Laparoscopically assisted bowel surgery in an era of double-balloon enteroscopy: from inside to outside

Background  This report describes an integrated therapeutic method of double-balloon enteroscopy (DBE) and laparoscopically assisted bowel surgery (LABS) for small bowel diseases. Methods  In this study, 34 patients with obscure gastrointestinal bleeding (OGIB, n = 25) and abdominal pain (n = 9) who underwent DBE and LABS were analyzed. Demographics, patient characteristics, diagnostic tests, DBE and LABS findings, surgical results, and long-term outcome were reviewed. Results  All 34 patients underwent DBE without significant complications. Biopsy was performed for 16 patients, ink mark for 25 patients, and temporary homeostasis during DBE for 5 patients. Laparoscopically assisted bowel resection was performed for 27 patients, converted laparotomy for 6 patients, and laparoscopic diagnosis alone for 1 patient. The pathologic diagnoses included gastrointestinal stromal tumor (GIST) for eight patients, primary adenocarcinoma for three patients, lymphoma for three patients, Meckel’s diverticulum for three patients, angiodysplasia for three patients, ulcer for two patients, lipoma for four patients, metastasis for three patients, jejunal diverticulosis for two patients, and tuberculosis ileitis, ileal varix, and lymphangioma for one patient each. No surgical mortalities or significant morbidities were noted. After a follow-up period of 14 ± 3 months, 29 patients were well without disease recurrence. Two patients had symptomatic recurrence, and three patients died of cancerous progression. Conclusions  The combination of DBE and LABS represents an ideal therapeutic method, especially for OGIB caused by small bleeding neoplasms or vascular lesions.     

Chronic rejection in a small bowel transplant with successful revision of the allograft by segmental resection: case report

An 8-year-old girl was admitted for severe electrolyte imbalance and for hyponatremic seizure. In July 2005, at 3 years of age, she underwent isolated small-bowel transplantation of 100 cm ileum from her father. Her own bowel was only 50 cm of proximal jejunum which had been directly connected to the anus due to extended total aganglionosis. The graft was placed into the middle of her remaining bowel, using the splenic artery and vein as feeding vessels with saving of the spleen. Daclizumab induction and tacrolimus monotherapy were applied for immunosuppression. Two acute cellular rejection episodes, E on day 10 and 4 years after transplantation, were successfully treated with OKT-3 and recombinant antithymocyte globulin, respectively. However, because of intermittent bowel dysfunction, she was hospitalized several times for hydration and metabolic care. On admission, her abdomen was moderately distended, and a simple abdominal film showed a fixed dilated loop. Colonoscopy could not pass the narrowed lumen, with stiffness at the anastomosis between the graft and the distal bowel. Endoscopic biopsy at the entrance to the stricture showed a nonspecific inflammatory reaction with fibrosis. Similar findings on a gastrograffin enema suggested chronic rejection (CR). On laparotomy, an irregularly narrowed fibrotic loop was noticed at the distal part of the graft, proximal to the anastomosis. We performed a 20-cm segmental resection with an end-to-end anastomosis. Histopathologic findings showed CR with fibrosis and hyalinization of the entire bowel wall and vessel walls with mild cellular infiltrations. She recovered in 10 days. The graft may have been saved, but intermittent requirement of hydration over the following months suggested progressive graft dysfunction. A case of segmental involvement of CR with subsequent successful graft salvage by partial resection is rare in the literature.     

Hepatic encephalopathy induced by small bowel obstruction in a noncirrhotic child with portal vein thrombosis

A case of hepatic encephalopathy in a noncirrhotic child, who has undergone a previous mesocaval shunt for extrahepatic portal vein thrombosis, is presented. Hepatic encephalopathy developed 5 years after the operation and is believed to have been precipitated by the presence of small bowel obstruction. Exploratory laparotomy and lysis of an adhesion relieved the obstruction and led to the resolution of the encephalopathy.     

Cecal bascule in a child: an unusual cause of postoperative bowel obstruction

Cecal bascule is a rare type of intestinal obstruction that occurs when a mobile cecum folds upward and obstructs the ascending colon. Most often occurring in the elderly, we present the first reported case of cecal bascule in a child. The cecal bascule occurred in a 4-year-old with trisomy 13 syndrome 5 days after a laparoscopic Nissen fundoplication. After a delay in diagnosis and cecal reduction in the operating room, the bascule recurred after 1 year, and the child was treated with a cecostomy tube for both cecopexy and cecal decompression. Cecal bascule should be considered in the differential diagnosis of children with early postoperative bowel obstruction, especially in the developmentally delayed status-post laparoscopic surgery. For the pediatric patient with cecal bascule, we recommend operative management with either cecopexy or resection.     

Intermittent small bowel obstruction by jejunal enteroliths in a patient with a Crohn's disease stricture

Small bowel obstruction is most frequently due to postoperative or inflammatory adhesions, intestinal neoplasms, hernias, or bezoars. Intermittent small bowel obstruction may be secondary to a Crohn's disease stricture or to chronic adhesive peritonitis. Enterolithiasis, usually associated with jejunal diverticulosis or with a Meckel diverticulum, should be considered in patients who have not previously undergone abdominal surgical procedures. X-ray evidence of stones in the abdominal field, outside the common sites, i.e. gallbladder, kidney, bladder, should suggest a diagnosis of enterolithiasis. The authors report a case of multiple enteroliths in a patient with a segmental ileal stricture and ulcerations (diagnosed as Crohn's disease) causing frequent, intermittent occlusive symptoms, treated by segmental ileal resection.     

An unusual case of small bowel obstruction in a child caused by ingestion of water-storing gel beads

Foreign body ingestion occurs most commonly in the pediatric population. Small bowel obstruction is a rare complication that can occur, and surgical intervention is required. We present the first report of a case of an 18-month-old child with a jejunal obstruction caused by ingestion of water-storing gel beads used for botanical arrangements. The child presented with obstipation and nonbloody, nonbilious emesis. Symptoms resolved after a large bead 3 cm in diameter was retrieved via laparoscopic-assisted excision. This case suggests that water-storing gel beads are particularly dangerous foreign bodies and should be kept out of the reach of children.     

Strictureplasty vs resection in small bowel Crohn''s disease: an evaluation of short-term outcomes and recurrence

AIM: To compare postoperative adverse events and recurrence following strictureplasty or bowel resection in patients with small bowel Crohn's disease (CD). METHOD: A literature search was performed to identify studies published between 1980 and 2006 comparing outcomes of CD patients undergoing either strictureplasty or bowel resection. Hazard ratios were calculated from Kaplan-Meier plots of cumulative recurrence data. Quality assessment of the included studies was performed. Random-effect meta-analytical techniques were employed. Sensitivity analysis and assessment of heterogeneity were performed. RESULTS: Seven studies comprising 688 CD patients (strictureplasty n = 311, 45%; resection with or without strictureplasty n = 377, 55%) were included. Patients undergoing strictureplasty alone had a lower risk of developing postoperative complications than those who underwent resection (OR = 0.60, 95% CI: 0.31-1.16) although this was not statistically significant (P = 0.13). Surgical recurrence after strictureplasty was more likely than after resection (OR = 1.36, 95% CI: 0.96-1.93, P = 0.09). Patients who had a resection had a significantly longer recurrence-free survival than those undergoing strictureplasty alone (HR = 1.08, 95% CI: 1.02-1.15, P = 0.01). CONCLUSION: Patients with small bowel CD undergoing strictureplasty alone may have fewer postoperative complications than those undergoing a concomitant bowel resection. However, surgical recurrence maybe higher following strictureplasty alone than with a concomitant small bowel resection. Patients may require appropriate preoperative counselling regarding the pros and cons of each operative technique.     

Chronic rejection after combined liver and small bowel transplantation in a child with chronic intestinal pseudo-obstruction: a case report

An 11-year-old boy with irreversible intestinal failure secondary to chronic intestinal pseudo-obstruction (CIPO) and intestinal failure-associated liver disease (IFALD) underwent a combined en bloc reduced liver and small bowel transplantation. He was discharged home after 9 weeks on full oral intake without requiring intravenous nutritional or fluid supplementation. The first episode of mild acute rejection, which occurred 18 months after transplantation, was successfully treated with steroids. An episode of rotavirus gastroenteritis led to severe exfoliative rejection of the bowel graft, which was resistant to steroid and Infliximab treatment but responded to OKT3. There was associated Epstein-Barr virus viremia with no evidence of posttransplant lymphoproliferative disease. Another episode of moderate to severe acute liver rejection occurred 5 months later. At the same time, multiple biliary strictures were diagnosed and treated. Persistent clinical symptoms of abdominal pain and increased stomal output as well as atrophy of the ileal mucosa on several biopsies, suggested the possibility of chronic rejection (CR). A second combined whole liver and small bowel transplant was performed. The diagnosis of CR was confirmed on histology of the explanted graft. The postoperative course was severely complicated and 71 days after the retransplantation, the boy died because of respiratory failure and multiorgan failure. In summary, intestinal transplantation can be successfully performed in children with CIPO, giving them the opportunity to be free from total parenteral nutrition. As survival following intestinal transplantation continues to improve, the problem of CR has become increasingly important and the only treatment available is retransplantation, which is associated with poor outcomes.     

Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value

Background

Adhesive small bowel obstructions are the most common postoperative causes of hospitalization. Several studies investigated the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in predicting the need for surgery, but there is no consensus.

Methods

A systematic review and meta-analysis was done of studies on diagnostic and therapeutic role of oral WSCA.

Results

WSCA had a sensitivity of 92% and a specificity of 93% in predicting resolution of obstruction without surgery; diagnostic accuracy increased significantly if abdominal X-rays were taken after 8 hours. The administration of oral WSCA reduced the need for surgery (odds ratio .55, P = .003), length of stay (weighted mean difference −2.18 days, P < .00001), and time to resolution (weighted mean difference −28.25 hours, P < .00001). No differences in terms of morbidity or mortality were recorded.

Conclusions

The administration of WSCA is accurate in predicting the need for surgery; the test should be taken after at least 8 hours from administration. WSCA is a proven safe and effective treatment, correlated with a significant reduction in the need for surgery and in the length of hospital stay.     

The creation of a small bowel pouch by tissue expansion —an experimental study in pigs

Summary Tissue expanders (inflatable silicone balloons) were implanted into a bypassed ileum segment of seven pigs and consecutively filled over 8 to 12 weeks. The mean increase of the volume of the small bowel loops was 12 fold with a maximum of 22.8 times the original volume. The final volume 9 weeks after expander removal still presented an increase of 500%. Histologically there was an increase of the thickness of all layers of the bowel wall, especially in the tunica muscularis. The mucosa showed a value above normal in mean in vitro ¹⁴C-resorption capacity per surface area in the reintegrated bowel. Possible clinical applications of the augmentation of the gut by expansion as a rectum substitute after proctocolectomy, as a urinary bladder or stomach substitute, and for the treatment of short bowel syndrome are discussed.

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Die Schaffung einer Dünndarmtasche durch Gewebeexpansion — eine experimentelle Untersuchung am Schwein

Zusammenfassung Gewebeexpander (auffüllbare Silikonballons) wurden bei sieben Schweinen in ein ausgeschaltetes Ileumsegment implantiert und anschließend über 8 bis 12 Wochen aufgefüllt. Die mittlere Volumenzunahme der Dünndarmschlinge lag beim Zwölffachen des Ausgangswertes (maximal 22,8fach). Neun Wochen nach Expanderentfernung und Wiedereinschaltung in die Kontinuität betrug das mittlere Endvolumen immer noch 500%. Histologisch fand sich eine Zunahme der Dicke aller Darmwandschichten, insbesondere der Tunica muscularis. Die mittlere in-vitro-^l4C-Glukoseresorptionsleistung des wiedereingeschalteten Ileums lag über den Kontrollen. Eine mögliche Nutzung der Darmvergrößerung durch Expansion als Mastdarm-, Blasen- oder Magenersatz und zur Behandlung des Kurzdarmsyndroms werden diskutiert.

Presented at the 106th Annual Meeting of the German Society for Surgery, Munich, March 29–April 1, 1989, and at the 24th Congress of the European Society for Surgical Research (ESSR), Brussels, May 29, 1989. Awarded with the Essay Prize of the Surgical Assoc. of Louisiana for 1989/90 at the joint meeting with the Louisiana Chapter of the American College of Surgeons, New Orleans, January 20–21, 1990     

Partial kidney transplantation: a successful kidney transplantation in a child with severe cardiac failure by surgical mass reduction of an adult donor kidney

We report on a trial of partial kidney transplantation performed on a low body weight child with impaired cardiac function due to mitral valve stenosis and uremic cardiomyopathy. The weight of the donated kidney was successfully reduced by one-third using bench surgery in order to obtain sufficient graft perfusion and function. Our procedure is justified when a graft is too large to be adequately perfused in a recipient suffering from cardiac failure.     

Severe gastrointestinal haemorrhage and ischaemic necrosis of the small bowel in a child with 70% full-thickness burns: a case report

Splanchnic ischaemia is an important problem in patients with large burns. This reports the case of an 11-year-old boy with 70% full-thickness TBSA burns who sustained multiple episodes of severe gastrointestinal haemorrhage due to both extensive ischaemic enterocolitis and severe gastric ulceration which required surgical intervention on several occasions. Causative mechanisms of splanchnic ischaemia in this patient including increased mesenteric vascular resistance, abdominal compartment syndrome and enteric feeding, are considered.     

Painful micturition in a small child: an unusual clinical picture of paroxysmal extreme pain disorder

Background

Paroxysmal extreme pain disorder (PEPD) is a rare autosomal dominant pain disorder linked to a mutation in the SCN9A gene, which encodes voltage-gated sodium channel Nav1.7. Abnormal pain sensitivity occurs because of changes in the properties of voltage-gated sodium channels. Different mutations in SCN9A and a spectrum of clinical expressions have been described.

Case-Diagnosis/Treatment

Here we describe a 3-year-old child with a rare clinical picture of PEPD. Extremely painful voiding had been present since the child’s birth. The diagnosis was confirmed by the detection of a heterozygous pathogenic mutation in the SCN9A gene, c.554G>A (p.Arg185His) inherited paternally. The same mutation was also found in the girl’s father, who has occasionally had some pain in his jaw while yawning since childhood. Significant reduction of the pain was achieved with carbamazepine.

Conclusions

The case is interesting because the same mutation as that found in the girl and her father has been found in patients with small fiber sensory neuropathy. These data do not correlate with the clinical picture of our case and her father, but intra- and interfamily phenotypic diversity in symptoms associated with a gain-of-function variant of Na(V)1.7 are also described and may explain our case.     

Primary effusion lymphoma with subsequent development of a small bowel mass in an HIV-seropositive patient: a case report and literature review

Primary effusion lymphoma is a distinct clinicopathologic entity usually characterized by presentation as a lymphomatous body cavity effusion in the absence of a solid tumor mass or dissemination during its clinical course. This lymphoma is typically present in human immunodeficiency virus (HIV)-infected patients and frequently associated with Kaposi's sarcoma-associated herpesvirus/human herpesvirus 8 (KSHV/HHV8) viral sequences. Here we report a rare case of KSHV/HHV8-associated primary effusion lymphoma with secondary involvement of the small bowel as an obstructive tumor mass in an HIV-infected man. The solid small bowel lymphoma demonstrated essentially identical morphology, immunophenotype, KSHV/HHV8 viral status, and immunoglobulin light chain rearrangements to the pleural cavity-based primary effusion lymphoma in the same patient.     

Femoral neck fracture in a child with autosomal-dominant osteopetrosis: failure of spica cast treatment and successful outcome by internal fixation

A case report of a 6-year-old child with autosomal dominant osteopetrosis who sustained a closed femoral neck fracture initially treated with a spica cast with subsequent fracture displacement is presented. Further treatment included closed reduction and operative fixation, first, with a guide pin placement for a cannulated screw insertion that was abandoned because of the hardness of the bone. Three Kirschner wires were then inserted to maintain the closed reduction, followed by immobilization in a spica cast. At the 2-year follow-up, the child was completely free of any complications resulting from her injury and treatment. Radiographs showed no evidence of avascular necrosis in the affected femoral head. Review of the literature supports evidence for early operative fixation of such cases, whether or not the femoral neck fracture is nondisplaced or displaced.