Search

The duodenum is the second most common location for a diverticulum to form after the colon. These duodenal diverticula (DD) are often found incidentally and rarely require intervention. In recent years, surgical management has been restricted to patients with significant complicated sequelae, such as perforation, abscess, or fistula formation. We present the rare case of a perforated broad-based diverticulum in the third portion of the duodenum necessitating surgical correction. The patient presented with persistent symptoms following failure of conservative management and underwent surgical resection. Due to difficulty visualizing the extent of the diverticulum, a novel intraoperative technique of bowel insufflation via nasogastric tube was used allowing for elucidation of the diverticular borders and complete resection. Although DD are common, there exists no consensus on when operative intervention is indicated. Given that significant morbidity and mortality can be associated with symptomatic DD, a systematic way to guide management decisions is needed. After conducting a review of the literature, we propose that the modified Hinchey classification can be used not only to categorize duodenal diverticulitis but to guide treatment choice in cases with unclear risk benefit profiles.

We present a rare case of a focal perforation of the jejunum after a high-speed motor vehicle crash. A 60-year-old restrained rear seat passenger presented with severe abdominal pain. She was hemodynamically stable and underwent the traditional trauma workup. CT scan of the abdomen showed large-volume free intraperitoneal air and L4/L5 compression fractures. Given the peritoneal physical exam finding and free air on CT scan she was taken emergently to the operating room. Operative exploration revealed free intraperitoneal air upon entry into the abdominal cavity as well as murky fluid throughout the mid abdomen. A focal perforation was discovered on the antimesenteric surface of a segment of jejunum. The perforation was repaired primarily in two layers and the abdomen was closed. Postoperative course was uncomplicated. Antibiotics were continued for 4 days. Focal perforation of the small bowel from high-speed blunt trauma is a rare isolated injury. Close attention to physical exam and radiologic findings allows for early diagnosis and treatment of these injuries.

In this study, we aimed to determine factors that cause appendix perforations and to identify the role of physicians and patients in contributing to the cause of these perforations. This study was conducted between April 2010 and May 2015 and included 64 patients with perforated appendicitis. Patients' medical records were examined for factors that might have contributed to perforation, and the roles of patients and physicians in perforation appendicitis were evaluated. The perforation rate of patients with appendicitis was 16.0 per cent. The average duration from symptom onset to hospital admission was 4.4 days (29 patients were admitted to hospital within two days, 35 were admitted later). In total, 38 patients had visited a different hospital before admission. Furthermore, six out of 26 patients who had not visited any other hospital had consumed analgesics. Factors contributing to appendix perforation included misdiagnosis at the patient's initial visit (56.0%), delayed admission to hospital (11.0%), and use of analgesics (9.0%). The cause of perforation was mostly physician-related in children and adults, and patient-related in older adults.

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with nonoperative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

Patients with findings suggestive of a perforated diverticulitis may be subject to colostomy with the attendant morbidity and quality-of-life concerns. Recent literature demonstrates decreased use of laparotomy and colostomy when diagnostic laparoscopy reveals absence of fecal peritonitis. Ten patients presenting with diverticulitis between May 2009 and February 2012 underwent diagnostic laparoscopy. The indication for surgery in nine patients was failure of medical management with or without percutaneous drainage and one had significant pneumoperitoneum at presentation. A comprehensive algorithm was subsequently developed governing medical and surgical management of diverticulitis including the use of diagnostic laparoscopy and laparoscopic peritoneal lavage for patients with Hinchey Stage 3 diverticulitis or abscess formation not amenable to percutaneous drainage. Eight patients underwent diagnostic laparoscopy and laparoscopic peritoneal lavage, whereas two patients underwent diagnostic laparoscopy with conversion to open procedures (low-anterior resection with diverting ileostomy and Hartmann's procedure). Mortality was 0 per cent. Four patients were subsequently readmitted for relapse or recurrence. Two required laparotomy at the time of readmission, ultimately receiving a diagnosis of adenocarcinoma. Two were managed medically and later underwent elective laparoscopic sigmoid colon resection. Diagnostic laparoscopy and laparoscopy peritoneal lavage appear feasible and safe and may be an alternative to more invasive surgery, avoiding laparotomy and colostomy and staging patients for elective laparoscopic resection. Based on our institutional experience, we propose a novel algorithm for the treatment of hospitalized patients with diverticulitis, which incorporates diagnostic laparoscopy and laparoscopic peritoneal lavage while emphasizing patient selection based on clinical examination and imaging.

Nontraumatic bowel perforation has always been a consideration because of associated morbidity and mortality. The aim of this study is to define etiologies, treatment, and outcomes as well as to highlight difficulties in the diagnosis and management of nontraumatic bowel perforation. We conducted a retrospective study of 35 patients with less common nontraumatic bowel perforations hospitalized during a six-year period. The most common cause was ulcerative colitis (34.3%). Abdominal pain was the constant symptom. Physical examination showed signs of peritoneal irritation in 29 cases. The abdominal radiograph failed to reveal abnormal findings in two patients; the abdominal computed tomography scan confirmed the diagnosis in all cases. Twenty patients (57.1%) were operated on within 24 hours of developing perforation, whereas seven patients (20%) were initially misdiagnosed. Most of the perforations were located only in the large intestine (60%). There was only one perforation in 25 patients (71.5%) and two or more perforations in 10 patients (28.5%). Many less common diseases are responsible for the spontaneous perforation of the bowel. Early diagnosis before the patient's general condition deteriorates decreases mortality and morbidity rates. Adequate resuscitation and emergency laparotomy followed by resection with or without anastomosis remains the treatment of choice.

Recently, the risk of colonic perforation has been increasing with the increased frequency of advanced therapeutic endoscopy. However, guidelines for the management of colon perforations after colonoscopy have not been established. This study aimed to evaluate the indications for nonsurgical management. This study was conducted as a case-control study with 22 patients who were managed for colorectal perforations after colonoscopy from June 2004 to July 2009. Colonoscopy was performed in 12 patients (54.4%) for diagnostic purposes and 10 (45.5%) for therapeutic reasons. The most common site of perforation was the sigmoid colon (77.3%). Five patients underwent nonsurgical treatment, and 17 patients received surgical treatment. The duration of hospital stay did not differ significantly between the two groups. Abdominal pain and fever were significantly more commonly encountered in the surgical management group (P = 0.043 and 0.011, respectively). All of the patients who were suitable for nonsurgical treatment were diagnosed within 24 hours and received bowel preparation before the colonoscopy. The nonsurgical treatment of colonic perforation after colonoscopy could be feasible in afebrile patients with less severe abdominal pain. Moreover, cases that were diagnosed within 24 hours and received bowel preparation before colonoscopy were associated with better outcomes.

Synchronous colonic events are rare. Diverticulitis is the most common and lethal cause of colonic perforation. The first case in the literature of a synchronous diverticular perforation is presented. The patient was admitted with peritonitis. An exploratory laparotomy showed cecal and sigmoid perforations. Resection and primary anastomosis with a protective loop ileostomy was performed. Microscopic evaluation confirmed the presence of cecal and sigmoid perforated diverticuli. Diverticular disease is present in up to two-thirds of patients 80 years of age and older. Right-sided free colonic perforation is rare. Resection and primary anastomosis is feasible in the treatment of perforated diverticular disease. In this report, we emphasize the importance of a thorough abdominal exploration at the time of surgery.

Appendicitis within an Amyand's hernia is rare; when it occurs it is often misdiagnosed as a strangulated inguinal hernia. We present a case report of such a case and a review of the literature. It is our recommendation that repair should be undertaken without the use of synthetic mesh through a properitoneal incision that gives access to the peritoneal cavity and the inguinal regions.

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 +/- 2 vs 64.7 +/- 3; P < 0.04) and had a longer length of stay (46.8 +/- 17 vs 11.6 +/- 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.

The ideal management of suspected colon perforation following colonoscopy remains elusive because the incidence is only 0.1 to 2.0 per cent. The patient with obvious perforation deserves immediate exploration, but the patient with equivocal findings poses a diagnostic dilemma. We propose an algorithm based on the results of water-soluble contrast enema that allows for rapid, definitive surgical decision-making. If perforation is confirmed, early operation allows for primary repair without resection or colostomy, or if no perforation is identified, medical management can be undertaken with confidence. This algorithm should ensure that the surgical management of this potentially lethal complication is not unnecessarily delayed.

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.

Other pathology besides appendicitis may be found in patients with right lower quadrant pain. This has led some to advocate diagnostic laparoscopy/laparoscopic appendectomy for all such cases. This policy would substantially raise the costs of care without a priori proof of its efficacy. However, a selective approach on when to proceed with diagnostic laparoscopy will depend on the frequency of finding unexpected, nonappendiceal pathology. To determine this, we reviewed our experience with 202 appendectomies. For females < 50 years old, 33 per cent had normal appendices, 12 per cent had periappendicitis, 47 per cent had acute appendicitis, 12 per cent had perforated appendicitis, and 26 per cent had other nonappendiceal pathology. For males < 50 years old, 13 per cent had normal appendices, 8 per cent had periappendicitis, 67 per cent had acute appendicitis, 15 per cent had perforated appendicitis, and 5 per cent had other pathology. For patients > 50 years old, 7 per cent had normal appendices, 13 per cent had periappendicitis, 33 per cent had acute appendicitis, 60 per cent had perforated appendicitis, and 20 per cent other pathology. Other nonappendiceal pathology was found in 42 per cent of females < 50 with normal appendices, 57 per cent with periappendicitis, and 14 per cent with acute/perforated appendicitis. In males < 50 years, 50 per cent of those with normal appendices, 10 per cent of those with periappendicitis, and 0.7 per cent of those with acute appendicitis had nonappendiceal pathology. In conclusion, women of childbearing age and patients > 50 years old have a significant incidence of nonappendiceal pathology. In this group of patients, a diagnostic laparoscopy appears justifiable to identify the cause of the abdominal pain.

The use of seatbelts has reduced the overall mortality associated with motor vehicle accidents. The use of lap belts has, however, been associated with a constellation of abdominal injuries, which has been termed "the seatbelt syndrome." Previous studies have shown no increase in overall rates of abdominal injury but an increase in intestinal injury with the use of lap belts. Retrospective reviews suggest that the presence of a "seatbelt sign" may further increase the risk of intestinal injury. The purpose of this study is to prospectively evaluate the incidence of abdominal and intestinal injuries in patients with a "seatbelt sign." A consecutive sample of 117 adult motor vehicle accident victims were studied between July 1993 and January 1994. The use of seatbelts and the presence or absence of a seatbelt sign were determined on admission. Patients were evaluated with computed tomography scan of the abdomen, diagnostic peritoneal lavage, serial abdominal examinations, and operative findings. On arrival, 14 of 117 (12%) had an abdominal seatbelt sign. Of these 14, 9 (64%) had abdominal injury, 5 (36%) required operative intervention, and 3 (21%) had small bowel perforation. In contrast, the 103 patients without a seatbelt sign had significantly fewer abdominal injuries (9; 8.7%), laparotomies (4; 3.8%), and small intestine perforations (2; 103; 1.9%). We conclude that the presence of a seatbelt sign is associated with an increased likelihood of abdominal and intestinal injuries and mandates a heightened index of suspicion.

The role of right colectomy in controlling inflammatory conditions and intra-abdominal sepsis remains controversial. The objective of this study was to define the outcome following emergency ileocecal resection for infectious and inflammatory causes. Retrospective analysis of 83 consecutive patients who underwent such treatment in a university-affiliated public hospital over a 7-year period was performed. Preoperative diagnosis was correct in 54 per cent of patients; CT scan (29 patients) did not improve this rate (59%). Free perforation was noted in 16 per cent of patients, and a defined abscess was found in 39 per cent. Common pathologic diagnoses included appendicitis (39%), diverticulitis (23%), cancer (14%), and Crohn's disease (8%). Primary ileocolic anastomosis was performed in 74 patients (89%); 9 patients (11%) required an ileostomy. Mean postoperative stay was 10 days, and there was no mortality. Complications occurred in 15 patients (18%), and 2 required reoperation (2%). Preoperative presence of an abscess was not associated with an increased complication rate (16%), but free perforation was associated with a 31 per cent complication rate. Definitive emergency treatment of infectious and inflammatory disease of the ileocecum can be safely accomplished by resection with primary anastomosis in the majority of patients, obviating the need for ileostomy and a second operation.

Jejunal diverticular (JD) perforation is an uncommon cause of acute abdominal pain in the elderly. From 1971 to 1994 we treated 13 such patients, 9 men and 4 women, with a mean age of 68 years. All patients experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis (range of white blood cell counts, 14,000-21,000). On physical examination, three patients had localized peritonitis, were thought to have appendicitis, and underwent immediate laparotomy and segmental jejunal resection for perforated JD. The remaining 10 patients had abdominal tenderness without peritoneal signs. They were hospitalized and managed expectantly. All experienced worsening signs and symptoms and underwent exploratory laparotomy and resection of the involved jejunal segment 13 hours to 8 days after admission. Although 6 of 13 patients had had JD documented previously, in only 2 patients was perforated JD diagnosed preoperatively. In 8 of 13 patients peritoneal contamination was minimal and was contained within the leaves of the mesentery. Soilage was severe with abscess formation in 5 patients. The longer the delay in operative intervention, the greater the peritoneal soilage. The 3 patients undergoing immediate surgery had minimal contamination. Of the 10 patients initially observed, the mean interval before operation was 74 hours in the 5 patients with severe soilage versus 21 hours in those with minimal contamination. The postoperative course was uneventful in 11 patients. Two patients died. Surgical consultation was delayed (8 days, 12 days) in both patients, who had severe peritoneal contamination and died of sepsis. In conclusion, JD perforation is an uncommon and frequently overlooked cause of acute abdominal pain in elderly patients. Timely operative intervention and resection of the involved jejunum are the keys to a successful outcome. Because the presentation and physical findings of perforated JD can be highly variable, a history of preexisting JD should arouse suspicion for JD perforation as the etiology of acute abdominal pain in the elderly.

The early diagnosis of acute appendicitis before progression to gangrene or abscess formation is recognized as important to minimize morbidity from this common disease process. As our population ages, the challenge for expedient diagnosis and intervention in older age groups will become more significant. Prompted by recent unexpected complications occurring in elderly patients, we reviewed 100 consecutive admissions with the diagnosis of appendicitis to a tertiary Veterans Administration hospital. All patients were males and were arbitrarily divided into three age groups: less than 50, 50-70, and greater than 70 years of age. There were no patients less than 20 years old. Operative findings were classified as simple acute appendicitis, ruptured or perforated appendicitis, appendicitis associated with intra-abdominal abscess, and finally other when the operative diagnosis differed from appendicitis. Of the 37 patients less than 50 years of age, 28 were found to have simple acute appendicitis, making this by far the most common finding in this age group (P < 0.05). Only two of the 18 patients aged 50-70 with appendicitis demonstrated simple acute appendicitis, with the remainder having progressed to perforation or abscess formation (P < 0.05). Patients greater than 70 years of age were significantly more likely than any other age group to manifest appendicitis associated with intra-abdominal abscess (10 of 19, P < 0.05). Eight patients died in this series, six of whom were more than 70 years of age. In most cases, mortality was directly attributable to infectious complications of perforated appendicitis. There were no deaths in the under 50 age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute appendicitis is a common disorder and, ideally, should be diagnosed prior to the onset of gangrene or perforation. Nonetheless, the goal of early diagnosis remains elusive. In a prospective study, 100 appendectomies were performed for suspected acute appendicitis over 19 months. The location of the appendix was noted by the operating surgeon and was listed as anterior intraperitoneal, retrocecal, pericolic gutter, retroileal, pelvic, or retroperitoneal. The latter four positions were regarded as sites in which the appendix was hidden from the anterior parietal peritoneum. Fifteen patients did not have appendicitis. Of the 85 inflamed appendices, 25 were indurated, 19 were suppurative, and 41 were gangrenous or perforated. Patients with gangrene or perforation were more likely to have pain and tenderness at a site other than the right lower quadrant and had a higher mean heart rate on admission than patients with simple appendicitis, but there were no other differences in symptoms, signs, or laboratory findings among the groups. The appendix was in a hidden location in 15 per cent of patients with simple appendicitis or without appendicitis, compared with 68 per cent of patients with gangrenous or perforative appendicitis (P < 0.001). Complications were more frequent, and hospital stays were longer in patients with advanced appendicitis (P < 0.001). Patients and physicians were equally responsible for delays in treatment, but the high incidence of hidden appendices in those with advanced appendicitis resulted in less severe symptoms and signs than expected. Anatomic variations in the location of the appendix are often responsible for delays in the diagnosis of appendicitis.

Whether prophylactic antibiotics should be employed routinely in all patients with presumed appendicitis rather than be administered selectively to those with suspected perforation remains a controversial issue. The outcome of 312 adult patients undergoing appendectomy during periods of selective (I, n = 153) and routine (II, n = 159) antibiotic use were compared. Although the rates of misdiagnosis were comparable (9% vs 13%), significantly more patients with appendicitis in Period II had perforated appendicitis (29 of 139 vs 44 of 139, P less than 0.05). Prophylactic antibiotics were given to 43 (28%) patients in Period I compared to 132 (83%) in Period II (P less than 0.001). This, increased frequency was true for both simple (21% vs 81%, P less than 0.001) and perforated (66% vs 86%, P less than 0.05) appendicitis. A single antibiotic, most frequently a cephalosporin, was used significantly more often in Period II (44% vs 82%, P less than 0.001). There was no significant difference in the methods of wound closure between the two periods. The incidence of infectious complications was similar in patients with simple appendicitis in both periods (8% vs 11%), but it was significantly greater during Period I in patients with perforated appendicitis (45% vs 20%, P less than 0.05). The overall infection rate was similar in both periods (16% vs 22%). Thus, high-risk patients with perforated appendicitis were more likely to receive antibiotics and had a lower infection rate with routine antibiotic use. Furthermore, there was no overall change in the infection rate during this period, despite the use of less toxic, single drug regimens and a greater percentage of perforated appendicitis.

Duodenal perforation resulting from endoscopic sphincterotomy (ES) is a serious complication with a high mortality. Diagnosis is often problematic and the optimum treatment is controversial. Eight proven perforations occurred following 441 ES at University of Colorado Hospital, a rate of 1.8 per cent. Physical and laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86 per cent. All patients were operated on promptly after diagnosis of perforation. Delay in diagnosis of perforation beyond 24 hours in six patients was associated with a high morbidity and two deaths. Analysis of published series confirmed that delay in diagnosis and delay in operation after perforation were associated with a higher mortality rate than early diagnosis with or without operation. We recommend operative intervention in all patients with clinical evidence of perforation following ES.

The management of seven patients with colonoscopy-related perforations is described. This study demonstrates the need for an early laparotomy. A high index of suspicion is required to reach an early diagnosis. Patients with no preexisting medical problems who underwent early surgery recovered with little morbidity. In elderly patients (greater than 75 years), colonoscopic perforation can be fatal. Endoscopy should be performed with special care in such patients.

The records of 102 patients operated on by one of the authors for Crohn's disease during the past 15 years were reviewed. Twenty-seven patients with confined (abscess present) or free perforation were evaluated. The average age was 31 years and the mean duration of disease was four years. Only two of the 27 patients had had previous surgery. All patients presented with a combination of pain, weight loss, and diarrhea. Twenty-three patients were afebrile, 17 had abdominal tenderness, and 6 had an abdominal mass. The average serum albumin was 3.7, the average hematocrit was 35 per cent and the average WBC was 13,000. Radiologic tests were abnormal in 23 of the 27 patients. All patients had been on medical treatment for Crohn's disease, and 19 of 27 were on high-dose steroids at the time of surgery. Ten of the 27 had a bowel prep before surgery and all had preoperative and postoperative antibiotics. All patients were surgically managed by resection and primary anastomosis without proximal diversion or delayed reconstruction. Drains were used in one third of the patients. Intraoperative cultures revealed gram-negative rods with Escherichia coli, enterococcus, and Enterobacter the most common. One enterocutaneous fistula, two superficial wound infections, and one death were recorded. Based on these results, the authors believe that an aggressive one-stage surgical approach for these complicated problems can be recommended. The low morbidity and mortality justifies this approach that results in considerable improvement in lost work time, length of hospital stay, number of readmissions, and significant cost control.

Massive diffuse subcutaneous emphysema resulting from perforation of the proximal jejunum is presented. Seventy-nine reported instances of subcutaneous emphysema of gastrointestinal origin were reviewed. Emphysema originating from the jejunum has not been previously reported. The colon (26 patients) and rectum (16 patients) were the more common sites of perforation. Perforations of the stomach and duodenum were found in 14 patients. The most common site for presentation of the subcutaneous air was the lower abdominal wall and thigh, and the more common causes were carcinoma of the colon and rectum and diverticulitis. The pathogenesis of emphysema in the patient described, as well as in the great majority of other patients, is from intraluminal gas rather than from gas-forming organisms. The air spreads along neurovascular bundles and other anatomic planes and may rapidly reach areas distant from the perforation. The recognition of these phenomena in the diagnosis of gastrointestinal perforation is important.

Widespread acceptance of Limulus Amoebocyte Lysate testing in clinical situations has been elusive. The results obtained in this series of 38 patients seem to support the contention that the amylase-endotoxin complex can be of value in detecting rapidly and with reasonable sensitivity the presence of pancreatic injury and gastrointestinal perforations. A corrected WBC count appears to add diagnostic possibilities to the technique. Despite the promising evidence detailed in this paper, further studies are required to establish the true sensitivity/specificity of the test. Its validity and utility could be assessed rapidly if traumatologists who routinely perform lavage would utilize this method and report their findings.

Necrotizing enterocolitis (NEC) is the single most common surgical emergency of the newborn. Yet the indications for surgery in NEC are still not clearly established. Pneumoperitoneum is an absolute indication for surgery. A paracentesis indicative of intestinal gangrene, prior to intestinal perforation, has also been proposed as an indication for surgery. A prospective study was conducted to answer two questions: 1) How accurate and safe is paracentesis in detecting bowel necrosis in neonates with NEC? and 2) Do infants with NEC who are operated on for a positive paracentesis have a decreased morbidity and mortality over those operated on for pneumoperitoneum? Between July 1980 through June 1984, 39 infants with definite NEC and without pneumoperitoneum underwent a paracentesis because of suspected bowel necrosis. There were no false "positive" taps. There were 34 "positive" taps in 36 infants who were proven to have bowel necrosis, for an accuracy of 94 per cent. There were two false "negative" taps (40%) and three true "negative" taps (60%). There were no complications related to the procedure. During this same time period, 68 infants with NEC were operated upon. The indication for surgery was pneumoperitoneum in 29, a "positive" paracentesis in 34, and other reasons in 5. A comparison was made between those operated upon for pneumoperitoneum and those operated upon for a "positive" paracentesis. There was no significant difference in survival between the two groups (76% versus 71%). The early and late complications and the causes of death in each group were similar. A positive paracentesis is a valid objective indication for operation in infants with NEC.(ABSTRACT TRUNCATED AT 250 WORDS)

Five cases of rectosigmoid injury in homosexual males are presented. Early diagnosis based upon an index of suspicion and supported by careful history and physical examination and roentgenography led to prompt surgical intervention and resulted in low morbidity.