Factors associated with emergent colectomy in patients with neutropenic enterocolitis.

PURPOSE: Neutropenic enterocolitis (NEC) is a severe complication of neutropenia. NEC is characterized by segmental ulceration, intramural inflammation, and necrosis. Factors present in patients who underwent colectomy have never been studied. The present study aimed to describe the clinical factors present in patients who underwent emergent colectomy for the treatment of neutropenic enterocolitis. METHODS: Patients admitted with neutropenic enterocolitis from November 2009 to May 2018 were retrospectively analyzed. Logistic regression analysis was used to determine clinical factors associated with emergent colectomy. RESULTS: Thirty-nine patients with NEC were identified. All patients had a hematological disorder. Medical treatment was the only management in 30 (76.9%) patients, and 9 (23.1%) patients underwent colectomy. No differences were found between the treatment groups regarding sex, age, or comorbidities. Patients were more likely to undergo colectomy if they developed abdominal distention (OR = 12, p = 0.027), hemodynamic failure (OR = 6, p = 0.042), respiratory failure (OR = 17.5, p = 0.002), multi-organic failure (OR = 9.6, p = 0.012), and if they required ICU admission (OR = 11.5, p = 0.007). Respiratory failure was the only independent risk factor for colectomy in multivariable analysis. In-hospital mortality for the medical and surgical treatment groups was 13.3% (n = 4) and 44.4% (n = 4), respectively (p = 0.043). CONCLUSIONS: In our study, most NEC patients were treated conservatively. Patients were more likely to undergo colectomy if they developed organ failures or required ICU admission. Early surgical consultation is suggested in all patients with NEC.

Severe ileocecal inflammatory syndrome in adult patients with cystic fibrosis.

The relevance of gastrointestinal manifestations of cystic fibrosis (CF) is increasing due to an improved life expectancy. We report on 2 adult patients with prior lung transplantation who presented with a severe inflammatory disorder of the ileocecal region. One patient underwent ileocecal resection; the second patient died after emergency surgery for intestinal perforation. Both cases did not show typical signs of CF-related distal intestinal obstruction syndrome or extensive fibrosing colonopathy. However, the clinical and histopathological findings revealed CF-induced inflammatory alterations of the intestinal mucosa. Thus, these cases illustrate a further CF-related bowel disorder, which can be especially relevant in long-term CF survivors.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM: The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires. METHOD: In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data. RESULTS: We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant. CONCLUSION: We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

Neutropenic enterocolitis affecting the transverse colon: an unusual complication of chemotherapy.

A 66-year-old woman presented with a 1-day history of sudden onset of generalised abdominal pain associated with fever and vomiting. She was previously diagnosed with left breast cancer 2 months ago and completed a course of chemotherapy 1 week prior to presentation. She was clinically unwell with generalised tenderness in her abdomen. Blood investigations showed severe neutropenia. A CT scan was requested which reported a marked oedematous swelling of the transverse colon with features suggestive of a contained perforation. The decision was made to operate. Intraoperatively, the transverse colon was found to be thickened with omentum adherent focally around the distal third. A right hemicolectomy was performed with an end ileostomy and mucus fistula. The patient made a successful recovery and was discharged within 7 days of presenting. Pathology reported typical features of neutropenic enterocolitis affecting the transverse colon with a normal terminal ileum, caecum and ascending colon.

The surgical management of abdominal pain in the multiple myeloma patient.

BACKGROUND: The purpose of this retrospective study was to characterize the presentation, treatment, and outcomes of patients with multiple myeloma requiring surgical evaluation for abdominal pain. METHODS: Medical records of patients with myeloma and abdominal pain evaluated by surgery over a period of 18 months were examined. RESULTS: Twenty-one patients underwent surgical evaluation, with 23 diagnoses. Neutropenic enterocolitis (n = 5 [22%]) and ileus (n = 4 [17%]) were common diagnoses. Eleven patients (52%) were neutropenic. Peritonitis was noted in only 1 patient. Eastern Cooperative Oncology Group performance status was either 3 or 4 in most patients (67%). Surgery was performed in 5 patients. The 90-day mortality rate for all patients was 43%, with all deaths secondary to sepsis in patients managed without surgery. CONCLUSIONS: Patients with myeloma requiring surgical evaluation for abdominal pain have a unique differential diagnosis, with notable findings at presentation including the presence of cytopenia, lack of peritoneal signs, and low performance status.

Diagnosis and outcome of neutropenic enterocolitis: experience in a single tertiary pediatric surgical center in China.

BACKGROUND/PURPOSE: Neutropenic enterocolitis (NE) is clinically defined by the triad of neutropenia, abdominal pain and fever. This retrospective study is to review 24 cases of NE in a single Chinese tertiary center, to elucidate clinical feature, treatments and outcome for this dangerous gastrointestinal complication of neutropenia. PATIENTS AND METHODS: The medical records of pediatric patients who were diagnosed with neutropenic enterocolitis from 2000 to 2009 were reviewed. RESULTS: Of 24 cases, the ratio of male to female was 2:1, the mean age was 7.2 years. There were eight cases of acute lymphocytic leukemia, eight cases of acute non-lymphocytic leukemia, four cases of non-Hodgkin's lymphoma, one case of severe aplastic anemia, one case of neuroblastoma and two cases of simple neutropenia without underlying cause. The hematologic malignancy was significantly associated with the occurrence of NE (OR = 19.4). Seventeen cases developed NE during anticancer chemotherapy (chemo group), four cases presented with leukemia and one case presented with aplastic anemia before the initiation of chemotherapy and their presenting event leading to diagnosis. Two cases simply presented with NE without definitive reasons (no chemo group). All the patients had the typical clinical presentation, six cases had disseminated peritonitis, toxic shock, and assisted ventilations were necessary in three of these six cases. CT or ultrasound demonstrated bowel wall thickness, paucity of air in the cecum and/or right colon, pneumatosis or pneumoperitoneum. There was no difference in the nadir neutrophil count in patients, who received chemotherapy versus those who did not (P = 0.001), but the recovering time from NE in chemo group (9.3 ± 1.9) was shorter than non-chemo group (10.7 ± 5.3, P = 0.034). Sixteen (88.8%) cases have been successfully managed medically, using aggressive hemodynamic support, bowel rest, and broad-spectrum antibiotic therapy with surgical intervention reversed only for the more severe six cases (25%). Two cases died. CONCLUSION: NE is a life-threatening gastrointestinal complication of neutropenia. Physicians might remain vigilant and consider NE in any neutropenic patient rather than only in oncologic patients. It has typical clinical presentation and CT can provide clear delineation for diagnosis. Early recognition and progressed management have reduced mortality. Most children with NE may be treated without surgery with favorable outcome.

[Treatment of neutropenic enterocolitis]. / Behandling av nøytropen enterokolitt.

BACKGROUND: Neutropenic enterocolitis is a life-threatening complication that usually occurs in connection with chemotherapy for acute leukemias. Our experience with diagnosis and treatment of these patients is presented. MATERIAL AND METHODS: Medical records from patients treated for neutropenic enterocolitis at Ullevaal University Hospital in the period 2000-2008 were retrospectively reviewed. RESULTS: 16 patients with median age 33 years were treated for neutropenic enterocolitis. Induction chemotherapy was given for acute myelogenic (n = 9) or lymphatic (n = 4) leukemia, myelomatosis (n = 2) or lymphoma (n = 1). The patients developed aplasia five days (median) after start of chemotherapy. All patients were first treated conservatively with broad-spectrum antibiotics, fluids and electrolyte supplementation; nine of them recovered without complications. Four underwent surgery for perforation or ileus and these had the longest period with aplasia (median 31 days). Surgery for perforation is mainly limited resection and construction of ileostomy reservoirs (one or two). Three patients died. These were only treated conservatively; aplasia occurred quicker in these patients (after median two days) and they had the largest number of affected bowel segments (median nine). INTERPRETATION: Neutropenic enterocolitis is a heterogeneous condition and the treatment is mainly conservative. Surgical intervention is mandatory in patients with free intraabdominal air, ileus and intractable intestinal bleeding. The prognosis seems to worsen when aplasia develops after a short time and when there is a large number of affected bowel segments.

Challenges in surgical management of abdominal pain in the neutropenic cancer patient.

BACKGROUND: Abdominal pain in neutropenic cancer patients presents a unique clinical challenge for surgeons. The purposes of this retrospective study were to characterize the clinicopathologic factors associated with the presentation of neutropenia and abdominal pain, examine the treatment strategies used, and define associated outcomes for these patients. METHODS: We identified patients with concomitant neutropenia (absolute neutrophil count <1000 cells/microL) and abdominal pain who had been evaluated by surgical oncologists over a period of more than 6 years. A Cox proportional hazards regression model was used to analyze the association between clinicopathologic factors and overall survival time. RESULTS: Sixty patients were included in this analysis. After our clinical and radiographic evaluations, we determined that the most frequent causes of the abdominal pain were neutropenic enterocolitis (28%) and small bowel obstruction (12%); the cause remained uncertain in 35%. Surgical interventions had been performed in 9 patients. The 30- and 90-day mortality rates for all patients were 30% and 52%, respectively. Multivariate analysis revealed that severe sepsis, a relatively long duration of neutropenia, and the lack of surgical intervention were significant adverse prognostic factors for overall survival. CONCLUSIONS: Abdominal pain as a symptom in neutropenic patients continues to be a diagnostic and therapeutic challenge and is associated with a high mortality rate. Based on our results, we conclude that efforts should focus on improving neutrophil counts and on treating the frequent and serious comorbidities found in these patients. Surgery should be delayed, when possible, to allow for neutrophil recovery.

[Neutropenic enterocolitis in adult patients with acute leukemia or stem cell transplant recipients: study of 7 cases]. / Enterocolitis neutropénica en adultos con leucemia aguda o receptores de un trasplante de progenitores hematopoyéticos: estudio de 7 casos.

BACKGROUND AND OBJECTIVE: Neutropenic enterocolitis (NE) is a complication arising in neutropenic patients with acute leukemia or solid tumours while treated with intensive chemotherapy. The optimal therapeutic procedures have not been well established. PATIENTS AND METHOD: Seven cases of NE diagnosed and treated in a tertiary hospital between 2000 and 2007 are described. Their clinico-biological characteristics, therapeutic procedures and evolution were analysed retrospectively. RESULTS: Five of the patients were males, their median age was 39 years. Acute myeloblastic leukemia was the most frequent diagnosis (5 cases). Two other patients had received an stem cell transplantation. Abdominal pain was present in all patients, diarrhoea in 6, and fever in 5. Microorganisms were isolated from blood cultures in 4 cases (Clostridium septicum, Escherichia coli, Pseudomonas aeruginosa and Aeromonas hydrophila). Abnormal mural thickening of the caecum was observed in the 6 cases in which a computed tomography scan could be performed. The median mural thickness at its maximum section was 11 mm (range: 8-16). All patients first received medical treatment with wide spectrum antibiotics and intestinal rest, and abdominal surgery was indicated in 6 cases after a median time from first symptom of 4 days (range: 0-12). NE was confirmed histologically in all 6 patients. Five patients required admission in Intensive Care Unit and 2 (29%) died as a result of NE. CONCLUSIONS: NE is a severe complication of patients with hematologic malignancies submitted to intensive chemotherapy or receiving stem cell transplantation. Abdominal computed tomography scan is the most valuable diagnostic tool. Prompt surgical intervention may improve the prognosis in patients with NE.

Neutropenic enterocolitis: is there a right timing for surgery? Assessment of a clinical case.

Neutropenic enterocolitis is a severe and potentially life-threatening complication that may affect patients undergoing chemotherapy for acute leukemia or lymphoma. These patients may develop systemic sepsis through bacterial or fungal translocation across the intestinal wall. In many cases neutropenic enterocolitis is confined to the cecum, but the entire colon is sometimes involved. Most patients are treated conservatively because an improvement occurs when the absolute neutrophil count rises. However, a surgical approach consisting of resection of the colon may sometimes be necessary, even in patients with complete aplasia and a high risk of complications. The right time to perform surgery is hard to define. Intestinal wall thickness, evaluated by ultrasound, is an important prognostic factor which could act as a guide to surgical indication. We analyze a case of neutropenic enterocolitis which occurred in a patient with acute myeloid leukemia during chemotherapy and we suggest that, as well as intestinal wall thickness, hemodynamic worsening should be considered an indication for surgery.

[Ladd laparoscopic procedure in the neonate]. / Operación de Ladd laparoscópica en el recién nacido.

The treatment of the intestinal malrotation with or without midgut volvulus with the Ladd procedure for laparoscopic way has been proposed by several authors since 1995. We carry out this treatment in a patient of 15 days old with intestinal malrotation and midgut volvulus. After clinical and radiologic diagnosis, the procedure consisted in the careful counterclock reduction of the volvulus, division of the Ladd's bands, incision of the common mesentery and appendectomy. The jejunum and ileum was positioned on the rigth and the colon on the left in the abdominal cavity. The postoperative evolution was appropiate. We recommend the laparoscopic Ladd's procedure like an alternative in the patients with midgut volvulus that fulfill minimum approaches during the preoperative study that allow to carry out the surgery with security.

[Isolated edematous swelling of Bauhin's valve -- sonographically suspected diagnosis of a rare ileocoecal disease]. / Isolierte ödematöse Schwellung der Bauhin-Klappe -- Sonographische Verdachtsdiagnose einer seltenen ileozäkalen Erkrankung.

Isolated edematous swelling of Bauhin's valve is a rare finding in cases of non-specific abdominal complaints in the lower right abdominal quadrant. The differential diagnosis includes entities such as tumours, chronic gastrointestinal inflammation and ileocoecal intussusception as well as specific infections, all of which require individual therapy. Based on two current cases and a review of the literature, aetiology, clinical picture and diagnostic findings of isolated edema of the ileocoecal valve are described. The typical ultrasound findings are presented. Due to its potential of excluding other diseases, modern ultrasound offers promising results in the case of isolated edematous swelling of Bauhin's valve.

Neutropenic enteropathy.

Neutropenic enteropathy (NE) is used to describe the inflammation of the bowel in neutropenic patients under aggressive chemotherapy, mainly for lymphoproliferative and hematologic malignancies. Surgical intervention may be required in patients with the advent of the disease. We report our experience in 7 children with NE who had to be treated surgically. Absolute neutrophil counts were less than 1000/mm3 in all, with positive blood cultures in five patients. Four patients recovered with rapid resolution of neutropenia, while three patients died with persistent neutropenia.

Neutropenic enterocolitis in adults: case series and review of the literature.

Necrotizing enterocolitis in adults is a rare disease and, in the past, has been associated with nearly uniform mortality. In recent years, necrotizing enterocolitis, now termed neutropenic enterocolitis, in adults has become more prevalent as a complication of aggressive systemic chemotherapy. In this report, we discuss two cases of neutropenic enterocolitis secondary to the administration of systemic chemotherapy in adult cancer patients: one with lung carcinoma, the other with leukemia. Both patients were successfully treated with early surgical intervention for resection of all necrotizing enteric lesions, and subsequent aggressive critical care support. Our experience suggests that early surgical intervention in adult patients with intestinal necrosis due to chemotherapy is essential to avoid mortality from this condition. Given the widespread, aggressive use of systemic chemotherapy in the neoadjuvant setting, patients at risk for this potentially lethal complication of neutropenic enterocolitis are increasingly common.

[Surgery for neutropenic enterocolitis, a complication in acute lymphoblastic leukemia]. / Hirurske komplikacije neutropenijskog enterokolitisa kod akutne limfoblastne leukemija.

Neutropenic enterocolitis (NE) is an unusual acute complication of neutropenia, associated with leukemia and lymphoma. It has been observed mainly in the first phase of therapy when drugs are used in maximally tolerated dose. This is a case report of neutropenic enterocolitis in a patient with acute lymphoblast leukemia who received prednisone, vincristine, daunorubicin and L-asparaginase, with perforation of cecal and terminal ileum. Perforation and defect intestine wall was excised and sutured directly in two layers. Protective proximal loop ileostomy was performed at that time.

Neutropenic enterocolitis: is it possible to break vicious circle between neutropenia and the bowel wall inflammation by surgery?

BACKGROUND: Neutropenic enterocolitis is a devastating bowel wall inflammation in patients with protracted neutropenia. The approach for diagnosis and treatment is still controversial, and it is difficult and challenging to decide on what should be the next step in the management. CASE PRESENTATION: We report a 10-year-old boy who developed neutropenic enterocolitis in the course of the conservative treatment for aplastic anemia. Oral mucositis and the perianal fissure with an ulcer were important indicators for what was happening on the colonic mucosa. Colonoscopy and biopsy confirmed the diagnosis. A fast recovery was achieved with a right hemicolectomy and ileostomy. CONCLUSION: Retrospective analysis of the long-term follow-up of our patient suggests that defunctioning the colon by ileostomy breaks the vicious circle between neutropenia and bowel wall inflammation, and an early surgical intervention could be considered as an adjunctive approach to the conservative management of persistent cases.