Drainage of a Subphrenic Abscess Followed by Two-Stage Gastrectomy and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Perforated Gastric Carcinoma: A Case Report.

BACKGROUND Perforated gastric cancer accounts for less than 1% of patients who present with an acute abdomen and for up to 16% of all gastric perforations. A two-stage laparoscopic procedure may be the therapeutic strategy of choice in selected patients, and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) can reduce the incidence of peritoneal recurrence. A rare case of subphrenic abscess and gastric perforation due to carcinoma of the gastric fundus, followed by two-stage gastrectomy and adjuvant HIPEC is presented. CASE REPORT A 65-year old man presented with a left subphrenic abscess secondary to perforated gastric carcinoma. Laparoscopic drainage of the abscess was performed. Ten days later, following recovery from sepsis, the patient underwent total laparoscopic gastrectomy, and adjuvant HIPEC followed by a Roux-en-Y esophagojejunostomy. Histopathology showed an intestinal-type gastric adenocarcinoma. The tumor was staged as pT4aN0. The postoperative course was uneventful except for transient atrial fibrillation. The patient was discharged home on postoperative day 11. Systemic adjuvant chemotherapy was begun one month later. At six-month follow-up, the patient had no discomfort on eating or any other symptoms. CONCLUSIONS In this case, a two-stage laparoscopic treatment for perforated gastric carcinoma combined with adjuvant HIPEC was feasible and safe and may be considered at the time of laparoscopic gastrectomy in selected patients with perforated gastric carcinoma.

Burst abdomen in pregnancy: A proposed management algorithm.

Management of the burst abdomen is complex due to the co-morbidities associated with it. When coupled with intraabdominal sepsis and pregnancy, it becomes even more difficult due to the ethical issues that have to be considered when managing both mother and child. Due to the paucity of literature on this subject, a management algorithm has been proposed which aims at tackling this delicate issue. However, the major consideration in the management of these cases is that decisions are to be made based on optimization of the condition of the mother.

THE OVER-THE-SCOPE-CLIP FOR THE TREATMENT OF THE DIGESTIVE TUBE LEAKS AND TEARS: A CASE-SERIES. / LIJECENJE OSTECENJA PROBAVNE CIJEVI PRIMJENOM ENDOSKOPSKE STEZALJKE: PRIKAZ SERIJE BOLESNIKA.

Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device ­ the-over-the-scope clip (OTSC) ­ has been introduced for non-surgical treatment of gastrointestinal perforations, fi stula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic effi cacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: fi ve patients, a vessel with a large caliber: one patient), fi stula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fi stulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic effi cacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC.

[Effects of moxibustion at Shenque (CV8) on gastrointestinal function in rats undergoing gastric perforation repair].

OBJECTIVE: To assess the effects of moxibustion at Shenque (CV8) in promoting gastrointestinal function recovery in rats following gastric perforation repair and explore the underlying mechanism. METHODS: Thirty male SD rats with glacial acetic acid-induced gastric perforation underwent surgical repair of the perforation. The rats were then randomized 8 days later into model group (n=10), domperidone group (n=10), and moxibustion group(n=10) and treated with physiologic saline, domperidone suspension, and moxibustion at Shenque (CV8), respectively. Gastric antral myoelectric activities of the rats were observed and peripheral blood levels of TNF-α, IL-6, and T lymphocyte subpopulation were determined. RESULTS: Gastric antral myoelectric activities in rats receiving moxibustion were stronger than those in the model group (P<0.05) but comparable with those in domperidone group (P>0.05). TNF-α and IL-6 level were decreased significantly and T lymphocyte subpopulations increased significantly in moxibustion group compared with those in the model and domperidone groups (P<0.05). CONCLUSION: Moxibustion at Shenque (CV8) can promote the recovery of gastrointestinal functions in rats undergoing gastric perforation repair possibly by enhancing gastrointestinal electric activity, suppressing inflammation, and improving the cellular immune function, and can therefore serve as a simple and effective adjuvant therapy during the perioperative period.

Late-onset Leclercia adecarboxylata sepsis in a premature neonate.

The epidemiology, etiology and outcome of neonatal sepsis are changing over time. While monitoring longitudinal trends in neonatal sepsis in our institution, we encountered a case of late-onset neonatal sepsis due to Leclercia adecarboxylata. A Gram-negative rod previously not encountered in the clinical setting, L. adecarboxylata has recently emerged as a human pathogen, primarily in immunosuppressed patients. This report describes the clinical and laboratory features of this case of late-onset L. adecarboxylata sepsis, and reviews significant features of infection associated with this emerging pathogen.

Pseudoaneurysm of the inferior phrenic artery presenting as an upper gastrointestinal bleed by directly rupturing into the stomach in a patient with chronic pancreatitis.

Pseudoaneurysms occurring in patients with chronic pancreatitis are associated with significant morbidity and mortality. These pseudoaneurysms occur more commonly in the splenic, pancreaticoduodenal, and gastroduodenal arteries. Upper gastrointestinal bleeding (UGIB) due to pseudoaneurysms in patients with pancreatitis with pseudocyst usually presents as hemosuccus pancreaticus. However, pseudoaneurysm directly perforating the gastrointestinal tract and presenting as UGIB is a rare complication. We report here the first case of UGIB from the inferior left phrenic artery pseudoaneurysm rupturing directly into the stomach of a patient with chronic pancreatitis.

Ruptura gástrica idiopática en niño preescolar: informe de un caso / Idiopathic gastric rupture in toddler: case report

La ruptura gástrica idiopática es una patología muy poco frecuenteen niños. La gran mayoría de los casos ocurre en el período neonatal. Comunicamos el caso de una paciente preescolar de 2 años, sexo femenino, sin antecedentes mórbidos. Consultócon antecedente de 48 h de dolor abdominal, náuseas y vómitos.Ingresó al servicio de urgencia en malas condiciones generales, con un abdomen distendido y signos de irritación peritoneal. Se realizó laparotomía exploradora de emergencia que reveló ruptura gástrica en pared posterior ocasionada por múltiples perforaciones. Se efectuó gastrectomía parcial. Ingresó a UCIen shock. Recibió asistencia ventilatoria mecánica, reanimación con fluidos (260 ml/kg en 12 h), fármacos vasoactivos y tratamiento antibiótico con cefotaxima-metronidazol. El laboratorio evidenció leucopenia y trombopenia. El estudio etiológico fue negativo para ingesta de tóxicos y medicamentos. Se descartócolagenopatía y su gastrinemia fue normal. Su postoperatorio se caracterizó por persistencia de fiebre originada porcolección subfrénica izquierda (cultivo positivo para Candida galabrata). Se realizó limpieza quirúrgica mediante laparotomía y drenaje percutáneo de las colecciones residuales. Completótres semanas de terapia antibiótica y antifúngica con evolución satisfactoria. El control ambulatorio de la paciente a los 12 meses fue normal.

Spontaneous gastric perforation in a child with heterotaxy syndrome.

Gastric perforation is a potentially fatal condition that is rare in infants and children. Most case reports in the pediatric population are of neonates or in patients with various associated risk factors including prematurity, ischemia, trauma, or ulcers. Heterotaxy syndrome is characterized by abnormal symmetry and malposition of the thoracoabdominal organs and vessels. Spontaneous gastric perforation has not previously been reported in a child with heterotaxy syndrome. We present a case of a child with heterotaxy syndrome who presented with spontaneous gastric perforation. We review the signs and the symptoms, radiographic clues, and diagnostic considerations of gastric perforation.

Gastric variceal rupture successfully treated with repeated EIS and EVL.

A 68-year-old female with liver cirrhosis presented at the Emergency Room of our hospital with copious tarry stools. Upper gastrointestinal endoscopy showed an isolated gastric variceal rupture, and we performed endoscopic injection sclerotherapy using cyanoacrylate, on four occasions, resulting in successful hemostasis. Injection of CA is a useful emergency treatment option for gastric variceal bleeding without gastro-renal shunt.

Neonatal gastric perforation: report of 15 cases and review of the literature.

BACKGROUND: Gastric perforation among neonates is a rare but frequently fatal condition of uncertain etiology. The aim of this study was to review the clinical course of neonatal gastric perforation and to evaluate possible prognostic factors. METHODS: We retrospectively analyzed the medical records of 15 patients with neonatal gastric perforation over a 19-year period. Another 97 patients described in the medical literature, for whom the gestational ages and birth weights were clearly stated, were also reviewed. RESULTS: In our series, there were three girls and 12 boys, nine of whom were full-term infants and six preterm infants. The most common initial manifestations were poor activity, abdominal distension, and respiratory distress. The overall mortality was 47% (7/15). Prematurity was the only statistically significant risk factor; 83% (5/6) of premature infants died compared with 22% (2/9) of term babies (p < 0.05). Combining our series with the patients reported in the literature, there were a total of 50 premature infants and 62 term infants. Gastric perforation occurred on postnatal days 2-7 and presented with nonspecific manifestations. The mortality was significantly higher in premature than in term infants (31/50, 62% vs. 16/62, 26%; p < 0.001). A trend towards higher mortality in infants with lower birth weights was observed (>2500 g, 28%; 1501-2500 g, 52%; 1000-1500 g, 60%; <1000 g, 100%). Infants with birth weights <2500 g had a significantly higher mortality than infants with birth weights >2500 g (32/58, 55% vs. 15/54, 28%; p<0.05). CONCLUSION: Neonatal gastric perforation is associated with high mortality, particularly in premature infants. There is also a trend towards higher mortality in lower-birth-weight infants.

[Oncologic emergencies in gastric cancer patients].

Many complications frequently occur in gastric cancer patients which require urgent treatment. Oncologic emergencies in gastric cancer vary widely and include hemorrhage, perforation and obstruction due to gastric cancer tumors, obstructive jaundice, hydronephrosis, intestinal obstruction and disseminated intravascular coagulation due to advanced metastatic, recurrent, or systemic tumors, and adverse effects secondary to chemotherapy. In gastric cancer treatment, we must recognize the occurrence of oncologic emergencies resulting from gastric cancer progression and recurrence. It is important that the knowledge of advanced stages and the prognosis of gastric cancer patients be taken into consideration when treating patients in a critical state.

Extracorporeal membrane oxygenation for newborns with gastric rupture.

Extracorporeal membrane oxygenation (ECMO) has been recognized to be beneficial to overcome not only persistent pulmonary hypertension of the newborn, but also cardiopulmonary distress due to neonatal sepsis. However, few papers have reported on the efficacy of ECMO for surgical sepsis in neonates with underlying diseases. This paper reports our experience with ECMO in three newborns with gastric rupture, one of the most serious causes of surgical sepsis in the neonatal period. Over the past 12 years, 14 newborns had gastric rupture; 3 developed lethal cardiopulmonary distress that conservative strategies, including aggressive intensive care, failed to manage, and were selected for ECMO. The clinical data of these patients were retrospectively analyzed. The onset time and duration of ECMO varied from 23 to 143 h of age and 72 to 294 h, respectively. In case 3, complicated by massive intra-abdominal hemorrhage during ECMO, anticoagulants were changed from heparin alone to combined use with nafamostat mesilate, a thrombin inhibitor with a very short half-life. Ultrafiltration or hemodialysis was added in two cases to regulate massive volume overload associated with renal failure. Despite major hemorrhagic complications in two cases, all patients survived. Thus, ECMO may be beneficial in managing neonates with therapy-resistant gastric rupture.

Conservative management of gastric rupture following scuba diving.

Gastric rupture is an uncommon surgical problem which normally presents with an acute abdomen and peritonism. An unusual case following underwater ascent and its conservative management is presented.

Gastric perforation with Candida tropicalis invasion in a previously healthy girl.

Fungal cells were observed infiltrating the submucosal margins of an acutely perforated gastric ulceration in an apparently immunocompetent 3-year-old girl. Perforation had occurred 24 h after hospital admission because of pain and vomiting. Colonies of Candida tropicalis were grown from peritoneal fluid and blood cultures. After surgical repair and a 30-day treatment with amphotericin B at a daily dose of 1 mg kg-1 body weight, the child was discharged in good health. No further infections have occurred in the 3 years since treatment.

Rupture of the stomach complicating diving accidents.

All reported cases of rupture of the stomach after a diving accident were reviewed for this study. This is a rare event that complicates brief and deep dives. It is always the consequence of equipment failure or panic reactions which induce swallowing air while under water. During a rapid ascent, the gas expands causing rupture. Diagnosis is based on the presence of abdominal distention associated with pneumoperitoneum on the x-ray and with gastric tears seen on gastroscopy. Pneumoperitoneum from gastric rupture must be distinguished from that caused by pulmonary barotrauma. Peritoneal decompression by paracentesis may quickly improve the patient's condition. After air embolism or decompression sickness has been ruled out, a surgical operation is necessary. Exploratory laparotomy exposes, in two thirds of cases, a gastric full-thickness tear that requires closing by suture. The outcome is good because subjects are young and healthy. The rupture of a filled stomach may lead to postoperative complications (abscess or fistulas).