Colonic perforation due to inadvertent intraperitoneal LVAD driveline placement.

BACKGROUND: Left ventricular assist devices (LVAD) are placed for patients with advanced heart failure or cardiogenic shock as destination therapy or as a bridge to cardiac transplantation. Significant complications associated with LVAD placement include bleeding, infection, pump thrombosis, right heart failure, device malfunction and stroke. The case below illustrates inadvertent intraperitoneal driveline placement causing colonic perforation and the subsequent management. CASE PRESENTATION: A 54 year old male with a history of Wolff-Parkinson-White syndrome resulting in multiple readmissions for heart failure, ultimately required placement of a left ventricular assist device (LVAD). Several weeks later, he was found to have stool draining from the driveline site. The patient was taken to the operating room for limited exploration by the Cardiothoracic Surgery team and a bowel injury was identified and repaired. Three days after this repair, stool was once again leaking from the driveline site, requiring re-exploration by the Acute Care Surgery team. Intraoperatively, the prior repair was found to be leaking and multiple intra-abdominal abscesses were discovered. The transverse colon was resected and left in discontinuity. On a planned second look operation, the LVAD driveline was relocated to be extra-peritoneal and a colostomy was formed. DISCUSSION AND CONCLUSION: This case demonstrates the importance of early recognition and involvement of an Acute Care Surgeon in the management of this complex problem. Appropriate treatment involves a complete exploration, source control, driveline relocation and possible fecal diversion. Although the incidence of this complication is low, it must be considered in the differential in a septic LVAD patient.

Bowel Perforation During Peritoneal Dialysis Catheter Placement.

Interventional nephrologists and radiologists place peritoneal dialysis catheters using the percutaneous fluoroscopic technique in both the inpatient and outpatient setting. Nephrologists caring for such patients may have to diagnose and manage the complications resulting from these procedures. Abdominal pain can occur following peritoneal dialysis catheter placement when the local and systemic analgesia wears off. However, abdominal pain with hypotension is suggestive of a serious complication. Bleeding into the abdomen and perforation of the colon or bladder should be considered in the differential diagnosis. In the case reported here, the peritoneogram showed contrast in the bowel, and correct interpretation by the interventionist would have prevented this complication. The characteristic pattern of peritoneogram images in this case will guide interventionists to avoid this complication, and the discussion of the differential diagnosis and management will assist nephrologists in taking care of such patients.

Iatrogenic perforations during colonoscopy.

The incidence of iatrogenic colonic perforations in the medical literature ranges between 0.005% and 0.63% with the majority of patients requiring laparotomy for repair. Colonoscopic perforation may occur due to several mechanisms: blunt trauma to the colonic wall, barotrauma from air insufflation, unintentional endoscopic resection or excessive thermal injury. Our clinical experience includes 1,953 colonoscopies, performed by three surgeons over the course of five years, between 2008 and 2012. During this period of time, four colonic perforations occurred, which corresponds to an incidence of 0.2%. None of these four colonoscopies included therapeutic procedures. Two of the four lesions were diagnosed during the procedure, while the other two were diagnosed after 24 hours. All patients needed a laparotomy for repair. Segmental colonic resections were performed in three cases, followed by a primary anastomosis (one case) or by a terminal colostomy (two cases). In the fourth patient, in whom a generalized peritonitis had developed, the suture of the perforation protected by a lateral colostomy was thought to be a safer solution. Colostomies were removed six months after the first operation. No major post-operative morbidity or mortality were recorded. Age over 75 years, female gender, lower BMI, associated comorbidities and diverticulitis were identified as possible risk factors associated with these injuries.

Atypical abdominal pain: post-traumatic transverse colon stricture.

A driver presented to the emergency department 1 day after an accident driving his excavator with abdominal pain and vomiting. He was admitted to the surgical ward 2 days later, after reattending. A CT scan revealed wall thickening and oedema in the transverse colon. This was supported by a subsequent CT virtual colonoscopy which raised the suspicion of neoplasia. A follow-up colonoscopy was not carried further than the transverse colon due to an indurated, tight stricture. Biopsies from that area showed ulceration and inflammatory changes non-specific for ischaemia, drug-induced changes or inflammatory bowel disease. As a consequence of the subocclusive symptoms and the possibility of a neoplastic diagnosis, a laparoscopic-assisted transverse colectomy was performed. The histology of the resected segment revealed post-traumatic inflammation and fibrosis with no evidence of neoplasia.

Perforation of transverse colon: a catastrophic complication of uterine artery embolization for fibroids.

We report a case of a 43-year-old woman who underwent uterine artery embolization (UAE) for a symptomatic large fibroid uterus and had spontaneous perforation of the transverse colon 3 months after embolisation with near-fatal consequences. We believe this is the first reported case in the literature of this serious complication of UAE. We briefly review the literature on bowel complications after UAE and discuss lessons to be learned regarding patient selection and postprocedure follow-up.

[Colonoscopic perforation: 6 cases in Abidjan, Cote d'Ivoire]. / Plaies coliques per coloscopiques: 6 observations à Abidjan (Côte d'lvoire).

OBJECTIVES: The purpose of this report is to describe diagnostic and therapeutic management of colonoscopic perforation and identify risk factors. MATERIAL AND METHODS: The charts of 6 patients who underwent surgery for colonoscopic perforation between January 2003 and December 2008 were reviewed. Study data included patient age, indication for colonoscopy, operative findings, repair technique, and outcome. RESULTS: All 6 perforations occurred during diagnostic colonoscopy. There were 5 females and 1 male. Endoscopy was performed by an experienced operator in 5 cases and by a training fellow in 1. Preparation of the colon was considered as good in 5 cases. The operator reported procedural problems in only 1 case. Diagnosis of perforation was immediate in 5 cases and delayed for 30 hours in 1. The lesion was located in the sigmoid colon in 5 cases and transverse colon in 1. All patients underwent laparotomy. The repair technique consisted of simple closure in 2 cases, closure with colostomy in one, and bowel resection with anastomosis (n=2). Two deaths occurred intraoperatively in I case and postoperatively in 1. The patient who died intraoperatively had not yet undergone repair when death occurred. In both patients who died, laparotomy was performed late in the presence of co-morbidity. CONCLUSION: Colonic perforation is a rare but severe iatrogenic complication following colonoscopic examination. Early recognition and treatment are essential to optimize outcome. Prevention depends on training to obtain skillful advancement technique.

[Diagnosis of injuries of the colon].

A detailed algorithm of the diagnostic methods of investigation for injuries of the colon is presented. The authors describe the data on the value of certain methods of investigation and shortcomings of the others.

[Surgical therapeutic strategy in vital risk polytrauma with multiple organ injuries, case report]. / Strategia terapeutica chirurgicala in plagile cu risc vital cu leziuni multiple de organ. Prezentare de caz.

The medical interest for trauma pathology is incresing, due to the gravity of the given injuries. The surgical therapeutic strategy used is directly related to the localization and to the type of the trauma. The supplementary lesions and their vital risk also matter. The multidisciplinary team approach is the key to resolve this type of lesions with a good outcome. We recently observed an increasing tendency toward the rise of number and variety of patients with trauma, due to the great diversity of the etiopathogenic agents. The most important factor, during the assessment of a politraumatised patient is to diagnose correctly the functional deficits of vital organs and establish the vital prognosis. It is necessary to adopt the best and fast therapeutic strategy in order to obtain rapid life-saving decisions.

[Magnetic items cause perforation of the bowel]. / Magneter som årsag til tarmperforationer.

Two cases of bowel perforation after ingestion of two or more magnetic foreign bodies by children are described. Both patients had only minor gastrointestinal symptoms when submitted to hospital. In both cases, acute exploratory laparatomy was performed and bowel perforation was found. The literature describes no consensus to surgical strategy in such cases. Based on the present cases, our recommendation is that an acute abdominal x-ray should be made, followed by either an acute endoscopy or acute laparatomy, even if the patient shows no signs of gastrointestinal symptoms.

[Multiple bowel perforations after swallowing magnetic toys]. / Multiple tarmperforationer efter indtagelse af magnetisk legetøj.

Ingestion of small foreign bodies is common in children, and usually does not cause any harm to the gastrointestinal tract. But ingestion of multiple magnets can be hazardous because of the strong attraction of the magnets through the bowel wall, which may lead to bowel wall necrosis and perforation. We describe the case of a 6-year-old autistic boy who swallowed 4 magnets which led to bowel obstruction and 8 small perforations. It is important to be aware of this potential risk if children ingest small magnetic toys.