludochno-tonko-tolstokishechnoi fistuloi.

During 16 years operations were performed on 423 patients with peptic ulcers of anastomoses, in 13 of them the disease was complicated by gastro-intestinal-colonic fistulas. Of 7 patients operated upon during first 11 years four patients died, of 6 patients operated upon during the second period (the last 5 years) there were no lethal outcomes. The less lethality was due to using less traumatic operations and longer preparing the patients for operations.

Free perforation in Crohn's disease: I. A survey of 99 cases.

A review of more than 181 reported cases of free perforation in Crohn's disease yielded 84 cases that fulfilled rigorous criteria for classification as spontaneous free perforation with generalized peritonitis. An additional 15 cases from The Mount Sinai Hospital, derived from a population of 1010 patients with Crohn's disease, bring the total number to 99. Separately tabulated are 116 other cases either occurring in bypassed segments, developing after surgery, presenting with ruptured abscesses, or not definitively documented. Most reported perforations in the literature occurred in the distal small bowel. Among the Crohn's disease patients in our hospital, however, the incidence of colonic and small bowel perforation were 1.6 and 0.7%, respectively, with the highest frequency actually occurring in diseased segments of jejunum (2/50 = 4%). Free perforation was the presenting manifestation of the disease in 25 of the 84 reported cases. In our 15 patients, although perforation was never the presenting manifestation, it tended to occur early in the course of the disease (mean 3.5 years from onset of symptoms). Ninety-six of the 99 cases were operated on. The three patients treated without surgery all died. Mortality was most frequent following simple suture in the earliest reported case (39%), but considerably less frequent after resection and anastomosis (3.7%). All 18 patients treated by resection and diversion survived. Immediate surgery with resection and/or diversion therefore appears to be appropriate treatment for free perforation in Crohn's disease.