Recurrent Ogilvie Syndrome as a Possible Manifestation of Alpha-Gal Syndrome (AGS) Requiring Surgical Management: A Case Report.

We present a case of a male in his 60s with a history of alpha-gal syndrome (AGS) who presented with recurrent acute colonic pseudo-obstruction, also known as Ogilvie syndrome, and underwent surgical treatment for life-limiting symptoms of colonic distention, constipation, and abdominal pain. Prior to surgery, he was hospitalized multiple times after beef consumption and was diagnosed with Ogilvie syndrome, requiring a colonoscopy with rectal tube placement for symptom resolution. He later underwent a robotic subtotal colectomy with ileocolic anastomosis. Follow-up visits showed improvement in symptoms of constipation and abdominal distention. This case highlights that AGS may lead to severe manifestations, such as recurrent Ogilvie syndrome. Due to the increasing prevalence of AGS and limited data on disease course, further research is needed to determine symptom manifestations and the potential utility of surgery in management.

Chilaiditi Syndrome: A Case Report, Literature Review, and Proposition of a Novel Management Staging System.

Chilaiditi's sign refers to colonic interposition between the liver and the diaphragm in the right subphrenic space secondary to the relaxation of the suspensory ligaments of the right colic flexure. The diagnosis of Chilaiditi's sign is based on radiological findings with the following three criteria: 1) The right hemidiaphragm must be adequately elevated above the liver by the intestine, 2) the bowel must be distended by air to illustrate pseudo-pneumoperitoneum, and 3) the superior margin of the liver must be depressed below the level of the left hemidiaphragm. In this report, we present the case of a 49-year-old female presenting with signs and symptoms suggestive of Chilaiditi syndrome managed with laparoscopic surgery. We also present a literature review with a summary of previous studies and propose a novel management staging system for this syndrome.

Adult intussusception of the small intestine caused by cystic fibrosis: a case report, review of the literature, and guide for management.

Intussusception, an uncommon but potentially severe condition primarily associated with infants and young children, can also present in adults, posing distinct challenges in diagnosis and treatment. This report presents the case of a 22-year-old male with cystic fibrosis, who developed intussusception due to severe constipation in his distal gastrointestinal tract. The patient's initial presentation included abdominal pain, constipation, and abnormal laboratory results. Computed tomography scans revealed intussusception affecting the ascending colon and cecum, necessitating surgical intervention and subsequent bowel resection. In adults, the presence of intussusception often triggers suspicion of underlying pathological lead points. However, in this instance, the root cause was attributed to cystic fibrosis induced constipation. Current evidence suggests limited efficacy with conservative treatment, with bowel resection being the most definitive treatment option. Further research is warranted to establish comprehensive guidelines for managing this uncommon condition, particularly when intertwined with cystic fibrosis.

Colo-Fallopian Fistula: A Rare Complication of Sigmoid Colon Diverticulitis.

Diverticulitis is a common colorectal disease present in Western countries that develops as infected protrusions (diverticula) along weak points in the colon due to increased intraluminal pressure. Most patients with diverticular disease can be asymptomatic; however, several complications can arise from the development of diverticulitis. Here, we discuss the diagnosis and management of a patient presenting with recurrent Escherichia coli (E. coli) vaginal infections due to sigmoid colon diverticulitis resulting in a colo-fallopian fistula that was unremarkable on diagnostic imaging. The patient was managed with minimally invasive surgery. A 65-year-old female with a medical history of hyperlipidemia and recurrent diverticulitis presented with over a year history of recurrent E. coli vaginal infections. She underwent a robotic anterior resection with extracorporeal colorectal anastomosis via a Pfannenstiel incision. Less than 48 hours following the surgery, she was discharged without complications and has remained symptom-free nine months postoperatively. Significant improvement was noted following the procedure. The patient was able to advance her diet and was discharged the next day. The patient was seen postoperatively, with no evidence of any recurrent E. coli vaginal infections. The case highlights the diagnosis and management of a rare case of colo-fallopian fistula in a situation where the patient had recurrent vaginal infections. It is quite difficult to identify the fistula radiologically. This patient was managed with a minimally invasive surgical technique that proved to be safe and beneficial to the outcome of this patient.

Pilonidal Disease: To Flap or Not to Flap.

Pilonidal disease is an acquired disease caused by infected hair follicles imbedded in the midline gluteal area. The diagnosis is made based on clinic examination. Treatment is based on disease severity with minimal invasive techniques like the Bascom I procedure, Moshe Gibs procedure, or video-assisted pilonidal sinus ablation best suited for less complicated cases. However, for recalcitrant diseases, more advanced techniques are needed such as the Karydakis, Limberg, or V-Y advancement flaps.

Laparoscopic Repair of Small Bowel Obstruction Caused by an Intersigmoid Hernia: A Case Report.

Bowel obstructions can be caused by internal hernias which are protrusions of the bowel into openings within the abdominal cavity. There are various types of internal hernias including sigmoid hernias which involve the sigmoid mesentery.Sigmoid hernias are very difficult to diagnose clinically, even with the aid of radiologic imaging. Computed tomography (CT) scan findings often reveal small bowel obstructions; however, they are not sensitive to intersigmoid hernias. Most of these rare herniations are repaired by open abdominal surgery followed by the closure of the mesenteric defect to prevent a recurrence. We present the case of a 57-year-old man who presented to the emergency department with a small bowel obstruction that was caused by an intersigmoid hernia and was successfully repaired through a minimally invasive laparoscopic approach. This case demonstrates an intra-operative diagnosis of an intersigmoid hernia and reviews the benefits of a laparoscopic approach for the reduction of the sigmoid mesentery.

The Effect of Barbed Sutures on Complication Rates Post Colectomy: A Retrospective Case-Matched Review.

Background and objective Colectomies are common general surgical procedures performed for a variety of gastrointestinal disorders ranging from benign to malignant. Early definitive fascial closure has been shown to improve outcomes in patients following abdominal surgery. Conventional loop sutures and their accompanying knots present several disadvantages and require technical expertise. Reducing complications has been a strong driver for innovations such as the use of barbed sutures. Barbed sutures consist of axially spaced barbed segments on each side of a midpoint at which the barbs change directions. This study is a retrospective case-matched review that evaluates the effects of barbed sutures compared to non-barbed sutures on the rates and severity of postoperative complications following colectomies for abdominal fascial closure. Materials and methods The study enrolled 151 patients who underwent open and minimally invasive colorectal abdominal surgeries from January 1, 2017, to November 30, 2019. Primary outcome measures included operative time, length of hospital stay, and postoperative complications compared between barbed and non-barded suture types. The sub-analysis further compared the surgical approach (open vs. robotic/laparoscopic) and incision type (Pfannenstiel vs. midline and other) between the suture types. Results The mean operative time for barbed sutures was 177 minutes, while it was 157 minutes for non-barbed sutures, resulting in a significant difference (p=0.0264). No significant difference was noted in postoperative complications between the groups. Conclusions The results of this study indicate that the use of barbed sutures in colorectal surgery does not increase the chances of postoperative infections, prolonged hospital stays, or other postoperative complications. Barbed sutures resulted in fewer class IV complications and more class I complications when compared to non-barbed sutures. Barbed sutures have proven to be beneficial in cases that require good wound approximation in high-tension areas and they eliminate the need for knots.

Acute Immunoallergic Hepatitis in the Presence of Crohn's Disease: A Case Presentation and Review of the Literature.

In this case presentation, we discuss a patient with acute immunoallergic hepatitis after fluoroquinolone use. The patient presented with a complex perianal abscess two months after the initial procedure for a perianal abscess. He was placed on broad-spectrum antibiotics and underwent fecal diversion with partial colectomy to aid in wound care and diagnosis of Crohn's disease. Acute hepatic insufficiency and ascites in the presence of a maculopapular rash suggested an immunoallergic reaction. The patient's condition improved after discontinuation of the offending drug and utilizing intravenous steroids. The diagnosis of acute immunoallergic hepatitis was made based on clinical suspicion and a careful review of the patient's medical records.

Giant Proximal Right Colon Submucosal Hematoma Leading to a Large Bowel Obstruction.

A 41-year-old female with a previous history of chronic obstructive pulmonary disease (COPD) and polycythemia presented to the emergency department with worsening shortness of breath and cough which progressed to respiratory distress requiring mechanical ventilation. During her hospital stay, she developed abdominal distention followed by a fever and a four-point decrease in hemoglobin. A non-contrasted abdominopelvic CT scan was ordered which showed a very large retroperitoneal hematoma adjacent to the right colon with subtle active bleeding. Selective angioembolization of a distal segment of the right colic artery was performed by Interventional Radiology (IR) to achieve hemostasis and hemodynamic stability. Due to the persistent and worsening abdominal distention, a CT scan with contrast was ordered which clearly showed a submucosal hematoma in the region of the right colon extending from the hepatic flexure to the cecum. The hematoma was completely obstructing the proximal and mid ascending colon leading to a large bowel obstruction. Exploration of the abdomen showed severe bowel dilation, and frank ischemia of the hepatic flexure of the colon. Right hemicolectomy with primary ileocolonic anastomosis to evacuate the right retroperitoneal hematoma was subsequently performed. The patient was discharged on post-operative day 16 with no major complications.

Increasing Fecal Immunochemical Test Return Rates by Implementing Effective "Reminder to Complete Kit" Communication With Participants: A Quality Improvement Study.

Background The incidence of colorectal cancer (CRC) in the United States is increasing. It remains the second leading cause of cancer death in the United States for men and women combined, mainly due to underutilization of screening methods. The American Cancer Society now recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or structural (visual) examination, depending on patient preference and test availability. The primary objective of this quality improvement project was to determine if reminder methods, such as telephone or letter reminders, increased the return rate of fecal immunochemical tests (FIT) for CRC screening. Methodology At public outreach events and daily clinics in the West Texas Panhandle area, participants in the GET FIT program were provided with FIT kits after completing the education on CRC. Participants who fit the inclusion criteria and had received a FIT kit from the program were included. They were instructed on how to perform the test and mail it back. Participants who did not return the completed kits within two weeks were reminded either through (1) a reminder letter, (2) telephone, or (3) a combination of letter reminder and telephone call every two weeks (±three days) for 60 days or five attempts to contact. We de-identified and analyzed the FIT kit return data from April-September 2019 before analyzing these reminder methods. We then calculated the change in return rates from October 2019 to March 2020. Our goal was to increase the FIT return rates by 25% compared to the baseline return rate. Results The pre-intervention return rate of kits for April-September 2019 was 61.52%, and the post-intervention return rate for October 2019-March 2020 was 71.85%. This rate was equal to an approximately 16.79% increase in return rates that was statistically significant (p < 0.01). There was a significant difference in the method of reminder between the two groups, but no significant differences in gender and race/ethnicity between the two groups. There was a significant difference in return rates between race/ethnicities in the October-March cohort with black and Hispanic participants having the highest return rates of 82.3% and 77.25%, respectively. Conclusions FIT remains one of the primary options for CRC screening. Due to its lower cost and noninvasiveness, FIT was offered to patients at average risk. We demonstrated an increase in return rates, although we did not meet our target return rate goal for this project. This study was limited due to a gradual increase in coronavirus disease 2019 (COVID-19) cases and a subsequent shift and conversation of ongoing research into COVID-19.

Improving Adenoma Detection Rates: The Role of the Fecal Immunochemical Test.

Background There is limited knowledge about adenoma detection rates (ADRs) in patients with a positive fecal immunochemical test (FIT). We hypothesized that colonoscopy performed after FIT would result in higher ADRs. Methods We reviewed ADRs for colonoscopies performed after a positive FIT test and compared them to ADR rates for routine colonoscopy performed without an initial FIT test between November 2014 and March 2017 at multiple endoscopy sites. Results A total of 979 patients underwent a FIT testing in the Texas panhandle, of whom 12.1% (n=119) tested positive. Also, 32.8% (n=39) were found to have one or more tubular adenomatous polyps on final pathological examination. Among these patients, the majority were female (64.1%; n=25). Of the patients, 15.9% (n=19) had a hyperplastic polyp, 1.7% (n=2) had findings consistent with ulcerative colitis, and 0.8% (n=1) were positive for an adenocarcinoma. In the control group of 2,603 patients in whom routine colonoscopy was performed as the initial tool for screening, 719 were found to have one or more tubular adenomas, with an ADR rate of 27.5%. In this group, the cancer rate was found to be 1%. Conclusions There was a significant increase in the ADR when colonoscopy is conducted after a positive FIT test. Recommending colonoscopies after a positive FIT test will not only improve ADRs significantly but also lower the overall healthcare cost for screening colon cancer in this era of escalating healthcare costs.

The critical roles of tumor-initiating cells and the lymph node stromal microenvironment in human colorectal cancer extranodal metastasis using a unique humanized orthotopic mouse model.

Colorectal cancer (CRC) is the second-most common cause of cancer-related mortality. The most important prognostic factors are lymph node (LN) involvement and extranodal metastasis. Our objective is to investigate the interactions between CD133(+)CXCR4(+) (CXC receptor 4) colorectal cancer tumor-initiating cells (Co-TICs) and the LN stromal microenvironment in human CRC extranodal metastasis. We established a unique humanized orthotopic xenograft model. Luciferase-tagged CRC cell lines and human cancer cells were injected intrarectally into nonobese diabetic/SCID mice. Mesenteric LN stromal cells, stromal cell line HK, or CXCL12 knockdown HK (HK-KD-A3) cells were coinoculated with CRC cells. Tumor growth and metastasis were monitored by bioluminescent imaging and immunohistochemistry. We found that this model mimics the human CRC metastatic pattern with CRC cell lines or patient specimens. Adding LN stromal cells promotes CRC tumor growth and extranodal metastasis (P < 0.001). Knocking down CXCL12 impaired HK cell support of CRC tumor formation and extranodal metastasis. When HK cells were added, sorted CD133(+)CXCR4(+) Co-TICs showed increased tumor formation and extranodal metastasis capacities compared to unseparated and non-Co-TIC populations. In conclusion, both Co-TIC and LN stromal factors play crucial roles in CRC metastasis through the CXCL12/CXCR4 axis. Blocking Co-TIC/LN-stromal interactions may lead to effective therapy to prevent extranodal metastasis.

Evaluation of inflammatory markers as predictors of hospital stay and unplanned readmission after colorectal surgery.

UNLABELLED: Hospital length of stay (LOS) and readmissions continue to be expensive and unexpected events following colorectal surgery (CRS) whether patients follow enhanced recovery pathways or traditional care. Predictors of these adverse events could facilitate identification and optimization of CRS patients. THE AIM OF THE STUDY: To examine the impact of white blood cell count (WBC) and C-reactive protein (CRP) levels as predictors of delayed recovery or hospital readmission following CRS. MATERIAL AND METHODS: Patients undergoing laparoscopic or open abdominal colorectal surgery by a single surgeon were managed using standardized enhanced recovery pathways. Those with postoperative day 2 CRP and white blood cell values were evaluated. Outcomes included 30-day hospital readmission rates and postoperative length of hospital stay. RESULTS: CRP values were available for 193 patients (86 Male, mean age 58.6 years). Ninety-nine patients had surgery for colon cancer, 23 for Crohn's disease, 19 for ulcerative colitis, 31 for diverticulitis and 18 for other reasons. Twenty patients (10.4%) were readmitted to the hospital within 30 days of surgery. POD2 CRP accurately predicted short length of hospital stay (p< 0.01). Average CRP was 6.3 in the LOS of < 3 days or less, and 11.7 in patients with LOS >4 days. The mean CRP of the readmission and non-readmission groups was 11.8 and 9.9, respectively (p=0.29). The average POD 2 WBC of the readmission and non-readmission groups was 10.6 and 9 respectively (p=0.01). CONCLUSION: A low POD2 CRP level was correlated with a shorter LOS, but it did not predict readmission. Conversely, POD2 WBC, and the difference in WBC from baseline were associated with readmission. These markers may be useful indicators to predict suitability of early discharge in an ERP. Further evaluation in prospective trials is warranted.

Intramural colonic splenosis: a rare case of lower gastrointestinal bleeding.

BACKGROUND: A 41-year-old man had left upper quadrant abdominal pain, constipation, and melena. About 6 years previously, he received a single gunshot wound to the abdomen, which required partial gastrectomy and small bowel resection. He subsequently developed bleeding gastric varices for which he underwent a splenectomy 2 years before the current admission. DISCUSSION: A CT scan identified a 6.5 × 2.5 cm left upper quadrant mass. Upper endoscopy was unremarkable, but on colonoscopy, a 3-cm polypoid mass partially obstructed the descending colon. A left hemicolectomy was performed with a primary colonic anastomosis and incidental appendectomy. The mass involved the muscularis of the colon and caused ulceration of the mucosa was ectopic hyperplasic splenic tissue, indicating intramural colonic splenosis. We hypothesize that after the patient's splenectomy, a colonic focus of heterotrophic spleen became hyperplastic and led to a clinically apparent lesion.

Fecal impaction: a cause for concern?

Fecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.

The effect of alvimopan on recovery after laparoscopic segmental colectomy.

BACKGROUND: Alvimopan, a peripherally acting µ-opioid receptor antagonist, was recently approved for the reduction of postoperative ileus after open colectomy. No data are available regarding the use of alvimopan following laparoscopic segmental colectomy. OBJECTIVE: This study was designed to evaluate the effectiveness of alvimopan in patients undergoing laparoscopic segmental colectomy. DESIGN: A retrospective review of segmental laparoscopic colectomy was conducted in a population of patients using an accelerated postcolectomy care pathway. Patients that received alvimopan were identified from an institutional review board-approved database and matched with nonalvimopan patients for age, sex, procedure, and diagnosis. Patients with a diverting ileostomy or with contraindications for alvimopam were excluded. RESULTS: One hundred patients undergoing laparoscopic colectomy received alvimopan perioperatively and were matched with a similar group of nonalvimopan patients. Although patients on alvimopan were significantly less likely to develop postoperative ileus (4% vs 12%; P = .04), there was no difference in length of hospital stay (3.63 days in the alvimopan group vs 3.78 in the nonalvimopan group; P = .84) or 30-day readmission rate (4.0% vs 4.2%; P = .95). CONCLUSIONS: As the cost of providing health care continues to increase, reductions in perioperative complications and hospital stay are important to hospital efficiency and patient care. Alvimopan effectively reduces the incidence of postoperative ileus in patients undergoing open colectomy; however, hospital stay and readmission rates were not altered in this laparoscopic group. Further study is required before alvimopan can be routinely used in patients undergoing laparoscopic colectomy.

Teratomas in infants and children.

PURPOSE OF REVIEW: Teratomas are rare neoplasms composed of tissue elements derived from the germinal layers of the embryo. Although they may originate anywhere along the midline, teratomas are most commonly found in sacrococcygeal, gonadal, mediastinal, retroperitoneal, cervicofacial and intracranial locations. Clinical behavior varies significantly by site and size. The presence of immature or premalignant elements may influence therapy and long-term outcome. This report reviews the current literature with regard to the diagnosis, management and outcome of teratomas in infants and children. RECENT FINDINGS: Recently, large case series have further elucidated the biologic behavior and clinical course of these rare tumors. Emerging evidence indicates that age of diagnosis is an increasingly important prognostic feature independent of tumor location. Advances in imaging are facilitating earlier diagnosis and identification of patients at higher risk of adverse outcome. In select cases, fetal and early neonatal interventions are improving outcome and survival. SUMMARY: Presenting symptoms may vary widely based on location; however, independent of primary location, definitive therapy for teratomas is complete surgical resection. Early diagnosis, timely intervention and meticulous follow-up are critical in the long-term favorable outcome.