Chronic constipation that resulted in fecal impaction and colon perforation: A case report.

RATIONALE: Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ. PATIENT CONCERNS: A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids. DIAGNOSIS: An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying. INTERVENTIONS: Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed. OUTCOMES: The patient had an uneventful postoperative course and was discharged in good condition. LESSONS: Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

Endovascular Repair of a Pseudoaneurysm After Multiple Open Repairs of Aortic Coarctation.

Successful surgical repair of aortic coarctation during childhood may have major late complications such as pseudoaneurysm formation. If left untreated, pseudoaneuryms put patients at risk for morbidity and death; if treated surgically, they are associated with complications. Endovascular aortic repair, an established safe alternative to open surgical repair, is associated with encouraging outcomes and fewer complications, and it is especially feasible for patients who have undergone multiple aortic surgeries. We report the case of a 41-year-old man who underwent endovascular repair of a pseudoaneurysm after previous surgical corrections of an aortic coarctation at 6 and 14 years of age. The pseudoaneurysm, involving the distal portion of an ascending-to-descending aortic 20-mm Dacron bypass graft, was successfully excluded with a thoracic stent-graft and sealed off with vascular plugs to prevent both blood flow into the pseudoaneurysm and type II endoleak.

Proximal Descending Thoracic Aortic Pseudoaneurysm in a 24-Year-Old Man after 2 Childhood Repairs of Interrupted Aortic Arch.

Improved management of interrupted aortic arch has increased long-term survival rates. Longer life expectancies in neonates and children surgically treated for interrupted aortic arch may necessitate complex reinterventions when sequelae develop in adulthood. We report the case of a 24-year-old man who had undergone initial repair of interrupted aortic arch type B at one week and reintervention at 6 years of age. He presented with a 5.5 × 9-cm pseudoaneurysm of the proximal descending thoracic aorta. He underwent surgical replacement of his distal aortic arch and proximal descending thoracic aorta, with a bypass to his left subclavian artery. In addition to our patient's case, we discuss considerations in treating recipients of early interrupted aortic arch repairs as they live longer and undergo multiple reinterventions.

Predictors of dysplastic and neoplastic progression of Barrett's esophagus

Background: It is unknown why some cases of Barrett's esophagus progress to invasive malignant disease rapidly while others do so more slowly or not at all. The aim of this study was to identify demographic and endoscopic factors that predict dysplastic and neoplastic progression in patients with Barrett's esophagus. Methods: Patients with Barrett's esophagus who were assessed in 2000­2010 were assessed for inclusion in this retrospective study. Demographic and endoscopic variables were collected from an endoscopy database and the medical chart. Dysplastic and neoplastic progression was examined by time-to-event analysis. We used Cox proportional hazard regression modelling and generalized estimating equation methods to identify variables that were most predictive of neoplastic progression. Results: A total of 518 patients had Barrett's esophagus confirmed by endoscopy and pathology and at least 2 surveillance visits. Longer Barrett's esophagus segment (≥ 3 cm) (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1­1.3) and increased age (≥ 60 yr) (OR 3.5, 95% CI 1.7­7.4) were independent predictors of progression from nondysplasia to dysplastic or neoplastic grades. Presence of mucosal irregularities (OR 8.6, 95% CI 2.4­30.4) and increased age (OR 5.1, 95% CI 1.6­16.6) were independent predictors of progression from nondysplasia to high-grade dysplasia or adenocarcinoma. Conclusion: Increased age, longer Barrett's segment and presence of mucosal irregularities were associated with increased risk of dysplastic and neoplastic progression. In addition to dysplasia, these factors may help stratify patients according to risk of neoplastic progression and be used to individualize surveillance. More prospective studies with larger samples are required to validate these results.

Contexte: On ignore pour quelle raison certains cas d'oesophage de Barrett évoluent rapidement vers une maladie maligne envahissante, tandis que d'autres progressent lentement ou se stabilisent. Le but de cette étude était d'identifier les facteurs démographiques et endoscopiques prédicteurs d'une progression dysplasique et néoplasique chez les patients porteurs d'un oesophage de Barrett. Méthodes: Des patients présentant un oesophage de Barrett ayant été examinés entre 2000 et 2010, ont été évalués en vue de leur participation à cette étude rétrospective. Les variables démographiques et endoscopiques ont été recueillies à partir d'une base de données endoscopiques et des dossiers médicaux. La progression dysplasique et néoplasique a été évaluée par analyse du délai de survenue de l'événement. Nous avons utilisé le modèle de la régression de Cox (risques proportionnels) et les équations d'estimation généralisée afin d'identifier les variables les plus prédictives d'une progression néoplasique. Résultats: En tout, 518 patients présentaient un oesophage de Barrett confirmé par examen endoscopique et anatomopathologique et comptaient au moins 2 visites de surveillance. La présence de segments d'oesophage de Barrett plus longs (≥ 3 cm) (rapport des cotes [RC] 1,2, intervalle de confiance à 95 % [IC] 1,1­1,3) et un âge avancé (≥ 60 ans) (RC 3,5, IC à 95 % 1,7­7,4) ont été des prédicteurs indépendants de progression d'un grade non dysplasique vers un grade dysplasique. La présence d'irrégularités muqueuses (RC 8,6, IC à 95 % 2,4­30,4) et l'âge avancé (RC 5,1, IC à 95 % 1,6­16,6) ont été des prédicteurs indépendants de progression de la non-dysplasie vers une dysplasie de haut grade ou l'adénocarcinome. Conclusion: L'âge avancé, des segments d'oesophage de Barrett plus longs et la présence d'irrégularités muqueuses ont été associés à un risque accru de progression dysplasique et néoplasique. En plus de la dysplasie, ces facteurs peuvent faciliter la stratification des patients selon le risque de progression néoplasique et servir à individualiser la surveillance. Il faudra procéder à d'autres études prospectives auprès d'échantillons de population plus volumineux pour valider ces résultats.

Left Transthoracic Approach for Magnetic Sphincter Augmentation Device LINX Implantation.

Magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical, St. Paul, MN) is a recently introduced surgical option with comparable therapeutic efficacy for medically refractory gastroesophageal reflux disease. An appropriately sized LINX device is usually placed around the gastroesophageal junction through a laparoscopic approach. In general, redo abdominal surgeries are technically challenging, with a higher risk of associated morbidity. This highlights the need to obtain feasible alternative access to place the LINX device for certain patient populations. In this case series, we described 2 patients who underwent LINX device implantation through left thoracotomy because of previous abdominal surgeries that prohibited a transabdominal approach.

Successful Conservative Management of a Large Splenic Abscess Secondary to Infective Endocarditis.

The spleen is the most common abdominal site for systemic septic emboli that often complicate infective endocarditis. Management of an embolic splenic abscess usually involves surgical splenectomy or image-guided drainage, but the natural history of splenic abscess without drainage is unknown. We describe the successful conservative treatment of a large complex splenic abscess with antibiotics alone in a patient with aortic valve infective endocarditis who required an emergent valve replacement surgical procedure. Previous complex abdominal wall operation with the presence of a synthetic mesh made abdominal surgical intervention unfavorable. The splenic abscess resolved completely with no recurrence of infection at the 3-year follow-up.