Subcutaneous emphysema, muscular necrosis, and necrotizing fasciitis: an unusual presentation of perforated sigmoid diverticulitis.

With advancing age and the affluent, low-fiber Western diet, the incidence of diverticular disease is increasing. Fortunately, most cases can be managed conservatively without resorting to surgical intervention. Life-threatening complications such as perforation, especially when it is associated with gross fecal contamination, requires urgent aggressive surgical intervention. A 75-year-old man with absolute constipation and pain in the left iliac fossa underwent urgent laparotomy following fluid and antibiotic resuscitation. A posterior perforated sigmoid diverticulitis associated with myofascial necrosis and generalized pelvic emphysema was identified. In cases where perforation occurs posteriorly and the only external manifestation is surgical emphysema, the outcome is generally favorable.

Laparoscopic Hartmann's procedure: a viable option for treatment of acutely perforated diverticultis.

BACKGROUND: A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann's procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy. METHODS: A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann's procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated. RESULTS: Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann's takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis. CONCLUSIONS: Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer?

BACKGROUND: Patients who have undergone laparoscopic gastric bypass have a high risk of developing an internal hernia. Most patients present 9-18 months postoperatively with a weight loss of 75-120 lb and pain out of proportion to the physical findings. Given the risks of internal hernias and the difficulty in radiologic diagnosis, we have developed a single algorithm to avoid the triage complication of a "missed" diagnosis. METHODS: A retrospective review was performed of 1500 bariatric procedures performed from 2001 to 2006, 33% (laparoscopic Roux-en-Y gastric bypass) of which were performed using an antecolic antegastric Roux limb, with all potential defects, including Peterson's, closed. Of these 1500 patients, 75 were evaluated for abdominal pain to rule out an internal hernia. RESULTS: Of the 75 patients, 40 had signs of an internal hernia or abdominal obstruction on computed tomography and underwent laparoscopy. The operative time was 38-45 minutes, and the length of stay was 1.5 days. The remaining 35 patient's computed tomography scans were interpreted as "no evidence" of internal hernia or obstruction. Of the 35 patients, 29 underwent diagnostic laparoscopy and had either an internal hernia or critical adhesions. Thus, 69 patients (92%) underwent diagnostic laparoscopy. In 6 patients, the symptoms resolved completely without any surgical intervention. CONCLUSION: At our institution, patients who undergo laparoscopic Roux-en-Y gastric bypass with a weight loss of 75-120 lb undergo computed tomography with contrast to rule out other potential nonoperative causes. Also, unless clinically stable or the patient has complete resolution of their pain, they then undergo laparoscopy for evaluation.

Fate of retained capsule: a pathognomonic for surgery.

Since its introduction in 2001, Wireless Video Capsule enteroscopy is gaining acceptance due to its high diagnostic potential and minimal risk. In some centers, it offers an alternative approach to visualize the small intestine and to evaluate patients with suspected small bowel disease. We present a series of known complications of this procedure and call for a more proactive role in the management of retained capsule.

A 10-Year Review of Surgical Management of Complicated Peptic Ulcer Disease From a Single Center: Is Laparoscopic Approach the Future?

INTRODUCTION: The discovery of Helicobacter pylori (H. pylori) as the culprit in peptic ulcer disease (PUD) has revolutionized its management. Despite the presence of effective drug treatments and an increased understanding of its etiology, the percentage of patients who require emergent surgery for complicated disease remains constant at 7% of hospitalized patients. This study aims at reviewing the incidence of complicated PUD and analyze changes in surgical management. PATIENTS AND METHODS: From January 2002 to September 2012, records of all patients with a clinical or radiologic diagnosis of perforated PUD were evaluated. Short-term and long-term results were assessed with regard to type of surgical intervention. The primary end point was adverse events. Other end points were length of hospital stay, complications, and deaths. RESULTS: Included were 400 patients with a median age of 56 years (range, 17 to 89 y). Of these, males made up 70% (n=280), were older and had more comorbidities. Majority of perforations were located in the prepyloric region (80%) and duodenal bulb (20%). Nonsteroidal anti-inflammatory drug alone was involved in 50% of cases and in combination with H. pylori in 84%. H. pylori alone occurred in 40% of cases.Laparoscopic treatment was performed in 48 patients (12%) who remained hemodynamically stable. In the remaining 88% of patients, open approach was used. Simple closure with omentoplasty was performed in 98% and in 2%; definitive anti ulcer procedure was performed. Major complications occurred in 6% with an overall 30-day mortality rate of 2%. Most postoperative morbidity occurred after open approach. One patient who had laparoscopic repair died of other causes unrelated to the gastroduodenal perforation. Among the laparoscopic group, mean hospital stay was 4 days (range, 3 to 7 d), compared with 6 days (5 to 14 d) after open approach. CONCLUSIONS: Although the incidence of PUD is decreasing, it appears that among our patients, the incidence of complication is rising. Laparoscopic approach offers an alternative treatment with less pain, shorter hospital stay, and improved complications rate.

Does rectal washout during anterior resection prevent local tumor recurrence?

PURPOSE: Colorectal cancer is one of the leading causes of cancer deaths in the industrialized nations. Left-sided tumors, especially rectal, rectosigmoid, and sigmoid, account for more than half of these tumors. Among many colorectal surgeons, the practice of rectal washout with cytocidal agents before anastomosis is common. It is widely believed that this practice prevents implantation of free malignant cells. It is unclear whether this translates into a reduction in the incidence of local recurrence. This study was designed to evaluate the effectiveness of cytocidal rectal washout in reducing the incidence of local recurrence. METHODS: Case notes and histology reports of all patients who underwent curative anterior resection for adenocarcinoma of the rectum and rectosigmoid between 1992 and 1994 were reviewed. A total of 141 patients were deemed suitable for the study. Of these, 90 patients underwent rectal washout using cetrimide before anastomosis. Fifty-one patients did not have rectal washout before anastomosis. Local recurrences between the two groups were compared. RESULTS: The two study groups were identical in all respects. Overall, the local recurrence rate for all comers was 5 percent (n = 7). Among the washout group, the local recurrence rate was 4.4 percent (n = 4) compared with 5.9 percent (n = 3) among the no washout group. CONCLUSIONS: Because of the size of the study, we were unable to demonstrate the benefit or lack thereof of cytocidal agents in reducing local recurrence.