Impact of negative pressure wound therapy on enteroatmospheric fistulation in the septic open abdomen.

AIM: The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT. METHODS: Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups. RESULTS: A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p = 0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p = 0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%). CONCLUSIONS: Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study.

Laparoscopic double cholecystectomy for duplicated gallbladder: A case report.

INTRODUCTION: Duplication of the gallbladder (GB) is a very rare surgical encounter affecting 1 in 4000-5000 population that often eludes detection on preoperative ultrasonography, and might increase operative difficulty and risk. The H-type anomaly is the most common whereby each GB drains into the common bile duct via a separate cystic duct. PRESENTATION OF CASE: We report a young female patient with symptomatic gallstones who was incidentally found to have abnormal biliary anatomy on a CT colonography and an H-type duplication of the GB on MRCP. A challenging laparoscopic double cholecystectomy was performed uneventfully. DISCUSSION: Gallbladder duplication can be classified as a type-I anomaly (partiality split primordial gallbladder), a type-II anomaly (two separate gallbladders, each with their own cystic duct) or a rare type-III anomaly (triple gallbladders draining by 1-3 separate cystic ducts).Such anatomical variations are associated with increased operative difficulty and risks, including conversion to open cholecystectomy and common bile duct injury. CONCLUSION: A young female patient was pre-operatively diagnosed with a Harlaftis's type-II GB anomaly. Each gallbladder was drained by a distinct cystic duct (H-type anomaly). A laparoscopic cholecystectomy was performed with no complications afterwards. Awareness of this rare anomaly might require intraoperative cholangiography when initially suspected during a cholecystectomy to facilitate anatomical recognition and avoid missing a symptomatic pathologic GB and the need for a repeat cholecystectomy.

Gastric necrosis complicating acute gastric dilatation after Nissen fundoplication.

A woman in her 70s was referred for the management of complex intestinal fistulation, which had developed as a postoperative complication of laparoscopic Nissen fundoplication. Surgical treatment of a jejunocolocutaneous fistula and formation of a double-barrelled ileocolostomy was undertaken uneventfully. Routine postoperative nasogastric intubation was not undertaken. On the seventh postoperative day she had nausea and hiccupping. A chest x-ray demonstrated a massively dilated stomach which was decompressed with a nasogastric tube. The patient sustained a cardiac arrest and was resuscitated. A subsequent CT scan demonstrated acute gastric necrosis but the patient was judged too unwell for surgical intervention and died. Postmortem examination revealed emphysematous gastric necrosis. This case highlights the potentially fatal consequences of acute gastric dilatation following major abdominal surgery in patients who have previously had a Nissen fundoplication and are consequently unable to vomit.

Intractable positional borborygmi--an unusual cause diagnosed by barium contrast study.

The authors report the case of a 48-year-old woman, with a 2-year history of prominent borborygmi, nausea, abdominal discomfort after large meals and weight loss. Continuous, prominent, audible borborygmi were evident while the patient remained standing. However, these noises abated when she held her breath or when pressure was applied over the left hypochondrium. When lying flat, abdominal examination was normal. Gastroscopy, colonoscopy, small bowel follow-through, abdominal CT scan, small bowel transit study and laparoscopy were all normal. A barium meal showed that her stomach was normal when lying flat, but adopted an hourglass deformity in the sitting position due to compression from her left anterior ribs. Compression from the diaphragm, on inspiration, then resulted in audible borborygmi.

Sternocleidomastoid myocutaneous esophagoplasty for benign cervical stricture.

Benign strictures of the cervical esophagus that are resistant to dilation present a formidable challenge to the surgeon. Numerous varied techniques have been developed to restore swallowing. Reports of the sternocleidomastoid myocutaneous pedicled flap for repair of benign cervical strictures are scarce. We are reporting a case of residual lye stricture that was treated with sternocleidomastoid myocutaneous esophagoplasty in order to promote awareness of this procedure. This one-stage operation took 1 hour to complete. The patient began eating on postoperative day 4 and has not had any further symptoms.

The use of minimal preparation computed tomography for the primary investigation of colon cancer in frail or elderly patients.

AIM: To assess the place of computed tomography (CT) of the colon in frail or elderly patients with symptoms suggestive of colon cancer. METHOD: A total of 195 patients (median age 76 years) underwent CT of the abdomen and pelvis following the administration of positive oral contrast medium but no bowel preparation. All had symptoms suggestive of colon cancer. CT findings were classified as normal/diverticular disease (DD), possible colon cancer, definite colon cancer or extracolonic pathology. Accuracy of CT was assessed against patient outcome. Association between symptoms and colon cancer was assessed by chi-squared test. RESULTS: There were 47 deaths and median follow up for those alive was 16 months. Overall sensitivity of CT was 100% and specificity 87% for detection of colon cancer. One hundred and ten normal/DD CT examinations had no significant bowel lesion on follow up. Of 12 cases defined as 'definite cancers' on CT, there were nine colon cancers, two extracolonic cancers, and one normal. Of 23 'possible cancers' on CT, there were two colon cancers, three DD masses and 18 normal/DD. Fifty examinations had extracolonic findings including 33 (17%) cases of significant abdominal disease. CT findings led to a halt in investigations in 115 cases (59%), colonoscopy in 18 (9%) cases and surgery in 16 (8%) cases. None of the symptoms present showed a significant association with colon cancer (all P > 0.05). CONCLUSION: Minimal preparation CT is a non-invasive and sensitive method for investigating colon cancer in frail or elderly patients. It has a 100% negative predictive value and also detects a large number of extracolonic lesions.