Chronic jejuno-colonic fistula and intestinal malabsorption due to multiple magnet ingestions: A case report and systematic review.

Magnet ingestion in children can lead to serious complications, both acutely and chronically. This case report discusses the treatment approach for a case involving multiple magnet ingestions, which resulted in a jejuno-colonic fistula, segmental intestinal volvulus, hepa-tosteatosis, and renal calculus detected at a late stage. Additionally, we conducted a literature review to explore the characteristics of intestinal fistulas caused by magnet ingestion. A six-year-old girl was admitted to the Pediatric Gastroenterology Department pre-senting with intermittent abdominal pain, vomiting, and diarrhea persisting for two years. Initial differential diagnoses included celiac disease, cystic fibrosis, inflammatory bowel disease, and tuberculosis, yet the etiology remained elusive. The Pediatric Surgery team was consulted after a jejuno-colonic fistula was suspected based on magnetic resonance imaging findings. The physical examination revealed no signs of acute abdomen but showed mild abdominal distension. Subsequent upper gastrointestinal series and contrast enema graphy confirmed a jejuno-colonic fistula and segmental volvulus. The family later reported that the child had swallowed a magnet two years prior, and medical follow-up had stopped after the spontaneous expulsion of the magnets within one to two weeks. Surgical intervention was necessary to correct the volvulus and repair the large jejuno-colonic fistula. To identify relevant studies, we conducted a detailed literature search on magnet ingestion and gastrointestinal fistulas according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified 44 articles encompassing 55 cases where symptoms did not manifest in the acute phase and acute abdomen was not observed. In 29 cases, the time of magnet ingestion was unknown. Among the 26 cases with a known ingestion time, the average duration until fistula detection was 22.8 days (range: 1-90 days). Fistula repairs were performed via laparotomy in 47 cases.

Jejunal Diverticulosis Causing Small Intestinal Volvulus and Closed Loop Obstruction.

BACKGROUND Jejunal diverticulosis are false diverticula of the small bowel that form from outpouching of the mucosa and submucosa. They are pulsion diverticula that are often asymptomatic and can be found incidentally during surgery. In some instances, jejunal diverticula could result in intestinal obstruction. Small intestinal volvulus is an uncommon cause of small bowel obstruction that results in a closed loop obstruction and is an indication for emergent surgical intervention. CASE REPORT We report a case of an 84-year-old man who presented to the Emergency Department with abdominal pain and generalized weakness. A preoperative computerized tomographic scan demonstrated a closed loop small bowel obstruction with mesenteric swirling. The patient was taken for a diagnostic laparoscopy, which revealed extensive proximal jejunal diverticulosis and a volvulus of the involved jejunum. An exploratory laparotomy was warranted for safe detorsion of the small bowel and resection of the diseased segment. The small bowel was successfully detorsed, with resection of the involved jejunum. Intestinal continuity was established by a primary side-to-side anastomosis. CONCLUSIONS Jejunal diverticula have been reported in the literature as a cause of small bowel obstructions, and very few reports exist of concurrent small bowel volvulus. In very rare instances, both of these conditions can coexist. There should be prompt surgical intervention in all cases of closed loop small bowel obstructions to prevent intestinal ischemia, perforation, and sepsis.

Small bowel obstruction in adults, Ladd's band is an exceptional cause: a case report.

Malrotation of the gut is a congenital anomaly of foetal intestinal rotation and it's principally discovered in early childhood as acute intestinal obstruction. This condition is veritably rare and constantly silent in adults. Intestinal malrotation in adults is frequently asymptomatic and is diagnosed as a casual finding during a radiological examination performed for other reasons. Infrequently, it can be diagnosed in adults, associated with an acute abdomen. Adult patients rarely present with acute midgut volvulus or internal hernias caused by Ladd's bands. We present a case of an admitted 18-year-old female with a small bowel obstruction due to an intestinal volvulus complicating intestinal malrotation in the presence of Ladd's band. Laparotomic Ladd's procedure was performed successfully with division of Ladd's band, adhesiolysis, appendicectomy, and reorientation of the small bowel on the right and the cecum and colon on the left of the abdominal cavity; the postoperative evolution was favorable. Although it is a rare pathology, it should be kept in mind in cases of patients presenting small bowel obstruction.

To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus.

INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.

Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching.

BACKGROUND: There is limited data to guide decision-making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy. RESULTS: Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70-1.05). Results were similar in subgroup analyses of higher-risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09-1.67). CONCLUSION: Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus.

Small intestinal volvulus in 47 cows.

Objective: To describe the findings, treatment, and outcome of small intestinal volvulus (SIV) in 47 cows. Animals and procedure: Retrospective analysis of medical records. Comparison of the findings for 18 surviving and 29 non-surviving cows. Results: The most common abnormal vital signs were tachycardia (68.0%), tachypnea (59.6%), and decreased rectal temperature (51.1%). Signs of colic occurred in 66.0% of cows in the study. Rumen motility was reduced or absent in 93.6% of cows, and intestinal motility in 76.6%. Clinical signs on ballottement and/or percussion and simultaneous auscultation were positive on the right side in 78.7% of cows. Transrectal examination showed dilated small intestines in 48.9% of cows. The rectum contained little or no feces in 93.6% of cows. The principal laboratory abnormalities were hypocalcemia (74.1%), hypokalemia (73.8%), azotemia (62.8%), hypermagnesemia (61.6%), and hemoconcentration (60.0%). The principal ultrasonographic findings were dilated small intestines (87.1%) and reduced or absent small intestinal motility (85.2%). Forty-one of the 47 cows underwent right flank laparotomy and the SIV was reduced in 21 cows. When comparing the clinical and laboratory findings of 18 surviving and 29 non-surviving cows, the groups differed significantly with respect to severely abnormal general condition (16.7 versus 37.9%), rumen stasis (22.2 versus 79.3%), intestinal atony (16.7 versus 48.3%), serum urea concentration (6.5 versus 9.8 mmol/L), and serum magnesium concentration (0.98 versus 1.30 mmol/L). In summary, 38.3% of the cows were discharged and 61.7% were euthanized before, during, or after surgery. Conclusion and clinical relevance: An acute course of disease, little or no feces in the rectum, and dilated small intestines were characteristic of SIV in this study population.

Volvulus de l'intestin grêle chez 47 vaches. Objectif: Décrire les données, le traitement et les résultats du volvulus de l'intestin grêle (SIV) chez 47 vaches. Animaux et procédure: Analyse rétrospective des dossiers médicaux. Comparaison des résultats pour 18 vaches survivantes et 29 vaches non survivantes. Résultats: Les signes vitaux anormaux les plus courants étaient la tachycardie (68,0 %), la tachypnée (59,6 %) et la diminution de la température rectale (51,1 %). Des signes de coliques sont apparus chez 66,0 % des vaches étudiées. La motilité du rumen était réduite ou absente chez 93,6 % des vaches et la motilité intestinale chez 76,6 %. Les signes cliniques de ballottement et/ou percussion et auscultation simultanée étaient positifs du côté droit chez 78,7 % des vaches. L'examen transrectal a montré une dilatation de l'intestin grêle chez 48,9 % des vaches. Le rectum contenait peu ou pas de matières fécales chez 93,6 % des vaches. Les principales anomalies des analyses de laboratoire étaient l'hypocalcémie (74,1 %), l'hypokaliémie (73,8 %), l'azotémie (62,8 %), l'hypermagnésémie (61,6 %) et l'hémoconcentration (60,0 %). Les principaux résultats échographiques étaient une dilatation de l'intestin grêle (87,1 %) et une motilité intestinale réduite ou absente (85,2 %). Quarante et une des 47 vaches ont subi une laparotomie du flanc droit et le SIV a été corrigé chez 21 vaches. En comparant les résultats cliniques et biologiques de 18 vaches survivantes et de 29 vaches non survivantes, les groupes différaient significativement en ce qui concerne l'état général sévèrement anormal (16,7 contre 37,9 %), la stase du rumen (22,2 contre 79,3 %), l'atonie intestinale (16,7 contre 48,3 %), la concentration sérique d'urée (6,5 contre 9,8 mmol/L) et la concentration sérique de magnésium (0,98 contre 1,30 mmol/L). En résumé, 38,3 % des vaches ont reçu leur congé et 61,7 % ont été euthanasiées avant, pendant ou après l'intervention chirurgicale. Conclusion et pertinence clinique: Une évolution aiguë de la maladie, peu ou pas de selles dans le rectum et un intestin grêle dilaté étaient caractéristiques du SIV dans cette population étudiée.(Traduit par Dr Serge Messier).

Navigating Inconclusive Upper-Gastrointestinal Series in Infantile Bilious Vomiting: A Case Series on Intestinal Malrotation.

BACKGROUND Bilious vomiting in a child potentially portends the dire emergency of intestinal malrotation with volvulus, necessitating prompt surgical management, with differentials including small-bowel atresia, duodenal stenosis, annular pancreas, and intussusception. Although the upper-gastrointestinal series (UGI) is the diagnostic investigation of choice, up to 15% of the studies are inconclusive, thereby posing a diagnostic challenge. CASE REPORT We report a case series of 3 children referred for bilious vomiting, whose initial UGI was inconclusive and who were eventually confirmed to have intestinal malrotation at surgery. The first child was a female born at 37 weeks with antenatally diagnosed situs inversus and levocardia, who developed bilious vomiting on day 1 of life. The duodenojejunal flexure (DJ) could not be visualized on the UGI because of faint opacification on first pass of the contrast and subsequent overlap with the proximal jejunal loops. The second child was a male born at 36 weeks, presenting at age 4 months with bilious vomiting of 2 days duration. The third child was a female born at 29 weeks, presenting with bilious aspirates on day 3 of life. UGI for all 3 showed persistent hold-up of contrast at the proximal duodenum with no opacification of the distal duodenum or small bowel.Adjunctive techniques during the UGI and ultrasound examination helped achieve a preoperative diagnosis of malrotation in these children. CONCLUSIONS Application of diagnostic adjuncts to an inconclusive initial UGI may help elucidate a preoperative diagnosis of intestinal malrotation in infantile bilious vomiting.

Adult-onset congenital intestinal malrotation: A case report and literature review.

BACKGROUND: Intestinal malrotation is an infrequent congenital anomaly primarily observed in neonates, and adult-onset cases are exceedingly rare. Studies on adult congenital intestinal malrotation are limited. METHODS: A case with congenital intestinal malrotation is reported in our study. The clinical data were collected and the treatment process and effect were evaluated. RESULTS: A 45-year-old female who had been experiencing vomiting for over 40 years was admitted to our hospital. According to the result of CT scan, intestinal volvulus accompanied by bowel obstruction was suspected. Then laparoscopic examination was applied to the patient and was ultimately diagnosed with adult congenital intestinal malrotation. We performed Ladd's procedure combined with gastrojejunostomy and Braun anastomosis. The patient recovered well and was successfully discharged from the hospital on the 13th day after surgery. After a 6-month follow-up, the symptom of vomiting was significantly alleviated and body weight was gained for 10 kg. She was very satisfied with the treatment. CONCLUSION: Adult congenital intestinal malrotation is a rare disease that is often misdiagnosed owing to nonspecific clinical manifestations. Therefore, awareness about this condition should be enhanced. Surgery remains the cornerstone of treatment for this disease. Combining gastrojejunostomy and Braun anastomosis with the traditional Ladd procedure can optimize surgical outcomes.

Spleno-Sigmoid Knotting - An Unfamiliar Cause of Intestinal Obstruction.

INTRODUCTION: Spleno-sigmoid knotting is the twisting of the spleen around the sigmoid colon, causing obstruction of the sigmoid colon. It is an uncommon cause of intestinal obstruction. To our knowledge, there has been no previous case report of spleno-sigmoid knotting before our case. CASE REPORT: Here, we present the case of an 18-year-old female patient who visited the surgical emergency outpatient department with diffuse and progressive abdominal pain lasting for one and a half days. She also experienced obstipation and frequent episodes of vomiting of ingested matter. Upon initial evaluation, she exhibited tachycardia and tachypnea, and her abdomen was grossly distended with diffuse direct and rebound tenderness. Further investigation revealed significant leukocytosis with neutrophil predominance. Emergency laparotomy was performed with a possible diagnosis of generalized peritonitis secondary to gangrenous sigmoid volvulus, which revealed gangrenous spleno-sigmoid knotting. DISCUSSION: Various types of intestinal knots have been reported, with ileo-sigmoid knots being the most common and ileo-ileal knots being the rarest. Wandering spleen is a rare congenital anomaly with a variable clinical presentation ranging from asymptomatic to mild abdominal pain or acute abdomen due to torsion or acute pancreatitis. It can also cause intestinal obstruction, which may be the initial presentation. CONCLUSION: In patients presenting with acute abdominal pain and features of bowel obstruction, the possibility of spleno-sigmoid knotting should be considered, and early intervention should be instituted to prevent gangrenous progression and sepsis.

Impact of Focused Abdominal Ultrasound Utilization on Outcomes for Children With Midgut Volvulus.

BACKGROUND: Ultrasound (US) is gaining acceptance for the evaluation of midgut volvulus in children. However, its impact on clinical outcomes is unknown. We aim to determine whether using US as a first-line modality changes imaging mobilization, time to surgery and re-feeding, length of stay, and frequency of bowel necrosis, short bowel syndrome, and death. METHODS: An IRB-approved retrospective cohort study was performed at a tertiary pediatric institution. Eighty children with surgically confirmed midgut volvulus from 2014 to 2021 were compared before and after implementation of US as first-line imaging and based on the modality used to diagnose midgut volvulus. RESULTS: Outcomes were not statistically different pre- versus post-implementation. Compared with patients who had UGI only, those who had US only or both had significantly quicker imaging mobilization (median: -33 min; 95% CI: -61.2, -4.8; p = 0.023 and median: -31 min; 95% CI: -58.5, -3.6; p = 0.028 respectively). Patients with US only were less likely to have bowel necrosis compared with those who had UGI only (9.1% versus 43.8%, p = 0.042). Patients who had US only or both were less likely to develop short bowel syndrome compared to UGI only (4.8% US only, 0% both, 40% UGI only; p = 0.027 for US only, p = 0.005 for both). CONCLUSIONS: No statistically significant change in outcomes was found after implementation of US as first-line imaging for midgut volvulus. However, patients diagnosed with US only or US in combination with UGI had quicker imaging mobilization and decreased frequency of bowel necrosis and short bowel syndrome. Findings suggest that US has potential to improve patient outcomes. LEVEL OF EVIDENCE: III.

The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus.

BACKGROUND: Rapid diagnosis is crucial for pediatric patients with midgut volvulus and malrotation to prevent serious complications. While the upper gastrointestinal study (UGIS) is the traditional method, the use of ultrasound (US) is gaining prominence. OBJECTIVES: To assess the diagnostic sensitivity and specificity of US compared to UGIS for malrotation and midgut volvulus. METHODS: A cross-sectional study was performed on 68 pediatric patients who underwent US and/or UGIS before surgery for suspected midgut volvulus or malrotation in Kuala Lumpur (PPUKM and HTA), referencing surgical outcomes as the gold standard. RESULTS: US demonstrated a higher specificity (100%) than UGIS (83%) for diagnosing malrotation, with a slightly lower sensitivity (97% vs. 100%). For midgut volvulus, US surpassed UGIS in sensitivity (92.9% vs. 66.7%) while maintaining comparable specificity. The SMA/SMV criteria showed better sensitivity (91.1%) than the D3 assessment (78.9%) on US, though both had high specificity. CONCLUSION: US is equivalent to UGIS for identifying malrotation and is more sensitive for detecting midgut volvulus, supporting its use as a primary diagnostic tool. The study advocates for combined US and UGIS when either yields inconclusive results, optimizing diagnostic precision for these conditions.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis.

BACKGROUND: Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years. METHODS: We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups. RESULTS: Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates. CONCLUSION: Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.