Preoperative analysis of factors associated with prolonged pneumoretroperitoneum time during retroperitoneal laparoscopic nephroureterectomy for upper tract urothelial carcinoma.

BACKGROUND: Prolonged laparoscopic nephroureterectomy (LNU) for upper tract urothelial cancer (UTUC) can increase the frequency of intravesical recurrence after surgery. Therefore, it is important for urological surgeons to have knowledge on preoperative risk factors for prolonged LNU. However, few studies have investigated the risk factors for prolonged LNU. We hypothesized that the quantity of perirenal fat affects the pneumoretroperitoneum time (PRT) of retroperitoneal LNU (rLNU). This study aimed to investigate the preoperative risk factors for prolonged PRT during rLNU. METHODS: We reviewed the data of 115 patients who underwent rLNU for UTUC between 2013 and 2021. The perirenal fat thickness (PFT) observed on preoperative computed tomography (CT) images was used to evaluate the perinephric fat quantity. Preoperative risk factors for PRT during rLNU were analyzed using logistic regression models. The cutoff value for PRT was determined based on the median time.The cutoff values for fat-related factors influencing PRT were defined according to receiver operating characteristic curve analysis. RESULTS: The median PRT for rLNU was 182 min (interquartile range, 155-230 min). The cutoff values of posterior, lateral, and anterior PFTs were 15 mm, 24 mm, and 6 mm, respectively. Multivariate analysis revealed that a posterior PFT ≥ 15 mm (odds ratio [OR], 2.72; 95% confidence interval, 1.04-7.08; p = 0.0410) was an independent risk factor for prolonged PRT. CONCLUSIONS: Thick posterior PFT is a preoperative risk factor for prolonged PRT during rLNU. For patients with UTUC and thick posterior PFT, surgeons should develop optimal surgical strategies, including the selecting an expert surgeon as a primary surgeon and the selecting transperitoneal approach to surgery or open surgery.

Risk factor analysis of intravesical recurrence after retroperitoneoscopic nephroureterectomy for upper tract urothelial carcinoma.

BACKGROUND: One of the major concerns of patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy is intravesical recurrence (IVR). The purpose of the present study was to investigate the predictive risk factors for IVR after retroperitoneoscopic nephroureterectomy (RNU) for UTUC. METHODS: Clinicopathological and surgical information were collected from the medical records of 73 patients treated with RNU for non-metastatic UTUC, without a history of or concomitant bladder cancer. The association between IVR after RNU and clinicopathological and surgery-related factors, including preoperative urine cytology and pneumoretroperitoneum time, was analyzed using the Fisher exact test. RESULTS: During the median follow-up time of 39.1 months, 18 (24.7%) patients had subsequent IVR after RNU. The 1- and 3-year IVR-free survival rates were 85.9% and 76.5%, respectively. The Fisher exact test revealed that prolonged pneumoretroperitoneum time of ≥ 210 min was a risk factor for IVR in 1 year after RNU (p = 0.0358) and positive urine cytology was a risk factor for IVR in 3 years after RNU (p = 0.0352). CONCLUSIONS: In UTUC, the occurrences of IVR in 1 and 3 years after RNU are highly probable when the pneumoretroperitoneum time is prolonged (≥ 210 min) and in patients with positive urine cytology, respectively. Strict follow-up after RNU is more probable recommended for these patients.

Pneumatosis intestinalis and pneumoretroperitoneum post steroid use in a patient with superior mesenteric artery syndrome.

Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. PI can be both asymptomatic and life-threatening. The patient was a 50-year-old man with previous cervical spine abscess and osteomyelitis post debridement 4 years ago, with a heroin abuse history. He presented with abdominal distension ongoing for 4 days and vomiting for 3 times with fluid content. Abdominal computed tomography revealed pneumatosis with pneumoretroperitoneum. A surgeon was contacted and antibiotic treatment was started. The patient was kept on nothing per os and intravenous fluid supply. A drainage tube was inserted into retroperitoneum space on the same day. Tracing back his history, our patient was discharged from the hospital recently with a diagnosis of superior mesenteric artery dyndrome (SMAS), hypersensitivity pneumonitis, and asbestosis with soft tissue pleural plaques and calcified pleural plaques. During the hospitalization period, hydrocortisone dexamethasone and methylprednisolone were prescribed for hypersensitivity pneumonitis. Steroid use and SMAS maybe the cause of PI. Finally, he was discharged 5 days later with a nasojejunal and drainage tubes and was arranged for OPD follow-up. PI can be asymptomatic or life-threatening, and patient management varies based on the clinical condition. Although in this case PI was found in the emergency department, a patient's past history of underlying disease and medication should be reviewed to find the most possible etiology.

Anorexia nervosa with massive pulmonary air leak and extraordinary propagation.

A rare case combining pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, pneumorrhachis, air in retroperitoneum and extensive subcutaneous emphysema simultaneously in a severely anorectic male with BMI 9.2 (22.8 kg) and multiple vomitings is presented. This unusual condition was treated successfully with conservative medical approach in a specialized somatic unit for anorexia nervosa.

Pneumoperitoneum, pneumoretroperitoneum and pneumomediastinum: rare complications of perforation peritonitis: a case report.

BACKGROUND: Gas extravasation complications arising from perforated diverticulitis are common but manifestations such as pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum happening at the same time are exceedingly rare. This case report explores the unique presentation of these 3 complications occurring simultaneously, their diagnosis and their management, emphasizing the importance of interdisciplinary collaboration for accurate diagnosis and effective management. CASE PRESENTATION: A 74-year-old North African female, with a medical history including hypertension, dyslipidemia, type 2 diabetes, goiter, prior cholecystectomy, and bilateral total knee replacement, presented with sudden-onset pelvic pain, chronic constipation, and rectal bleeding. Clinical examination revealed hemodynamic instability, hypoxemia, and diffuse tenderness. After appropriate fluid resuscitation with norepinephrine and saline serum, the patient was stable enough to undergo computed tomography scan. Emergency computed tomography scan confirmed perforated diverticulitis at the rectosigmoid junction, accompanied by the unprecedented presence of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum. The patient underwent prompt surgical intervention with colo-rectal resection and a Hartmann colostomy. The postoperative course was favorable, leading to discharge one week after admission. CONCLUSIONS: This case report highlights the clinical novelty of gas extravasation complications in perforated diverticulitis. The unique triad of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum in a 74-year-old female underscores the diagnostic challenges and the importance of advanced imaging techniques. The successful collaboration between radiologists and surgeons facilitated a timely and accurate diagnosis, enabling a minimally invasive surgical approach. This case contributes to the understanding of atypical presentations of diverticulitis and emphasizes the significance of interdisciplinary teamwork in managing such rare manifestations.

Computed Tomography Findings in a Case of Uterine Rupture as a Complication of Pyometra.

Uterine rupture in the setting of pyometra is a rare occasion, with an incidence of less than 0.5%. The clinical manifestation of a perforated pyometra is non-specific; therefore, it can mimic many other causes of acute abdomen, such as perforated viscus, acute appendicitis, or diverticulitis, which poses unique challenges to diagnosis solely based on clinical information. We reviewed a case of an elderly postmenopausal lady who presented with a sudden onset of generalized abdominal pain, preceded by fever and vomiting. Physical examination revealed a distended abdomen with clinical signs of peritonism. She was initially diagnosed with possible obstructed gastrointestinal carcinoma by clinical examination, with the differential diagnosis of diverticular abscess. Eventually, further abdominal and pelvic contrast-enhanced computed tomography (CECT) study revealed a pyometra with uterine rupture, complicated with pneumoretroperitoneum and pneumoperitoneum. This case emphasizes the value of a CT scan in establishing an accurate diagnosis and early detection of life-threatening complications, such as uterine rupture, as in this case.

Dirty Mass sign of abdominal imaging: A case of silent pneumoperitoneum.

Pneumoperitoneum is a common complication after penetrating abdominal trauma, gastric ulcer, or colitis in which free air is present in the peritoneal or retroperitoneal space. Sole pneumoretroperitoneum, which refers to gas in the retroperitoneal space, is a rare entity, and when significant, results in a characteristic radiographic sign known as "Dirty Mass." Common causes include penetrating trauma or perforation of the retroperitoneal portions of the gastrointestinal tract (duodenum, ascending colon, descending colon, and rectum). Our case describes a 59-year-old female admitted for sudden onset RLQ abdominal pain with Dirty Mass sign on abdominal KUB. Early recognition of these key radiographic findings accelerates management and reduces the risk of developing complications.

A rare presentation of iliopsoas abscess - A case report.

INTRODUCTION: Psoas abscesses are usually confined to the psoas compartment due to its fascial attachments. However, in rare situations, the infection can locally spread beyond the psoas sheath. CASE PRESENTATION: A 65-year-old patient presented with; 3 weeks of lower back and right hip pain, progressive inability to walk and one week of urinary incontinence. CT abdomen showed a right psoas abscess with pneumo-retroperitoneum extending to the right gluteus muscle, posterior compartment of the upper thigh and mediastinum. Exploration in theatre showed copious amounts of pus, visible between the fascial layers and muscles of the thigh, tracking to the level of the knee and the gluteal region. DISCUSSION: Psoas abscesses are usually confined to the psoas compartment. However, in this case, it was spread to the posterior compartment of the thigh, gluteal region and pelvis with fascial necrosis and pus. Due to the extensive nature of the disease and the patient's clinical deterioration, he underwent open drainage of the psoas abscess, exploration and debridement of the posterior compartment of thigh and gluteal region with a good outcome. CONCLUSION: Psoas abscesses can penetrate the psoas sheath to cause extra pelvic extension. A high index of suspicion and early imaging, if necessary, should be arranged if in doubt. Depending on the clinical severity, patients may need to be managed with open drainage and debridement than conventional CT-guided drainage.

Pneumoretroperitoneum, pneumomediastinum, and neck emphysema due to rectal diverticulosis.

Intestinal diverticulosis is a chronic disorder that might present with acute symptoms, due to colonic perforation. Pneumoperitoneum and air bubbles spreading in different anatomical locations can be seen. These complications need careful consideration and, when appropriate, surgery, for an otherwise chronic condition that can be successfully treated through conservative measures.

Microperforation after colonic endoscopic submucosal dissection, air in 5 separate locations.

Endoscopic submucosal dissection (ESD) and endoscopic mucosal dissection (EMD) are recognized treatment procedures for mucosal lesions. There will always be a risk for complications even if they are performed by experienced specialists. In this study, we aimed to present a 58-year-old male patient in whom lesion was detected in the proximal part of the descending colon during a colonoscopy. Histopathological examination of the lesion revealed intramucosal carcinoma. The lesion was removed by ESD but after the intervention, bilateral pneumothoraxes, pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and pneumoderma complications observed. It is quite unlikely to encounter all of these complications together in one patient. In this paper, we would like to highlight the potential for complications after ESD, even for the rare and unexpected ones, to contribute to their recognition and treatment.

Pneumomediastinum, Pneumoretroperitoneum, Pneumoperitoneum and Subcutaneous Emphysema Secondary to a Penetrating Anal Injury.

Simultaneous occurrence of pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema is rare. The most reported mechanisms are barotrauma, thermal injury and instrument puncture caused by colonoscopy. Ectopic air may travel into different body compartments through distinct anatomical fascial planes. Definite curative treatment involves surgical repair of the bowel wall defect. Conservative treatment is available in selected patients. Here, we present a case of traumatic penetrating rectal injury leading to developing air in the peritoneum, retroperitoneum, mediastinum, and subcutaneous space with good recovery under conservative treatment.

Enterocutaneous Fistula and Pneumoretroperitoneum due to Ruptured Psoas Abscess.

Psoas abscess is a rare condition that can present with vague clinical features. Its insidious onset can lead to a delay in diagnosis, resulting in high rates of complications and mortality. Here we describe a unique case of a patient presenting with enterocutaneous fistula and pneumoretroperitoneum due to ruptured psoas abscess.

Pneumoretroperitoneum after a STARR Procedure Performed One Year after a Posterior Colporrhaphy: A Case Report and Review of the Literature.

Transanal rectal resection with a stapling instrument (STARR) has been shown to be effective and safe for the treatment of obstructed defecation syndrome (ODS). Nevertheless, the wide range of complications described in the literature necessitates a rigorous patient selection and a tailored approach for the management of complications. We present here a case of pneumoretroperitoneum which occurred after a STARR procedure for ODS was performed nearly a year after previous anterior and posterior colporrhaphy. The diagnostic workup did not reveal a staple-line defect. Laparoscopy did not show any intra-abdominal pathology. The symptoms resolved under oral antibiotics. The patient was discharged on day 10 after admission. Scarring in the rectovaginal septum from a colporrhaphy 1 year earlier might have contributed to a suboptimal staple-line closure during the STARR procedure, leading to a pneumoretroperitoneum. We discuss this complication and provide a brief review of the literature.

Idiopathic Hepatic Portal Venous Gas in a Healthy Young Man.

BACKGROUND: Hepatic portal venous gas (HPVG) is a pathological condition characterized by gas in the portal venous system and its branches. The clinical manifestations of HPVG range from benign to life-threatening conditions. Here, we present a rare case of HPVG accompanied by free air in a healthy young patient without any suspicious etiology. CASE PRESENTATION: A 28-year-old man without any specific medical history complained of sudden-onset dyspnea. On admission, his vital signs were stable, and the laboratory tests and physical examinations were within normal range. A plain chest and abdominal film revealed subphrenic free air and HPVG. Contrast-enhanced computed tomography (CT) showed extensive portal venous gas throughout the liver; however, there were no abnormal findings indicative of the etiology. Considering the stable vital signs and the lack of physical findings suggesting a surgical acute abdomen, the patient was managed conservatively. On admission day 3, the subphrenic free air and HPVG shown in the initial study had almost resolved, with no new symptoms. He was discharged on the fourth day after admission without any complications. Esophagogastroduodenoscopy, colonoscopy, and colonography protocol CT scan showed no significant abnormalities. CONCLUSION: This case suggests that idiopathic HPVG could appear in healthy patients complaining only of vague symptoms. Initial conservative management could be considered if HPVG does not result from a life-threatening condition that needs immediate management, and if the patient is stable.

Nonsurgical management of traumatic pneumoperitoneum in a cat.

OBJECTIVE: To describe the nonsurgical management of a cat with traumatic pneumoperitoneum. CASE SERIES SUMMARY: A 4-year-old cat was presented following vehicular polytrauma. Thoracic radiographs revealed 4 rib fractures, a scapular fracture, and pneumothorax. Abdominal ultrasound revealed a small volume of free abdominal fluid. Computed tomography showed a mild pneumoretroperitoneum and a pneumoperitoneum in the region of the porta hepatis. The cat was managed conservatively with close monitoring. Exploratory laparotomy was not pursued given patient stability and static serial imaging studies revealing no indications for surgical intervention. After 6 days, the pneumoperitoneum was no longer detectable. NEW OR UNIQUE INFORMATION PROVIDED: To the authors' knowledge, this is the first report of successful nonsurgical management of traumatic pneumoperitoneum in a cat.

Pneumoretroperitoneum, Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema after Diagnostic Colonoscopy.

Colonoscopy is a commonly performed endoscopic procedure. Although it is generally considered to be safe, serious complications, such as colorectal perforation, can occur. Most colonic perforations are intraperitoneal and cause pneumoperitoneum with acute abdominal pain as the initial symptom. However, extraperitoneal perforations with pneumoretroperitoneum may happen, albeit rarely, with atypical initial symptoms. We report a rare case of rectosigmoid perforation occurring after diagnostic colonoscopy that developed into pneumoretroperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema, with a change in voice and neck swelling as the initial symptoms. The patient was successfully treated with endoscopic closure of the perforation and conservative management.

Pneumo-thorax/mediastinum/(retro)peritoneum/ scrotum - a full house of complications following JET ventilation.

We present a patient who presented to our clinic with airway obstruction secondary to oropharygeal cancer. He underwent emergent tracheostomy with JET ventilation, the latter resulting in a "full house" of barotraumatic complications including pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and pneumo-scrotum. Free air, while sometimes dramatic as in our case, need not always be a cause for alarm and can often be managed expectantly. Our patient was treated with only a chest drain and otherwise made an uneventful recovery.

Pneumoretroperitoneum, Pneumomediastinum, Subcutaneous Emphysema After a Rectal Endoscopic Mucosal Resection.

An endoscopic mucosal resection (EMR) is an effective and safe therapeutic technique for treating a patient with a laterally-spreading tumor (LST). Colonoscopic-procedure-related complications are noted to be about 2.8% worldwide, and a perforation is the most common. Most colon perforations cause pneumoperitoneum. However, a perforation within the retroperitoneal portion of the colon (rectum and some of sigmoid colon) may cause an extraperitoneal perforation, and the leaking free air may induce pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema, depending on the amount of discharged air. Herein, we present the case of a patient with an extraperitoneal colon microperforation which manifested as pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema after an EMR for a sigmoid LST, which was successfully treated with medical treatment and endoscopic clipping.