[A retained foreign body in the peritoneal cavity causing intestinal obstruction by intraluminal migration]. / Der vergessene Fremdkörper als Ursache einer postoperativen Darmobstruktion.

BACKGROUND: Forgetting a foreign body in the abdominal cavity is an unpleasant and avoidable situation. It usually occurs when the preventive protocols are not followed precisely. In such a case clinical consequences are unpredictable and relaparotomy may become necessary. CASE PRESENTATION: We present the case of a temporary intestinal obstruction six months after a transabdominal hysterectomy. Diagnostic workup revealed a laparotomy-gauze left in the abdominal cavity at the previous operation. Exploration showed that the gauze was actually located in the intestinal lumen. The inflammatory reaction elicited by the foreign body eroded the intestinal wall and allowed its intraluminal migration. The gauze moved distally due to peristalsis until it became trapped in the ileocecal valve causing obstruction. When it finally passed through the valve the obstruction was relieved. Intraoperative maneuvers advanced the foreign body further forward until it was removed transanally. CONCLUSION: The formal processes - counting the gauzes continually and double crossing the counting - must be kept in every laparotomy to avoid the unpleasant experience of gauze remaining in the peritoneal cavity. In such an unfortunate case traditional open surgery provides a safe solution to the patient's problem.

Acute appendicitis: the reliability of diagnosis by clinical assessment alone.

BACKGROUND AND AIMS: This prospective study aimed to review the trustworthiness of the initial clinical assessment in acute appendicitis without employment of imaging modalities, laparoscopy or any other adjunct diagnostic test. PATIENTS AND METHODS: 717 patients were operated on for appendicitis by six different surgeons. Initial clinical and laboratory examination were evaluated in relation to the intraoperative and the pathological appreciation of the appendiceal inflammation. RESULTS: 598 patients were found to have appendicitis, 34 a different condition, 41 had both appendicitis and an additional condition and 44 no pathology. 6% of the laparotomies and 11% of the appendectomies were unnecessary. The severity of the inflammation correlated significantly with periumbilical pain, pain migrating to right lower quadrant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear predominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less frequent in aged patients. All the six surgeons were found to be equally reliable, although they all underestimated the setting compared to the pathologists. Patients with a long duration of symptoms had milder forms of inflammation and increased percentage of unanticipated abdominal conditions. CONCLUSIONS: Appendicitis can be reliably diagnosed clinically without employment of adjunct tests. These can be reserved for equivocal cases.

Primary rhabdomyosarcoma of the lung arising over cystic pulmonary adenomatoid malformation.

The authors report the case of a 2-year-old girl with pulmonary cystic adenomatoid malformation type II who presented with a mass on the lower lobe of the left lung. Resection and histological examination revealed pleomorphic rhabdomyosarcoma. Chemotherapy and radiotherapy followed the operation and the girl is alive and in perfect condition 10 years after the operation. The literature on primary rhabdomyosarcoma of the lung in children is reviewed.

Contrast-enhanced spiral CT evaluation of blunt abdominal trauma.

The purpose of this study was to examine the usefulness and validity of contrast enhanced-spiral computerized tomography in assessing blunt abdominal trauma. 257 patients were admitted in a general hospital over a period of five years and were examined with computed tomography. Two-dimension reconstruction and delayed imaging were used when appropriate. 169 patients underwent a laparotomy, while 88 were treated conservatively. Scans were true positive for intraabdominal damage in 212 patients depicting chiefly splenic, liver, renal, urinary bladder, and mesenteric/intestinal injuries (41%, 18%, 6.6%, 6.6%, and 13.7% respectively). True negative examinations amounted up to 35. 10 non-specific examinations displayed the existence of hemoperitoneum but not the actual damage itself, therefore they were considered false negative. No false positive examination existed. Overall sensitivity was 95%, specificity 100%, positive predictive value 100% and negative predictive value 78%. In conclusion spiral computed tomography is a valuable examination in blunt abdominal trauma as it facilitates diagnosis of intraabdominal damage, assists in defining treatment and occasionally allows foretelling the outcome.

Acute abdomen as initial manifestation of M4 - acute non-lymphocytic leukemia.

Visceral involvement in acute non-lymphocytic leukemia (ANLL) seldom precedes hematological manifestation. We report on a patient with M4 - ANLL presenting with acute abdomen without any evidence of blood disorder. Laparotomy revealed only ileal wall oedema. Postoperative clinical deterioration led to a second-look operation combined with intraoperative endoscopy. Biopsied tissues were diffusely infiltrated by blasts characterised as HLA-DR (+), PGM1 (50% +), MPO (50% +) and CD 34 (-). Bone marrow reconfirmed these findings and showed positivity for CD4 (44%), CD11b (50%), CD11c (42%), CD13 (33%), CD34 (32%), and CD56 (54%). Chemotherapy achieved a complete but short remission. Relapse occurred 7 months later. Immediately after consolidation chemotherapy the profoundly immunosuppressed patient passed away after a lower respiratory tract infection. We discuss the contrast between histology and short disease duration, the unusual presentation and the bad prognosis, and attempt to correlate the clinical course with the coexpression of markers.