[Comparison of the early analgesic efficacy of three different drugs after anterior cruciate ligament reconstruction].

OBJECTIVE: The pain-relieving effect and safety of compound aminopyrine phenacetin tablets, tramcontin (tramadol hydrochloride sustained-release tablets) and dolantin in the early stage of autologous tendon reconstruction of the anterior cruciate ligament (ACL) of the knee joint were compared. METHODS: Retrospective analysis of postoperative pain and drug analgesia in 45 patients performed by the same group from November 2018 to February 2019. The random area group design was divided into two groups according to whether ACL rupture was combined with meniscal injury, group A was 24 patients with ACL reconstruction of knee joint and group B was 21 patients with ACL fracture combined with meniscus injury. The two groups were divided into three subgroups respectively according to the actual treatment of postoperative analgesic drugs received by the patients, including 4 cases of compound aminopyrine phenacetin tablets, 11 cases of oral tramcontin, 9 cases of intramuscular dolantin combined with phenergan in group A; 3 cases of compound aminopyrine phenacetin tablets, 10 cases of oral tramcontin, and 8 cases of intramuscular dolantin combined with phenergan in group B. When the early postoperative patients complain about pain and actively ask for analgesia. When the patients complained about pain after the operation and actively asked for analgesia, they were randomly given painkillers, tramcontin or dolantin combined with phenergan to relieve pain. Pain visual analogue scale (VAS) was used to evaluate pain relief and observe the occurrence of adverse reactions. RESULTS: There were no significant dif-ferences in gender, age, body mass index, and time of hospital stay between the two groups of patients (P > 0.05). In the patients who used tramcontin and dolantin combined with phenergan to relieve pain judging by VAS score before and 1 h after taking the drug, it was found that the pain situation of the patient was significantly relieved, and the difference before and after taking the drug had statistical significance (P < 0.05). Pairwise comparisons of the three drugs applied in the two groups showed significantly greater pain relief in the dolantin combined with phenergan group than in the remaining two drugs. There was no significant difference (P > 0.05). Dolantin was prone to nausea and vomiting, but the application of phenergan was also used to reduce side effects. In terms of adverse reactions, only 1 case of nausea occurred in the tramcontin group for simple ACL reconstruction, and none of the patients in the other groups showed serious complications and allergic reactions. CONCLUSION: Whether in cruciate ligament reconstruction alone or combined with meniscus molding or suture, compound aminopyrine phenacetin tablets, tramcontin, dolantin combined with phenergan can effectively relieve pain. Among the three drugs, dolantin caused the largest pain relief. At the same time, the combination of phenergan effectively reduced the adverse reactions, such as vomiting and nausea, and increased the drug safety.

Epiploic foramen entrapment in a dog.

OBJECTIVE: To report small intestinal herniation through the epiploic foramen in a dog. ANIMALS: Nine-year-old male castrated Shih Tzu. STUDY DESIGN: Case report. METHODS: The dog presented with an 8-year history of vomiting and regurgitation and acute onset of melena, lethargy, anorexia, anemia, and suspected gastrointestinal mass or obstruction on prereferral imaging. Abnormalities on abdominal radiographs included a large, midcaudal soft tissue structure and cranial displacement and segmental dilation of the small intestine. On abdominal ultrasound, severe gastric dilation, jejunal tortuosity and stacking, and peritoneal effusion were observed. Epiploic herniation of the small intestine and segmental jejunal devitalization was diagnosed on exploratory laparotomy, and the dog underwent hernia reduction, jejunal resection and anastomosis, and nasogastric tube placement. RESULTS: Severe gastric distention and atony persisted 24 h after surgery, despite medical management. The dog was taken to surgery for decompressive gastrotomy and placement of gastrostomy and nasojejunostomy tubes for postoperative decompression and feeding, respectively. Three days after the original surgery, the dog developed a septic abdomen from anastomotic dehiscence and underwent jejunal resection and anastomosis and peritoneal drain placement. Gastric dysmotility gradually resolved with the administration of motility stimulants, removal of gastric residual volume, and nutritional support via nasojejunostomy tube feedings. Three months after discharge, the dog was clinically normal. CONCLUSION: Epiploic foramen entrapment should be considered a type of herniation in dogs. Clinical suspicion should be raised in dogs with unresolving regurgitation and vomiting, visceral displacement, and stacking and distension of small intestine.

Cyclical vomiting syndrome secondary to a Chiari I malformation-a case report.

BACKGROUND: Cyclical vomiting syndrome is a disorder characterised by recurrent episodes of profuse vomiting. There are no cases in the literature on the management of children with presenting with cyclical vomiting syndrome and a Chiari malformation type I. DISCUSSION: We report the case of a 12-year-old child diagnosed with cyclical vomiting syndrome and a Chiari malformation type I. The patient received symptomatic relief following a craniocervical decompression.

The "pouch" of the Douglas's pouch.

Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a peritoneal or mesentery defect, a normal or abnormal compartment of the peritoneal cavity. Hernias occurring in the pelvis cavity are usually classified according to the fascial margins breached and include sciatic, obturator and those through the rectouterin pouch: elytrocele and enterocele. Those hernias are defined by the protrusion of a viscus through the wall of the pelvis due to weakness of the pelvic fascia and/or muscles. Pelvic hernia through the pouch of Douglas (PD) involves the genital tract in female (elytrocele and enterocele). Sometimes described in the literature as Douglas hernia, this type of hernia must be distinguished from the conventional IH. As defined before, the borders to be considered for IH is the peritoneal membrane, which is not a real solid wall but delimitates the peritoneal cavity; and there is no peritoneal defect in elytrocele or enterocele. A PubMed search for IH through a defect in the peritoneal PD revealed only five female cases, making this an extremely rare condition. To our knowledge, we have presented here the only published case in a male. This probably congenital and morphologic anomaly (defect) of pouch of Sir Douglas must be distinguished as the real "Douglas IH". Authors discuss the concept of a new and more detailed classification of IH.

Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent.

BACKGROUND AND STUDY AIMS: Ring complications after a banded Roux-en-Y gastric bypass (RYGB) are usually managed surgically. The aim of this study was to analyze the safety and effectiveness of endoscopic removal of noneroded rings after banded-RYGB, by inducing intragastric erosion of the ring using a self-expandable plastic stent (SEPS). PATIENTS AND METHODS: A total of 41 patients with banded RYGB who had noneroded rings and food intolerance were prospectively enrolled. Patients were treated with endoscopic SEPS placement and ring removal. Data from time of stenting, resolution of symptoms, need for endoscopic dilation, and complications were recorded. RESULTS: Successful ring removal was possible in all patients. In 21 cases, the SEPS induced complete erosion, and in 17 cases the ring was removed a month later because of incomplete erosion at the time of SEPS removal. Nine patients (22.0 %) needed endoscopic dilation after stent removal in order to treat fibrotic strictures. Food tolerance was observed in 32 patients (78.0 %) after the procedure. No patient needed surgery and there were no deaths. CONCLUSIONS: Endoscopic removal of the ring using SEPS appeared to be safe and effective after a banded RYGB.

Self-reducing intrathoracic organo-axial gastric volvulus with paraoesophageal hiatus hernia in a toddler.

A toddler presented with complaints of multiple episodes of vomiting lasting 1 week. He had a history of similar episodes of vomiting several times as an infant. Clinically, he was underweight and had tachypnoea and tachycardia. Laboratory investigations revealed hyponatraemic metabolic acidosis. His chest radiograph revealed an intrathoracic herniation of the stomach with an atypical presence towards the right hemithorax, suggestive of a torsion. A contrast-enhanced CT of the chest and abdomen confirmed an intrathoracic gastric herniation, with an organo-axial gastric volvulus, with no features of strangulation. He underwent an emergency laparotomy and intraoperatively the stomach was found to have reduced to its intra-abdominal position, and the hernia and volvulus had also self-reduced. In view of the multiple symptomatic episodes, an anterior gastropexy was performed to prevent recurrences. The patient recuperated well and has not had any recurrences in the follow-up period. This report adds to the minimalistic literature.

Gastric duplication cyst of a bifid pancreas: cause of recurrent vomiting.

An infant girl first presented with recurrent episodes of non-bilious vomiting, having had five hospitalisations over the following months because of dehydration. Laboratory data showed no inflammatory response, normal pancreatic amylase, but increased lipase levels (between 67 and 425 U/L). Several abdominal ultrasound studies suggested an intestinal duplication cyst on left hypochondrium and, later, a dilated and irregular pancreatic duct. CT showed a bifid tailed pancreas and a change in the cyst's characteristics. A communication with the pancreatic duct was hypothesised, which was confirmed on MR cholangiopancreatography. On laparoscopic surgery, the cyst was confirmed to be at the end of the caudal side of the pancreatic bifid tail, having no communication with the stomach. Cystectomy with partial pancreatectomy was performed with pathological findings confirming a gastric duplication cyst originating from the pancreatic bifid tail. At latest follow-up, 4 months after surgery, she remains asymptomatic.

Internal hernia caused by exposed structures after laparoscopic lateral lymph node dissection for rectal cancer: A case report.

Internal hernias secondary to exposed structures after lateral lymph node dissection (LLND) for rectal cancer are rare. A 53-year-old man who underwent laparoscopic ultra-low anterior resection and bilateral LND presented to our emergency department with sudden-onset severe abdominal pain and vomiting. Computed tomography demonstrated a closed loop obstruction of the intestine in the right lateral pelvic cavity and a significantly dilated small bowel in the abdominal cavity. Laparoscopic surgery revealed small bowel migration into the space between the right ureter and umbilical artery. The herniated bowel was laparoscopically reduced, and the small bowel exhibited no ischemic changes. Meanwhile, the hernial orifice was left unrepaired. The patient was discharged on the seventh postoperative day without complications. An internal hernia caused by exposed structures after lymphadenectomy should be a differential diagnosis in patients who have undergone LLND for rectal cancer and then present with severe abdominal pain and vomiting.

Survival of children following Nissen fundoplication.

BACKGROUND: Analyses of survival after fundoplication in childhood are often restricted to 30-day mortality, or to the neurologically impaired. The objective of this study was to report actuarial survival and variables associated with mortality for all children undergoing fundoplication. METHODS: This was a prospective observational study of fundoplication surgery by one surgeon; the endpoint was survival. Using a Cox proportional hazards model, gastrostomy, neurological status, tracheostomy, congenital cardiac disease, syndromic status, presence of congenital anomaly, other chronic disease, weight z-score at time of surgery, need for revisional fundoplication, use of laparoscopic surgery, gastric drainage procedures, age and sex were assessed for their influence on survival. RESULTS: Two-hundred and thirty children underwent 255 fundoplications at a median age of 3·6 years. Forty-six children (20·0 per cent) died during a median follow-up of 2·8 (range 0·5-11·2) years. Statistical modelling showed gastrostomy (relative risk of death 11·04, P < 0·001), cerebral palsy (relative risk 6·58, P = 0·021) and female sex (relative risk 2·12, P = 0·015) to be associated with reduced survival. Revisional fundoplication was associated with improved survival (relative risk of death 0·37, P = 0·037). Survivors had significantly higher weight z-scores (-1·4 versus - 2·9 for those who died; P = 0·001). The 5-year survival rate after fundoplication for children with cerebral palsy and gastrostomy was 59 per cent. CONCLUSION: Survival of children following fundoplication is related principally to the presence of a gastrostomy and neurological status. Estimates of children's life expectancy should take account of the poorer survival of neurologically impaired children who undergo fundoplication, presumably due to the related co-morbidities that lead to a gastrostomy.

[Endoscopic management of the complications of bariatric surgery. Experience of more than 400 interventions]. / Manejo endoscópico de las complicaciones de la cirugía bariátrica. Experiencia tras más de 400 intervenciones.

BACKGROUND: Many patients who undergo bariatric surgery develop postoperative gastrointestinal complications that can require upper gastrointestinal endoscopy. OBJECTIVE: To prospectively describe the gastrointestinal complications diagnosed by endoscopy after bariatric surgery. PATIENTS AND METHODS: We followed up patients undergoing laparoscopic bariatric surgery between January 1998 and December 2006. The following data were recorded: age, sex, body mass index, comorbidity, type and duration of bariatric surgery, clinical presentation of complications, time of presentation, endoscopic treatment and follow-up. RESULTS: A total of 474 patients underwent surgery (74% women, 26% men) with a mean age of 44±11 years (range, 15-66) and a mean BMI of 47±7 (range, 33-82). The most frequent surgical procedure was Roux-en-Y gastric bypass (90%). We identified 68 complications (14%) requiring upper gastrointestinal endoscopy: anastomotic stenosis (21 cases, 5%), upper gastrointestinal hemorrhage (16 cases, 3.6%), epigastric pain (12 cases, 2.5%), vomiting (7 cases, 1.5%), heartburn (6 cases, 1.3%) and other (6 cases, 1.3%). No prognostic factor for the development of complications requiring postsurgical endoscopy was identified. CONCLUSIONS: Anastomotic stenosis is the most common complication requiring endoscopic treatment after bariatric surgery. Upper gastrointestinal bleeding in the immediate and late postoperative period can be safely and effectively treated with endoscopic techniques.

Tussive syncope in a pug with lung-lobe torsion.

The most common presenting clinical signs of lung-lobe torsion include dyspnea, tachypnea, lethargy, and anorexia. Tussive syncope secondary to lung-lobe torsion has not been documented. This article describes the presentation, diagnosis, management, and outcome of a pug with tussive syncope secondary to lung-lobe torsion.

Superior mesenteric artery syndrome in a 16-year-old with bilious emesis.

Superior mesenteric artery (SMA) syndrome describes vascular compression of the third portion of the duodenum and presents with nausea, postprandial vomiting, and epigastric abdominal pain. The syndrome is rare and may be missed if appropriate radiologic studies are not performed or the clinical presentation is atypical. The clinical contexts in which SMA syndrome develops usually involve rapid weight loss, alterations in spine anatomy, or external increases in abdominal pressure. Diagnostic methods for identifying duodenal obstruction by the SMA include upper gastrointestinal barium contrast studies, computed tomography scans, or angiography of the aorta with either contrast or magnetic resonance angiography. Medical therapy relies upon nutritional rehabilitation with either jejunal tube feedings or parenteral nutrition until weight gain results in relief of the obstruction. In instances where this approach fails, surgical correction is necessary, most often with laparoscopic duodenojejunostomy.

Bilious vomiting in the newborn: 6 years data from a Level III Centre.

BACKGROUND: Bilious vomiting in the newborn is an urgent condition that frequently requires neonatal and paediatric surgical involvement. Investigations involve abdominal X-ray and contrast imaging in most cases. We aimed to describe the prevalence of surgical intervention in this cohort and assess the reliability of contrast imaging in accurate prediction of underlying condition. METHODS: A retrospective audit of data from December 2001 to October 2007 was undertaken. Data on newborns admitted to a level III unit with bilious vomiting was extracted. Infants with bilious aspirates but no vomiting were excluded. RESULTS: Sixty-one infants were admitted to the unit during the period with bilious vomiting. Most of them were out born (83.6%). Mean (and standard deviation) gestation was 38.3 weeks (+/-3.2); weight was 3173.5 grams (+/-717.6); day of admission was 3.68 days (1-28); and length of stay in the unit was 9.96 days (1-48). There were 52 (85.2%) abnormal X-rays and 21 (34.4%) abnormal contrast studies. Sixteen (26.6%) babies had laparotomies of which 6 were malrotations with volvulus, 2 small bowel obstructions, 2 meconium ileus, 2 Hirschsprung's disease, 2 other findings, while 2 were normal. Positive predictive value (number of accurate predictions of surgical findings) for barium contrast studies was 85.7% in this series. CONCLUSION: Bile stained vomiting is a surgical emergency and prompt investigation is the key in the management. Contrast studies still form the backbone of such investigations.

Small bowel intussusception: an unusual presentation of angioedema.

This article presents a case report of a 13-year-old boy who presented to the Emergency Department with abdominal pain and vomiting. He had a known history of recurrent swelling but no previous abdominal episodes. A computed tomography scan revealed small bowel intussusception and he was scheduled for surgery. The patient had a history of multiple episodes of swelling of extremities, face, and genitalia. The Allergy Consult Service was consulted for perioperative management of his angioedema.

Delayed presentation of a congenital duodenal web managed successfully with incision of web.

One of the causes of congenital incomplete duodenal obstruction is the presence of congenital duodenal web with fenestration. This condition requires a high index of suspicion for an early and accurate diagnosis. We present an unusual presentation of duodenal web in a 6-year-old girl who presented with a 3-year history of cyclical and seasonal vomiting and abdominal pain. The diagnosis of congenital duodenal web with fenestration was made on contrast study and endoscopy and was treated surgically by incision of the web.

Digestive Duplication: A rare cause of abdominal mass in an infant.

INTRODUCTION: Intestinal duplications are rare malformations and hail sites are the most common. Today, the diagnosis is made in antenatal because of the performances of antenatal ultrasound. OBSERVATION: This was a 15-month-old male infant received for constant crying, vomiting and increased abdominal volume that had been evolving for two weeks. An abdominal ultrasound was performed and objectified an intraperitoneal cyst formation of 30 x 27 mm, surrounded by a stratified wall and contiguous to a digestive loop. Surgery was performed and confirmed the existence of non-communicating ileal duplication. CONCLUSION: Intestinal duplication is a rare malformation. Ultrasound is often sufficient for diagnosis based on the presence of a characteristic double-walled cystic mass.

Successful endoscopic treatment of a large impacted gallstone in the duodenum using laser lithotripsy, Bouveret's syndrome: A case report.

BACKGROUND: Bouveret´s syndrome is defined as a gastric outlet obstruction after passage of a gallstone through a fistula into the duodenum. Due to its rarity, the diagnosis of Bouveret's syndrome is often delayed and causes a high morbidity and mortality rate. CASE SUMMARY: A 93-year-old female presented with worsening pain in the right upper abdomen and vomiting. A gastroscopy revealed fluid retention caused by a massive obstructive stone in the bulbus. Endoscopic laser lithotripsy of the impacted stone was planned after multidisciplinary consultation. A Dornier Medilas H Solvo lithotripsy 350 µm laser fiber (10 Hz, 2 Joules) was used to disintegrate the stone into smaller pieces. The patient recovered completely. CONCLUSION: A mechanical obstruction due to a gallstone that has entered the gastrointestinal tract is a complication that appears in 0.3%-0.5% of patients who have cholelithiasis. Stones larger than 2 cm can become impacted in the digestive tract, which occurs mostly in the terminal ileum. In approximately 1%-3% of cases, the stones cause obstruction in the duodenum. This phenomenon is called Bouveret's syndrome. As this condition is mostly observed in elderly individuals with multiple comorbidities, treatment by an open surgical approach is unsuitable. Endoscopic removal is the preferred technique. The benefit of using laser lithotripsy is the precise targeting of energy onto the stone with minimal tissue injury. Endoscopic laser lithotripsy is a safe and feasible treatment option for Bouveret's syndrome.