From an incidental lipoma to ileo-ileal intussusception in an adult: A case report.

INTRODUCTION AND IMPORTANCE: Intussusception in adults is rare, constituting a miniscule number of bowel obstruction pathologies. Clinical practice often considers it a last-resort diagnosis, as other causes of mechanical small bowel obstruction are more common. The diagnosis is a challenging one to make, as the "telescoping" motion of the intestines fluctuates in a waxing-and-waning nature. In adults, the etiology is predominantly a pathological lead point being either benign or malignant. When encountering an obscure cause of abdominal pain, intussusception caused by a small bowel lipoma may be the culprit. CASE PRESENTATION: In this unique case, we present the journey of a 55-year-old Emirati male who presented with severe abdominal pain, nausea and vomiting. The patient underwent various imaging modalities, initially an "incidental" lipoma finding in the terminal ileum until a diagnosis of ileo-ileal intussusception emerged in later imaging, given its unusual and fluctuating nature. Ultimately, a resection of the bowel segment with side-to-side anastomosis was done. CLINICAL DISCUSSION: This case report aims to illuminate the diverse clues and incidental findings encountered during our patient's path to a diagnosis. By exploring the elements of this patient's journey to a diagnosis, we aspire to aid future clinicians in navigating the challenges of identifying obstructive pathologies and considering intussusception as a rare yet crucial differential diagnosis. CONCLUSION: This case highlights the importance of a comprehensive approach to diagnosis and management of patients presenting with obstructive symptoms, incorporating both clinical insight and imaging modalities such as CT to ensure optimal patient outcomes. When confronting such an obscure cause of abdominal pain, intussusception caused by a small bowel lipoma may be the culprit.

Role of body mass index in anastomotic leakage after curative treatment for rectal cancer.

BACKGROUND: Anastomotic leakage (AL) represents a severe complication after rectal surgery, leading to significant morbidity, mortality, and increased healthcare costs. Despite improvements in surgical methods and perioperative care, the challenge of AL persists. OBJECTIVES: Explore the impact of body mass index (BMI) on the risk of AL following curative treatment for rectal cancer, providing insight into its predictive value. DESIGN: Retrospective review. SETTINGS: Data were collected from a single tertiary center, emphasizing the specialized postoperative outcomes in a high-care setting. PATIENTS AND METHODS: The study population was comprised patients who underwent sphincter-saving surgery combined with neoadjuvant chemoradiation for rectal cancer from 2001 to 2011. Patients with anastomotic stenosis were excluded. MAIN OUTCOME MEASURES: The primary outcome investigated was the occurrence of AL post-surgery. Secondary outcomes included the assessment of local cancer recurrence rates within the AL group. SAMPLE SIZE: 224; 13 excluded. RESULTS: Of 237 patients who underwent surgery, 13 with anastomotic stenosis were excluded from this study. Of the remaining 224, 15 individuals (6.3%) developed AL. A potential association between higher BMI and increased AL risk was identified. Additionally, the study noted a higher incidence of local rectal cancer recurrence in the group that developed leakage. CONCLUSION: The findings suggest BMI as a significant predictive factor for AL after curative rectal cancer treatment. This emphasizes the need for heightened awareness and possible preoperative counseling for obese patients regarding their increased risk of postoperative leakage. LIMITATIONS: The study was retrospective with all the inherit biases of such studies. The sample size was small and this may have introduced a type 2 statistical error.

Deterioration in renal function after stoma creation: a retrospective review from a Middle Eastern tertiary care center.

BACKGROUND: Stomas are associated with multiple complications including dehydration which ultimately affects renal function. These complications begin with changes in the estimated glomerular filtration rate (GFR). OBJECTIVES: Evaluate changes in GFR after stoma creation by stoma type and identify how different types of stoma affect GFR. DESIGN: Retrospective, analytical cohort SETTING: Tertiary care center in Saudi Arabia PATIENTS AND METHODS: The colorectal surgery database was reviewed for all adult patients who underwent stoma creation (permanent and temporary ileostomies and colostomies) or reversal in 2000-2015. GFR was estimated at the first encounter, before the index surgery, at the time of stoma reversal, and upon the last follow-up. Patients with renal impairment, including low GFR before stoma creation, patients who had a temporary stoma converted to a permanent stoma, and patients who died with a stoma were excluded. We studied the association of several demographic and clinical factors on changes in GFR by univariate and multivariate analysis. MAIN OUTCOME MEASURES: Estimated GFR at the last clinic visit for the permanent stoma group and at stoma closure for the temporary stoma group. SAMPLE SIZE: 394 patients (149 ileostomates, 245 colostomates) RESULTS: Thirty-three (8.4%) of the 394 patients had a low GFR: 11 (7.4%) in the ileostomy group and 22 (9%) in the colostomy group (P= .579). The rate of readmissions with ileostomies was higher (11.4%) than with colostomies (3.3%) (P≤.001). The number of temporary ileostomies (n=9, 7.0%) differed from temporary colostomies (n=2, 1.9%) but the difference was not statistically significant (P=.06). In the multivariate analysis, stoma permanency, hypertension, chemotherapy and nephrotoxic drugs were risk factors associated with low GFR. CONCLUSION: Ileostomies were not associated with a high rate of renal function deterioration in comparison to colostomies, but had a significantly higher rate of readmission due to dehydration and electrolytes imbalance possibly due to the hot climate in Saudi Arabia. LIMITATIONS: Retrospective nature and limited sample size which may have resulted in a type 2 statistical error. CONFLICTS OF INTEREST: None.

Impact of the vertical division of the rectum on the decrease in reloading of the endostapler for a complete division in colorectal cancer

Background: Despite several improvements in surgical techniques, the intracorporeal division of the distal end of the rectum is still challenging, particularly when it is too deep in a narrow pelvis. Even though it helps avoid spillage, the double-stapling technique (DST) raises concerns regarding safety and anastomotic leakage if multiple stapler firings are essential to complete the rectal division. Objective: To assess the feasibility of vertically dividing the rectum and its impact in reducing the number of reloads essential for that division in non-low rectal cancer patients undergoing total mesorectal excision (TME). Materials and Methods A retroprospective study. Results: From January 2017 to November 2021, a total of 123 patients with sigmoid and rectal cancers were enrolled in the present study; their data were collected and analyzed, and 21 patients were excluded. The remaining sample of 102 subjects was composed of 47 male (46%) and 55 female (54%) patients with a median age of 54 years (range: 30 to 78 years). Only 1 reload was enough to complete the rectal division in 82 (80.39%) cases, and 2 reloads were used in the remaining 20 (19.61%) patients. Anastomotic leakage was clinically evident in 4 cases (3.9%). No statically significant difference was observed when firing one or two staplers. No 30-day mortality was recorded in this series. Conclusion: Our early experience indicates that this type of division has a real advantage in terms of decreasing the number of reloads needed and, in turn, lowering the incidence of anastomotic leakage after partial mesorectal excision (PME) or TME when applied with proper patient selection. (AU)