Cecal perforations due to descending colon obstruction (closed loop): a case report and review of the literature.

BACKGROUND: Cases of large bowel closed-loop phenomenon with cecal perforation are extremely rare, especially when extracolonic epiploic appendage and peritoneal bands are the cause. However, sporadic cases exist in the literature with various presentations, but very few occur in patients in the abdomen without a previous scar. CASE PRESENTATION: An 89-year-old Sudanese farmer was admitted to the emergency department with 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. Given his clinical presentation and assessment, he was diagnosed with peritonitis due to a perforated viscus in a virgin abdomen. Operative exploration revealed an extraluminal left-sided omento-epiploic band that resulted in closed-loop colonic obstruction with secondary multiple cecal perforations. Standard right hemicolectomy with adhesiolysis was done. Postoperative wound infection and hypoalbuminemia were treated, and the patient was discharged on postoperative day 9 on a regular oral diet. CONCLUSIONS: Although this condition is rare, it can be extremely dangerous, requiring prompt investigation and surgical intervention. It usually occurs secondary to raised intraluminal pressure with subsequent ischemia of the cecal wall. Through this case report, we aim to reflect on this rare experience, shedding light on the benign, extracolonic pathologies that can be life threatening or even fatal.

Total colonic aganglionosis with ileum extension Hirschsprung's disease in an adult: A case report.

INTRODUCTION: Hirschsprung's disease is a gastrointestinal anomaly affecting neuronal development and function. The primary abnormality is the absent ganglionic cells in the submucosal and myenteric neural plexuses. Disease presentation can vary, and patients may present with delayed meconium passage or late in adulthood. Total colonic aganglionosis is considered a rare subtype and even rarer to extend proximally into the small bowel. Therefore, adult Hirschsprung disease is frequently misdiagnosed as chronic constipation until comorbid events such as volvulus or perforation occur. CASE PRESENTATION: A 34 years South-Sudanese male presented with chronic constipation since early childhood, abdominal discomfort, pain, and distension. His bowel habits were infrequent, requiring occasional enemas. A strong family history of Hirschsprung disease was identified. He underwent total abdominal colectomy and end ileostomy. Postoperative diagnosis of TCA and small bowel extension of more than 50 cm was confirmed. The patient was discharged home after ileostomy education and possible future reconstruction. CLINICAL DISCUSSION: Hirschsprung's ileal extension resembles a risk of morbidities and mortality. It increases as the segment extends proximally. No international consensus on surgical management. It should be tailored to patient condition, diseased segment length, and the possible definitive primary reconstruction. Our patient's surgical diversion considered the patient's long-standing constipation history and dilated fecal-loaded ileum. CONCLUSION: TCA requires a high index suspension during the workup of chronic constipation patients. There is no reported superior surgical approach, and it depends on the institution's experience and surgeon's expertise. Primary reconstruction can be achieved, but we recommend an ileostomy for such cases.

Small bowel obstruction and ileocolic fistula caused by post-myomectomy Gossypiboma transmural migration: A case report and review of the literature.

INTRODUCTION: Post-myomectomy Gossypiboma causing Ileo-colic fistula is tremendously rare; it may present as a tumor and stand a diagnostic challenge. The duration between the primary procedure and the presentation is unpredictable. CASE PRESENTATION: A 37-year-old Sudanese/African woman presented with a 4-month history of left iliac fossa mass, pain, anorexia, and persistent, recurrent vomiting with episodes of diarrhea during the last month PTP. She had two gynecological surgeries. Abdominal X-ray & abdominopelvic CECT showed a left iliac fossa pelvic-abdominal collection, distal small bowel partial obstruction, and contrast passage from the small bowel to the sigmoid colon. Diagnosis retained foreign body with abscess causing distal ileal subacute obstruction and an ileo-sigmoid fistula. Surgical exploration, extraction of Gossypiboma with small bowel resection, primary sigmoid colon repair, and a protective transverse colon stoma were done. Six weeks later, colostomy closed after distal loopogram and flexible-sigmoidoscopy. CLINICAL DISCUSSION: A missed intraperitoneal gauze is the top differential diagnosis in patients presenting with acute abdomen after recent abdominal surgery. Transmural migration is slow but leads to difficult clinical situations, peritonitis, or fistulas. Our case reflects the light on the importance of the golden rule of perioperative gauze count and documentation. Thus, minimizing the surgical complications and preventing severe postoperative morbidities. CONCLUSION: Entero-colic fistula due to trans mural migration is not frequently encountered, and its complications can lead to morbidities and even mortality if not promptly diagnosed and treated. Strict adherence to the golden rule of counting and prevent such life-threatening complications and improves patients' safety.

Surgery in mycetoma-endemic villages: unique experience.

In this communication, the Mycetoma Research Center (MRC), University of Khartoum, WHO Collaborating Center on Mycetoma, shares its experience in field surgery for mycetoma. The surgery was conducted in two mycetoma-endemic villages in Sennar and the White Nile States in collaboration with local health authorities, local community leaders, activists and civil society associations. In these villages, the local health centres were renovated and operating theatres were established. The medical and health missions' team was established at the MRC. The team conducted 15 missions over the period 2013-2020 and 1200 mycetoma patients received surgical treatment. These included wide local excisions, minor amputations and debridement that were conducted under spinal or ketamine analgesia. The missions adopted a community holistic management approach, which included medical and surgical treatment, health education sessions, village hygiene improvement and socio-economic support. The latter offered the mycetoma amputees artificial prosthesis and financial support. All these services were provided free of charge. This holistic approach proved to be effective for early case detection and management, optimal treatment outcome and favourable disease prognosis. During the study period, the number of patients with massive lesions and the amputation rate decreased and this reduced the medical and socio-economic disease burdens on patients and families. This treatment approach needs the collaboration of all stakeholders for sustainability and quality improvement.

Challenging Presentations of Seven Cases of Gastrointestinal Basidiobolomycosis in Sudan: Clinical Features, Histology, Imaging, and Recommendations.

Basidiobolomycosis is a fungal infection caused by Basidiobolus ranarum which affects the skin and subcutaneous tissue and rarely the gastrointestinal tract. We report seven cases of gastrointestinal basidiobolomycosis with interesting clinical, radiological, and histological presentations. To our knowledge, this is the first case series of abdominal basidiobolomycosis to be reported from Sudan.

Mycetoma: The Spectrum of Clinical Presentation.

Mycetoma is a chronic infection, newly designated by the World Health Organization (WHO) as a neglected tropical disease, which is endemic in tropical and subtropical regions. It follows implantation of infectious organisms, either fungi (eumycetomas) or filamentous bacteria (actinomycetomas) into subcutaneous tissue, from where infection spreads to involve skin, bone and subcutaneous sites, leading to both health related and socioeconomic problems. In common with other NTDs, mycetoma is most often seen in rural areas amongst the poorest of people who have less access to health care. The organisms form small microcolonies that are discharged onto the skin surface via sinus tracts, or that can burrow into other adjacent tissues including bone. This paper describes the clinical features of mycetoma, as early recognition is a key to early diagnosis and the institution of appropriate treatment including surgery. Because these lesions are mostly painless and the majority of infected individuals present late and with advanced disease, simplifying early recognition is an important public health goal.

A holistic approach to the mycetoma management.

Mycetoma, one of the badly neglected tropical diseases, it is a localised chronic granulomatous inflammatory disease characterised by painless subcutaneous mass and formation of multiple sinuses that produce purulent discharge and grains. If untreated early and appropriately, it usually spread to affect the deep structures and bone resulting in massive damage, deformities and disabilities. It can also spread via the lymphatics and blood leading to distant secondary satellites associated with high morbidity and mortality. To date and despite progress in mycetoma research, a huge knowledge gap remains in mycetoma pathogenesis and epidemiology resulting in the lack of objective and effective control programmes. Currently, the available disease control method is early case detection and proper management. However, the majority of patients present late with immense disease and for many of them, heroic substantial deforming surgical excisions or amputation are the only prevailing treatment options. In this communication, the Mycetoma Research Center (MRC), Sudan shares its experience in implementing a new holistic approach to manage mycetoma patients locally at the village level. The MRC in collaboration with Sennar State Ministry of Health, Sudan had established a region mycetoma centre in one of the endemic mycetoma villages in the state. The patients were treated locally in that centre, the local medical and health personals were trained on early case detection and management, the local community was trained on mycetoma advocacy, and environmental conditions improvement. This comprehensive approach had also addressed the patients' socioeconomic constraints that hinder early presentation and treatment. This approach has also included the active local health authorities, community and civil society participation and contributions to deliver the best management. This holistic approach for mycetoma patients' management proved to be effective for early case detection and management, optimal treatment and treatment outcome and favourable disease prognosis. During the study period, the number of patients with massive lesions and the amputation rate had dropped and that had reduced the disease medical and socioeconomic burdens on patients and families.