Intravascular placement and migration of a colonic stent into the inferior mesenteric vein.

Colonic self-expanding metal stents (SEMSs) are commonly used to treat large bowel obstruction due to gastrointestinal malignancy with great success. While mortality is negligible, morbidity from both early and late complications can be significant. Stent perforation, erosion and migration are the most feared complications. We present the first reported case of wire-associated colon perforation with placement and migration of an SEMS into the inferior mesenteric vein (IMV). A man in his early 60s presented with a large bowel obstruction due to a colorectal mass. He underwent endoscopic colonic SEMS placement for colonic decompression. The stent was later found to be within the IMV, requiring a colon resection and retrieval of the stent.

Gastrojejunal Fistula Following Gastrostomy Tube.

Gastrostomy tubes are often placed in patients with poor voluntary intake, oropharyngeal dysphagia, or chronic illness to provide definitive nutritional access. Despite the widespread use of gastrostomy tubes, some patients can experience complications associated with this procedure including gastrocolic-cutaneous fistula and dislodgement of gastrostomy tube. This case discusses an instance of gastrojejunal fistula formation over one year after gastrostomy tube placement likely due to tube dislodgement. Imaging showed gastrostomy tube traversing the posterior wall of the stomach and creating a fistula into the jejunum, with the balloon inflated within the jejunum. Gastrostomy tube was removed and replaced, with gastrostomy tube study showing no extravasation of contrast. Patient is now doing well-tolerating tube feeds at goal.

Laparoscopic management of iatrogenic colon perforation.

BACKGROUND: Iatrogenic colon perforation (ICP) due to colonoscopy is a severe complication and is associated with significant morbidity and mortality. The global estimated incidence of ICP is 0.03% and up to 3% for diagnostic and therapeutic colonoscopies, respectively. Treatment options include endoscopic repair, conservative therapy, and surgery. Treatment decision is based on the time and the setting of the diagnosis, the type, and location of the perforation, the presence of related pathologies, the clinical status and characteristic of the patient, and surgeon's skills. We present our experience in the treatment of ICPs. METHODS: A retrospective review was undertaken of all patients suffering from ICP at Bnai-Zion Medical Center between 1/1/2010 and 1/3/2021. Clinical presentation, therapeutic approach, and short-term outcomes were analyzed. RESULTS: There were 51 cases of ICPs. Fourteen (27%) were diagnosed by the gastroenterologist during the procedure, 2 of whom were treated with endoscopic clips. The rest of the patients (72.5%) were diagnosed in the ER after a CT scan. Forty-three patients (84%) went on to operative management: 5 (11%) operations started with laparotomy-all were conducted in the early study period (until 2013). All other operations (88%) started with a diagnostic laparoscopy, 4 of whom (10%) were converted to laparotomy. Out of the 38 laparoscopic cases 29 (80%) were treated with primary suturing. Seven patients went on to colon resection (5 of whom with primary anastomosis). Six patients required ICU admission-with 1/38 (2%) from the laparoscopic cases, and 5/9 (55%) from the laparotomy cases. A total of 49/51 (96%) patients recovered and were discharged after 5 ± 2 for conservative and laparoscopic cases, and 12 ± 9 for open cases. CONCLUSION: Laparoscopic treatment of ICP is safe and feasible in most cases. Our data supports a laparoscopic attempt at any such scenario.

[Surgical treatment of a patient with tubular colonic duplication complicated by perforation and peritonitis]. / Uspeshnoe lechenie patsienta s tubulyarnoi duplikatsiei tolstoi kishki, oslozhnennoi perforatsiei i peritonitom.

We present successful treatment of a patient with tubular colonic duplication complicated by fecal impaction, perforation and fecal peritonitis. This anomaly is usually detected in children younger 2 years old. In adulthood, this diagnosis is of a precedent-setting nature. If the diagnosis was not confirmed in early childhood, the absence of typical clinical picture, long-term course of disease and difficult interpretation of clinical data complicate subsequent verification of congenital anomaly. Only infectious complications and emergency surgery in adults can make a correct diagnosis.

Colonic Perforation Secondary to COVID-19 Induced Hemorrhagic Colitis in a Patient Heterozygous for Factor V Leiden.

Up to 17.6% of COVID-19 positive patients present with gastrointestinal symptoms and bowel wall abnormalities have been described in up to 31% of COVID-19 positive patients. Here, we present a case of a 40-year-old male diagnosed with COVID-19 complicated by hemorrhagic colitis leading to colonic perforation. CT scan of abdomen and pelvis demonstrated markedly distended descending and sigmoid colon with poorly defined wall, pneumatosis, and pneumoperitoneum. The patient was taken for emergent exploratory laparotomy for extended left hemicolectomy, partial omentectomy, transverse colostomy creation, abdominal washout, repair of small bowel, and appendectomy. The patient was brought back for repeat exploratory laparotomy with ICG perfusion assessment. Patient was found to be heterozygous for factor V Leiden mutation and was never vaccinated for COVID-19. Our case demonstrates a novel use for indocyanine green (ICG) to assess perfusion and underscores the importance of completing a thorough hypercoagulable evaluation following COVID-19 induced thrombotic event.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos).

BACKGROUND AND AIMS: Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes. METHODS: This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes. RESULTS: Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization. CONCLUSIONS: This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study.

INTRODUCTION: With growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal surgery, but their misuse or malfunction encompass a unique risk of postoperative complications. The Digital Device Briefing Tool (DDBT) is a digital cognitive aid developed to enhance safe use of the Ethicon circular stapling device during colorectal resection. The purpose of this study is to evaluate how a digital operative workflow, including DDBT, compared with routine surgical care, affects morbidity and mortality in patients undergoing left-sided colorectal resection with primary stapled colorectal anastomosis for colorectal cancer or benign disease. METHODS AND ANALYSIS: A multicentre, prospective cohort study will be conducted at five certified academic colorectal centres in Germany. It compares a non-digital with a Johnson & Johnson digital solution (Surgical Process Institute Deutschland (SPI))-guided operative workflow in patients undergoing left hemicolectomy, sigmoidectomy, anterior rectal resection and Hartmann reversal procedure. The sample size is set at 528 cases in total, divided into 3 groups (a non-digital and two SPI-guided workflow cohorts, with and without DDBT) in a ratio of 1:1:1, with 176 patients each. The primary endpoint is a composite outcome comprising the overall rate of surgical complications, including death, during hospitalisation and within the first 30 days after colorectal resection. Secondary endpoints include operating time, length of hospital stay and 30-day hospital readmission rate. ETHICS AND DISSEMINATION: This study will be performed in line with the Declaration of Helsinki. The ethics committee of the Charité-University Medicine Berlin, Germany, approved the study (No: 22-0277-EA2/060/22). Study Investigators will obtain written informed consent from each patient before a patient may participate in this study. The study results will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: DRKS00029682.

Development of risk scores for early and late recurrence of colonic diverticular hemorrhage.

OBJECTIVES: Colonic diverticular hemorrhage (CDH) often recurs. Although several studies have suggested that early rebleeding (ER) and late rebleeding (LR) should be treated independently, and several ER/LR risk factors have been identified, an integrated system for risk evaluation is still lacking. This study aimed to develop risk scores for early and late rebleeding of CDH. METHODS: This two-center, retrospective cohort study included 218 patients between 2008 and 2021. ER and LR risk factors were identified using multivariate analysis, and risk scores were developed using the odds ratios of each risk factor. RESULTS: The ER and LR rates were 32.6 and 25.7%, respectively. High heart rate on admission, early endoscopy from the visit, no bowel preparation and no endoscopic treatment were identified as risk factors for ER. On the other hand, LR risk factors included a history of hypertension and diabetes, early endoscopy from the visit, and the use of endoscopic clips. The ER risk score [area under the curve (AUC) = 0.71] was highly sensitive (90.3%) at a cutoff point of 6 and highly specific (98.0%) at a cutoff point of 15. The LR risk score (AUC = 0.70) was highly sensitive (91.1%) at a cutoff point of 2.6 and highly specific (88.3%) at a cutoff point of 7.1. CONCLUSIONS: The ER and LR risk scores were established for the first time, and they can divide CDH patients based on their risk of rebleeding as well as provide clinicians with practical information about the CDH management.

Volvulus of the Transverse Colon.

BACKGROUND: In the United States, the third leading cause of a large bowel obstruction (LBO) is colonic volvulus with torsion occurring most commonly in the sigmoid and the cecum. Transverse colonic volvulus (TCV) is exceedingly rare and specific involvement of the splenic flexure (SFV) is even less common. The present analysis was undertaken to interrogate current trends in presentation, management, and outcomes of TCV. METHODS: In the present report, the world literature was reviewed for the past 90 years (1932 to 2021). We conducted a systematic review to identify all cases of TCV following the PRISMA guidelines. RESULTS: We identified 317 cases of TCV. This included SFV (n = 75), TCV in pediatric patients (n = 63), TCV in pregnant patients (n = 8), and TCV associated with other pathology such as Chilaiditi's syndrome (n = 11). Compared to sigmoid and cecal volvulus, TCV was rare (.94%). It affected slightly more women (54%) than men, commonly in their third decade of life (37.7 ± 23.8). The clinical presentation and diagnostic imaging were consistent with LBO. Compared to sigmoid volvulus, there was a limited role for conservative management and colonoscopic decompression was less effective. The most common operation was segmental resection (25%). Mortality was (20%) commonly because of cardiopulmonary complications and affected more women (63%). The average age of this cohort was 55.7±24.6 years old. DISCUSSION: Our review showed that TCV is an uncommon surgical entity. The diagnosis is likely to be made at laparotomy. Prompt recognition is paramount in preventing ischemia necrosis and perforation. Compared to sigmoid and cecal volvulus, the mortality for TCV remains high.