Pneumoretroperitoneum and pneumomediastinum after Stapled Anopexy Is conservative treatment possible?

INTRODUCTION: Stapled anopexy is considered the gold standard in treating haemorroidal disease associated to mucosal prolapse, but severe complications have been described. Among these, a minimal anastomotic leakage may lead to gas spreading into surrounding soft tissues. CASE REPORT: We report the case of a 61 year old male who developed pneumoretroperitoneum and pneumomediastinun two days after a Stapled Anopexy. CT scans showed a minimal leakage with no abscess. The patient was successfully treated by bowel rest, antibiotics and total parenteral nutrition, avoiding surgical approach. CONCLUSION: A minimal anastomotic leakage following Stapled Anopexy, when leading to air diffusion into soft tissues and not associated to abscess or peritonitis may be treated conservatively avoiding ileostomy or colostomy. KEY WORDS: Anastomotic leakage, Pneumoretroperitoneum, Stapled Anopexy.

Spontaneous rupture of a sigmoid colon gastrointestinal stromal tumor manifesting as pneumoretroperitoneum with localized peritonitis: report of a case.

Colonic gastrointestinal stromal tumors (GISTs) account for only 5%-10% of tumors arising in the digestive tract. Spontaneous rupture is a very rare manifestation of a GIST; however, we report what to our knowledge is the first documented case of pneumoretroperitoneum caused by the rupture of a GIST. A 77-year-old woman was admitted to our hospital with acute abdominal pain and hematochezia. Colonoscopy showed luminal narrowing in the sigmoid colon, but no definite mucosal defect. Computed tomography (CT) showed an air-containing heterogeneous mass, 9.7 × 9.3 cm, in the pelvic cavity and a small amount of air in the retroperitoneum. Emergency laparotomy revealed a ruptured sigmoid colonic GIST with localized peritonitis. Pathologic examination confirmed that the tumor was composed mainly of round epithelioid cells. It was immunohistochemically positive for CD34 and negative for C-kit protein. This report describes how we successfully managed pneumoretroperitoneum with localized peritonitis caused by the spontaneous rupture of an epithelioid GIST originating from the sigmoid colon.

[Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. / Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie.

HISTORY AND ADMISSION FINDINGS: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

[Management of perforations as adverse events of ERCP plus ES. Personal experience]. / Trattamento degli eventi perforativi post-colangiopancreatografia retrograda con sfinterotomia endoscopica. Esperienza personale.

UNLABELLED: INTRODUCTION. ERCP has brought real progress in the study and treatment of pancreatic and biliary diseases, because of its ambivalence as diagnostic and therapeutic procedure. Among its complications, perforations occur in fewer than 1% of patients, but are associated with a mortality rate of 16% -18%. CASE REPORTS: CASE 1- F, 89 years old with obstructive jaundice by choledocholithiasis submitted to ERCP plus ES, during which occurs type II lesion; the partial removing of stones from choledochus during the procedure allow us to opt for a conservative treatment, with resolution on post-ERCP day 12. CASE 2- F, 53 years old with recurring cholangitis and post-cholecystectomy stenosis of choledochus already treated by stenting; for the occurrence of type I lesion during ERCP, the patient undergoes surgery in emergency with healing in postoperative day 23. CASE 3- M, 84 years old with lithiasic cholecystitis, obstructive jaundice, lung emphysema and ischemic heart disease; after percutaneous cholecystostomy in emergency, we attempt to ERCP with evidence of type I lesion. Because of comorbility, we opt for a conservative treatment, not resolving, and then proceed to surgery. Exitus for cardio-respiratory complications. CASE 4- M, 89 years old with obstructive jaundice; ERCP is suspended for respiratory complications and then a PTC is perform; during it we note a type IV lesion, which is treated conservatively with resignation in day 12. CASE 5- F, 68 years old with cholecystitis and choledocholithiasis; during ERCP plus SE a type II lesion occurs with worsening signs of acute abdomen. Because of clinical conditions and the impossibility of carrying out stones from choledochus by endoscopy, we opt for a surgical treatment in emergency. Exitus for respiratory complications. DISCUSSION: Because of the controversy exists on what should be the management of perforations as adverse events of ERCP plus ES (immediate surgery or conservative therapy), we can only hope an eclectic approach based on the anatomical and clinical peculiarity of each case.

Pneumomediastinum: retroperitoneal pathway.

This is the first in vivo demonstration of the pathway of the gaseous column arising from an intra-abdominal source, traveling in the retroperitoneal space alongside the great vessels into the mediastinum, resulting in a pneumomediastinum.

Pneumomediastinum: an unusual complication of bronchial asthma in a young man.

We report a patient with bronchial asthma who presented with pneumomediastinum, pneumopericardium, pneumoretroperitoneum, pneumorrhachis and extensive subcutaneous emphysema, after a period of coughing. Pathogenesis, diagnostic procedures and treatment of pneumomediastinum and its complications are discussed.

Pneumatosis cystoides intestinalis with pneumoperitoneum and pneumoretroperitoneum following chemotherapy.

Pneumatosis cystoides intestinalis (PCI) is a relatively rare, mostly benign, condition. We report a case of chemotherapy-induced PCI with free retro- and intraperitoneal gas in a 17-year-old man with acute lymphoblastic leukemia. Chest radiography and upright abdominal radiography showed free intra- and retroperitoneal gas; computed tomography demonstrated subserosal gas collections. Conservative treatment with oxygen, metronidazol, and parenteral alimentation was performed, and PCI resolved within 2 weeks.

Retroperitoneal and abdominal wall emphysema after transanal excision of a rectal carcinoma.

The use of transanal excision to remove rectal carcinomas is a relatively new application of this surgical procedure, which may require full thickness excision. Retroperitoneal and abdominal wall emphysema are potential complications of surgical procedures that breach the wall of the colon and rectum. Computed tomographic scans provide the clearest diagnostic picture of developing emphysema, and prompt diagnosis through accurate interpretation of the scans is essential to minimize morbidity and mortality. When the diagnosis is made early and no active infection accompanies the emphysema, the preferred approach to initial treatment is nonsurgical. This article presents a case in which local transanal excision was performed on a 70-year-old male to remove a superficial adenocarcinoma from the lower rectal wall. He developed postoperative retroperitoneal and abdominal wall emphysema. Conservative treatment is discussed.

[Radiologic aspects of endoscopic sphincterotomy complications]. / Aspects radiologiques des complications des sphinctérotomies endoscopiques.

Endoscopic sphincterotomy (ES) is a minimally invasive technique which is the standard of reference in many clinical situations (e.g distal choledocolithiasis, recurrent lithiasis or bile duct stenosis). Complication are rare but are often misdiagnosed although radiological aspects are demonstrative. The purpose of this study is to illustrate the patterns of the complications. Ten patients have been treated for the last four years in our institution for ES complications. There were eight cases of pancreatitis, three of which had associated perforation, one arterioportal fistula, and one isolated perforation. Diagnosis was reached with CT in all but one case. Two patients have been successfully treated with percutaneous treatment (one embolization with Gianturco coils, and one drainage). Two patients died, one of necrotizing pancreatitis and the second of decubitus complication. The other patient were followed with CT. We give exemples of different observations and discuss their follow up. The severity and extent of post ES pancreatitis were readily assessed by CT and response to therapy monitored by serial examinations. Severity of disease, evaluated according to the length of hospitalization, correlated well with the presence and degree of pancreatic necrosis. CT also highlights perforations including minimal effusions. In our study differential diagnosis between post ES pancreatitis and perforation is not significant regarding the initial conservative therapy in both situations. CT scan helps us to opt for a surgical decision or for a percutaneous drainage. It also permits to follow the evolution of the lesions. In our cases involving perforations, we noted a spontaneous complete resolution of gas effusion on control and we also observed that pancreatitis evolution was similar to standard pancreatitis evolution. In a life threatening post ES hemobilia, not responding to standard medical treatment, angiography is the diagnostic exam of choice before embolization which is regarded as the best initial treatment of vascular lesions. We conclude that CT is the exam of choice in the initial diagnosis and follow up post ES complications.

Pathophysiology, recognition and management of pneumoretroperitoneum.

The medical records of 15 patients found to have pneumoretroperitoneum in a 10-year period were reviewed. The cause of retroperitoneal emphysema was infection in six patients, trauma in five and iatrogenic in four. Emphysema was confined to the retroperitoneum in 11 patients, and extended to the mediastinum in four and to the soft tissue of the neck in three. Failure to diagnose pneumoretroperitoneum resulted in delayed intervention in two patients. One patient with pneumoretroperitoneum and pneumoperitoneum secondary to a lung lesion underwent unnecessary laparotomy. Outcome was favourable in these three patients. The presence of air in the retroperitoneum is not dangerous but its early recognition and detection of the source are important as septic conditions may be involved.