Search

BACKGROUND : There have been cases reporting anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) and associated serious gastrointestinal (GI) adverse drug reactions (gastrointestinal obstruction, perforation, and ulceration). These adverse drug reactions are not in the drug package inserts, and the drug relationships are not proven in the literature. AIM: We aimed to examine the potential association between GI obstruction, perforation, and ulceration, and ALK-TKIs by data mining of the US FDA Adverse Event Reporting System (FAERS). METHOD : We conducted a disproportionality analysis of GI obstruction, perforation, and ulceration by estimating the reporting odds ratios (ROR) and the information component (IC) with 95% confidence intervals. RESULTS : A total of 279 cases of ALK-TKI-associated GI obstruction, perforation, and ulceration from January 1, 2011, to December 31, 2020, were identified. GI obstruction, perforation, and ulceration cause 16% of cases of death. A significantly increased reporting rate for GI obstruction [ROR 1.77 (1.45-2.15); IC 0.82 (0.53-2.03)] and perforation [ROR 1.61 (1.28-2.02); IC 0.68 (0.35-1.92)] was observed for ALK-TKIs as a drug class. The signal of GI ulceration was detected only in crizotinib [ROR 1.23 (1.01-1.50); IC 0.29 (0.01-1.51)]. A statistically significant ROR and IC emerged for the site of the esophagus. CONCLUSION : Overall, the pharmacovigilance study of the FAERS indicates slightly increased reporting of GI obstruction and perforation, which may cause severe or even fatal outcomes among ALK-TKIs users.

To assess whether either duration and magnitude of ductal shunt or medical treatment for patent ductus arteriosus (PDA) are related to spontaneous intestinal perforation (SIP).Clinical charts of infants29 weeks' gestation born from 2006 to 2018 were reviewed. Echocardiographic examinations were evaluated according to McNamara and Sehgal's staging system.A higher percentage of patients with SIP had a hemodynamically significant PDA (HSPDA) and was treated with either NSAIDs or paracetamol (79% vs 53% and 81% vs 54%, respectively). Among non-treated patients, we found a 1.32 increase in the odds of SIP per day of persistence of HSPDA. In the cohort of patients treated despite the absence of HSPDA, we found a 2.35 increase in the odds of SIP per dose of drug administered.Both treating a non-HSPDA and leaving a HSPDA to its natural history seem to be associated with SIP.

Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. To compare the mortality of primary peritoneal drainage versus primary peritoneal laparotomy as initial surgical intervention for NEC. All data were extracted from PubMed, Embase, and the Cochrane Library. Studies published up to December 2021. Patients with NEC. Studies centered on primary peritoneal drainage and primary peritoneal laparotomy as the initial surgical treatment. Mortality outcomes were available for both interventions. Randomized controlled trials, retrospective cohort studies, and case series in peer-reviewed journals. Language limited to English. Odds ratio (OR) with 95% confidence intervals (CIs) was used to evaluate mortality outcome. Subgroup analyses and linear regression were performed to ascertain the association between mortality pre-specified factors. Data of 1062 patients received peritoneal drainage and 2185 patients received peritoneal laparotomy from five case series, five retrospective cohort studies, and three randomized controlled trials. Peritoneal drainage caused similar mortality (OR 1.49, 95% CI 0.99-2.26) compared with peritoneal laparotomy as initial surgical management for NEC infants. The subgroup analysis of study design, sample size, birth weight, and sex showed similar findings, but inconsistent results were found for country (USA: 1.47, 95% CI 0.90-2.41; Canada: 2.53, 95% CI 0.30-21.48; Australia: 10.29, 95% CI 1.03-102.75; Turkey: 0.09, 95% CI 0.01-0.63) and gestational age (age mean difference 3: 1.23, 95% CI 0.72-2.11; age mean difference ≥ 3: 2.29, 95% CI 1.04-5.05). No statistically significance was found for the linear regression between mortality and sample size (P = 0.842), gestational age (P = 0.287), birth weight (P = 0.257), sex (P = 0.6). Small sample size, high heterogeneity, NEC, and spontaneous intestinal perforation (SIP) had to be analyzed together, lack of selection criteria for the future selection of an intervention, and no clear, standardized procedures. Conclusion: There was no significant difference in mortality between peritoneal drainage and laparotomy as initial surgical intervention. The results suggest that either intervention could be used in selected patients. What is Known: • Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. What is New: • No significant difference of mortality between peritoneal drainage and laparotomy as initial surgical intervention.

Mesenteric lymphatic malformations result from abnormal proliferation of disorganized mesenteric lymphatic channels. Sclerotherapy is often preferred over surgery as it is less invasive and has lower post-procedure morbidity. Sclerotherapy has been described as durable and effective with a low complication rate. We describe a serious complication from sclerotherapy of a lymphatic malformation extending from the mesentery through the bowel wall, highlighting the spectrum of this pathology and the need for multidisciplinary management of complex cases.

Ingestion of magnetic foreign bodies in pediatric settings has become more common in the last years due to the marketing of various toys containing small magnetic parts. Most magnets, especially if a single element is ingested, usually pass through the gastrointestinal tract without complications. However, ingestion of multiple magnets or magnets and small metallic components may require a prompt intervention due to the risk of attraction across bowel layers, leading to pressure necrosis, perforation, and even death. Routinely, serial radiological evaluations are needed to follow the progression of magnets through the intestine, while the role of small bowel ultrasound is regarded as marginal. Here we report a case of a 5-years old boy who ingested 8 magnets and in which small bowel ultrasound was pivotal for the correct assessment of magnets location to correct address the surgical approach.

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.

COVID-19 pandemic is one of the most devastating worldwide crises in recent years. During this pandemic, people have been exposed to products that have not been proven to be safe and effective against COVID-19. We present an adult chronic consumer of chlorine dioxide, in which a fatal outcome is described. This case demonstrates that for people searching products to protect themselves from COVID-19, unregulated access to industrial disinfectants represents a dangerous alternative. To date, there is no scientific evidence to uphold the use of chlorine dioxide or chlorine derivatives as preventive or therapeutic agents against COVID-19. Researchers and general population must take into consideration the fatal possible consequences of not following communications and warnings from health authorities and government institutions.

Typhoid perforation is still prevalent in children in developing countries. Hence, the need for a review of the morbidity and mortality from typhoid perforation in children from poor countries. We review the clinical features, morbidity, and mortality of typhoid perforation in children aged ≤ 5 years in a developing country. A retrospective 10-year study of children aged ≤ 5 years with typhoid perforation in two tertiary hospitals in northeastern Nigeria. Data regarding clinical presentation, investigations, intra-operative findings, treatment, and outcome were reviewed. Out of 221 children aged ≤ 15 years with typhoid perforation, 45 (20.4%) were aged ≤ 5 years. Fever and abdominal distension were present in all 45 (100.0%), followed by abdominal pain 33 (73.3%), constipation 19 (42.2%), diarrhoea and vomiting 18 (40.0%) and vomiting 13 (28.8%). All patients presented in second week of infection. Plain abdominal radiograph showed pneumoperitoneum suggestive of bowel perforation in 39 (86.7%) patients. Forty-one (91.1%) patients had ileal perforations with various severities of peritonitis. Out of which, 30 (73.2%) were single and 11 (26.8%) were multiple perforations. Two (4.4%) patients had peritonitis without bowel perforation, while 2 (4.4%) others had caecal, gall bladder perforations, respectively. Serious post-operative wound complications occurred in patients with severe peritonitis, multiple perforations, prolonged pre-operative resuscitation, and operation beyond 2 h. Overall, mortality rate was about 26.7% mainly in patients who had multiple perforations, severe peritonitis, prolonged pre-operative resuscitation, and operation time more than 2 h. Multiple perforations, severe peritonitis, and operation time more than 2 h are poor post-operative factors that were associated with poor post-operative outcome in our patients.

Colorectal injuries caused by high-pressure air compressors are rare and reported especially among industrial workers. They may appear because of intended or accidental injury. In the present paper, we report a case of colorectal injuries due to air insufflation from a distance towards the anus with the clothes on, as a means of a practical joke. The patient presented one day after the trauma to the Emergency Department with complaints of severe abdominal pain and vomiting. On examination, he had signs of peritonitis. A computed tomography (CT) scan did not show any perforation. Emergency laparotomy was performed with the suspicion of pneumatic pressure-induced lesions. A total resection of the colon was made with enterostomy. The pathologic examination of the resected piece revealed multiple gangrenous areas without perforation associated to signs of peritonitis. Follow up was uneventful. A reversal of the enterostomy was scheduled.

Undifferentiated pleomorphic sarcoma (UPS) in the gastrointestinal tract is rare. According to the diagnostic criteria after the World Health Organization 2013 reclassification, there has been only one case of UPS with perforation of the gastrointestinal tract. A 71-year-old man who was undergoing outpatient chemotherapy at the department of respiratory medicine of our hospital for lung cancer and brain metastasis, was admitted to our hospital with sudden high fever and abdominal pain. A computed tomography scan showed free air in the abdominal cavity with thickening of part of the jejunal wall. We suspected jejunal metastasis of lung cancer and performed emergency surgery for acute peritonitis due to gastrointestinal perforation in the same area. A Bormann type 2 tumour was found in the jejunum with perforation. The histopathological diagnosis was UPS. Ten months have passed since the surgery, and there has been no recurrence of UPS and no significant change in lung cancer. Primary UPS of the gastrointestinal tract is rare, and cases with perforation are extremely rare. Currently, ten months have passed since the surgery, and no recurrence has been observed. We encountered a case of UPS in which it was difficult to distinguish metastasis from lung cancer to the jejunum, and the emergency surgery gave us the chance to confirm the definitive diagnosis and save the patient's life.

No abstract available

Background Congenital diaphragmatic defects are rare, with most cases presenting in childhood. Diagnosis in adulthood is usually incidental or when symptoms develop. We present a case of a strangulated Bochdalek hernia complicated by possible tension pneumothorax and iatrogenic bowel injury in a healthy young male. Case presentation A 23-year-old Chinese man initially presented with complaints of mild back pain and was discharged with symptomatic treatment. He presented again 3 days later, with dyspnea and left upper back pain and was haemodynamically unstable and hypoxic. A chest x-ray was reported as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax. Needle decompression resulted in feculent fluid being aspirated with no resolution of symptoms. The patient required an immediate transfer to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and left tension pneumothorax, with accidental puncture of the herniated bowel. He underwent an emergent laparotomy with requirements for rapid lung isolation and continued aggressive resuscitation. Conclusions Patients with congenital diaphragmatic hernias may present in adulthood, either incidentally or emergently. In the well adult patient with good reserves, these initial symptoms may be mild, and may be symptomatically treated with no further workup. However, patients may deteriorate rapidly once their compensatory mechanisms are exhausted. This is the first reported case of a patient with diaphragmatic rupture and bowel herniation, complicated by iatrogenic tension pneumothorax. This rare case illustrates the speed at which a diaphragmatic rupture may progress, possible pitfalls and offers insights on how a misdiagnosis may be avoided.

Purpose Perforation and obstruction in colorectal cancer are poor prognostic factors. We aimed to evaluate the oncological outcomes of patients with colon cancer presenting with perforation or obstruction. Methods A total of 260 patients underwent surgery for colon cancer between January 2015 and December 2017. Among them, 54 patients who underwent emergency surgery for perforated (n = 32) or obstructive (n = 22) colon cancer were included. Results The perforation (PG, n = 32) and obstruction groups (OG, n = 22) did not differ significantly in age (p = 0.486), sex (p = 0.821), tumor stage (p = 0.221), tumor location (p = 0.895), histologic grade (p = 0.173), or 3-year overall survival rate (55.6% vs. 50.0%, p = 0.784). However, the PG had a higher postoperative complication rate (44% vs. 17%, p = 0.025), longer intensive care unit stay (4.8 days vs. 0.8 days, p = 0.047), and lower 3-year recurrence-free survival (42.4% vs. 78.8%, p = 0.025) than the OG. In the multivariate analysis, perforation was significantly increased risk of recurrence (hazard ratio = 3.67, 95% confidence interval: 1.049–12.839, p = 0.042). Conclusion Patients with colon cancer initially presenting with perforation had poorer recurrence-free survival, higher postoperative complication rates, and longer ICU stays than those who had obstruction.

BACKGROUND: Neonates are at risk of gastrointestinal emergencies including necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP). Identifying biomarkers to aid in diagnosis is imperative. We hypothesized that circulating intestinal-specific protein concentrations would distinguish infants with intestinal injury from controls. AIMS: To identify serum concentrations of intestinal-specific protein(s) in infants with intestinal injury and controls. METHODS: We used an in-silico approach to identify intestinal-specific proteins. We collected serum from control infants and infants with NEC or SIP, and measured protein concentrations using ELISA. If baseline concentrations were near the detection limit in initial control assays, we proceeded to assess concentrations in a larger cohort of controls and infants with injury. Control infants were frequency matched to infants with injury and compared with non-parametric and mixed-effects models analysis. RESULTS: We evaluated four proteins with high intestinal expression: Galectin-4 (Gal-4), S100G, Trefoil Factor-3, and alanyl aminopeptidase. Only Gal-4 demonstrated consistent results near the lower limit of quantification in controls and was studied in the larger cohorts. Gal-4 concentration was low in 111 control infants (median 0.012 ng/ml). By contrast, Gal-4 was significantly increased at diagnosis in infants with surgical NEC and SIP (n=14, p≤0.001 and n=8, p=0.031) compared to matched controls, but not in infants with medical NEC (n=32, p=0.10). CONCLUSIONS: Of the intestinal-specific proteins evaluated, circulating Gal-4 concentrations were at the assay detection limit in control infants. Gal-4 concentrations were significantly elevated in infants with surgical NEC or SIP, suggesting that Gal-4 may serve as a biomarker for neonatal intestinal injury.

OBJECTIVES To assess the prevalence and outcomes of spontaneous intestinal perforation (SIP) in very low birth weight infants. STUDY DESIGN This cross-sectional study utilized the National Inpatient Sample dataset for the years 2002-2017. All premature infants with birth weight (BW)

The perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition. This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases). All patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II–V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0–I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1 year after surgery. Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.

The aim was to assess the results of primary anastomosis (PA) compared to enterostomy (ES) in infants with spontaneous intestinal perforation (SIP) and a weight below 1000 g. Between 2014 and 2016, enterostomy was routinely carried out on extremely low birth weight (ELBW) patients with SIP. From 2016 until 2019, all patients underwent anastomosis without stoma formation. We compared outcome and complications in both groups. Forty-two patients with a median gestational age of 24.3 weeks and a birth weight of 640 g with SIP were included. Thirty patients underwent PA; ES was performed in 12 patients. Overall in-hospital mortality was 11.9% (PA: 13.3%, ES: 8.3%). Reoperations due to complications became necessary in 10/30 patients with PA and 4/12 patients with ES. Length of stay was 110.5 days in the PA group and 124 days in the ES group. Median weight at discharge was higher in the PA group (PA: 2258 g, ES: 1880 g, p = .036).Conclusion: Primary anastomosis is a feasible treatment option for SIP in infants What is Known:• Enterostomy (ES) and primary anastomosis (PA) are feasible treatment options in preterm infants with spontaneous intestinal perforation (SIP).• Stomal complications or failure to thrive due to poor food utilization can pose significant problems. What is New:• Primary anastomosis in case of SIP is equal to enterostomy in terms of mortality and revision rate; however, length of stay and weight gain can be presumably positively influenced.• Primary anastomosis is a valid treatment option even for patients weighing less than 1000 g.

Necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI) are major diseases that cause gastrointestinal disorders in extremely low-birth-weight infants (ELBWIs). We conducted a review to compare the postoperative outcomes of ELBWIs with these diseases in our neonatal intensive-care unit. A retrospective chart review of ELBWIs surgically treated for NEC (n = 31), FIP (n = 35), and MRI (n = 16) in 2001–2018 was undertaken. This period was divided into early (2001–2005), middle (2006–2010), and late (2011–2018) periods. Data were analyzed with the Cochran-Armitage test. Statistical significance was defined as p

Background Ingestion of dental instruments is rare during dental surgery but can result in serious complications. Here we describe a case in which an endodontic hand file was accidentally misplaced in situ during endodontic (root canal) therapy. Plain radiographs were used to identify its location, and serial imaging was used to monitor passage of the endodontic file through the gastrointestinal tract, and it ultimately passed without intervention. We conclude by describing methods for surveillance and management of ingested dental instruments. Case report A 62-year-old Caucasian male presented to the Emergency Department approximately 2 hours after suspected ingestion or inhalation of an endodontic hand file. He had experienced two episodes of excessive coughing and dyspnea while undergoing endodontic therapy, and was promptly referred by his dentist for further investigation. On admission, plain abdominal radiographs confirmed the position of the file in the duodenum, and serial radiographs were used to monitor its transition and clearance through the gastrointestinal tract. During this time, the patient did not demonstrate any clinical signs of bowel perforation, nor was there any radiographic evidence of pneumoperitonium. The patient was discharged after a final radiograph confirmed the absence of the foreign body. Conclusion Ingestion and inhalation of dental instruments can be life threatening and should be managed cautiously, with early input from general surgeons, gastroenterologists, or respiratory physicians for possible endoscopic retrieval, emergent laparotomy, or surgical intervention. Imaging studies are useful for discerning the position of the foreign body and to determine whether retrieval is possible, and the management will ultimately depend on the position and characteristics of the foreign body, as well as risk factors from the patient which may increase the likelihood of perforation, obstruction, or impaction.

Purpose The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. Methods Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. Results Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p p p p p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p p = .044). Conclusions In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

Background The aim of this study was to evaluate the experience of surgery in IBD patients during the COVID pandemic. Methods A survey was distributed among patients undergoing IBD-related surgeries from January 2020 to March 2020 via an online platform. The response was submitted anonymously. Results A total of 78 patients responded to the survey. COVID-19 testing was conducted in 60 (76.9%) patients, and they were all tested negative. Emergent surgery was performed in 12 (15.4%) patients and postponed surgery in 18 (23.1%) patients. The surgical indications were mainly bowel obstruction (N = 21, 26.9%) and perianal abscess (N = 18, 23.1%). Postoperative complications were noted in 5.1% of cases, but no re-operation was required. Due to the ongoing COVID pandemic, 58 (74.4%) patients reported various levels of concern and anxiety for surgery. Conclusions Common surgical indications were for bowel obstruction and perianal abscess. Surgery can be postponed, but disease progression should be monitored closely and surgically intervened as needed. Most patients expressed anxiety resulting from the pandemic. The overall experience was satisfactory.

Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation.A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Purpose The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann’s procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence. Methods A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs). Results From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients. Conclusion Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann’s procedure in selected patients with Hinchey III or IV diverticulitis.

Background Typhoid fever incidence and complications, including intestinal perforation, have declined significantly in high-income countries, with mortality rates Methods We searched EMBASE, PubMed, Medline, and Cochrane databases for studies reporting mortality rates due to typhoid intestinal perforation in children, under 18 years old, in sub-Saharan Africa published from January 1995 through June 2019. Results Twenty-four papers from six countries were included. Reported mortality rates ranged from 4.6–75%, with 16 of the 24 studies between 11 and 30%. Thirteen papers included postoperative morbidity rates, ranging from 16–100%. The most documented complications included surgical site infections, intra-abdominal abscesses, and enterocutaneous fistulas. High mortality rates can be attributed to late presentation to tertiary centers, sepsis and electrolyte abnormalities requiring preoperative resuscitation, prolonged perforation-to-surgery interval, and lack of access to critical care or an intensive care unit postoperatively. Conclusions Current estimates of mortality related to typhoid intestinal perforation among children in sub-Saharan Africa remain unacceptably high. Prevention of typhoid fever is essential to reduce mortality, with the ultimate goal of a comprehensive approach that utilizes vaccination, improvements in water, sanitation, and hygiene, and greater access to surgical care.

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial. Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated. A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16–85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p

Surgical strategies for acute perforated diverticulitis with generalised peritonitis remain controversial. This study aimed to meta-analyse trials comparing primary resection and anastomosis (PRA) to Hartmann’s procedure (HP) for Hinchey III/IV diverticulitis. A systematic literature search was conducted to identify observational studies and randomised control trials (RCTs) of patients with Hinchey III/IV diverticulitis undergoing sigmoidectomy that compared PRA to HP. The methodological quality of the included studies was assessed systematically (Newcastle–Ottawa, Jadad and Cochrane risk of bias scores) and a meta-analysis was performed. After removal of duplicates, 12 studies including 4 RCTs were identified. The analysis included 918 patients, of whom 367 (39.98%) underwent PRA. Both the initial stoma rate (risk ratio [RR] persistent stoma 0.43, 95% confidence interval [CI] 0.26, 0.71, p = 0.001; I2 = 99%, p

Gastrointestinal tract (GI) perforations can occur due to various causes such as trauma, iatrogenic factor, infectious condition, peptic ulcer, inflammatory disease, or a neoplasm. Because GI perforations represent an emergency and life-threatening condition, prompt diagnosis and surgical treatment are required in most cases. However, according to the underlying causes of GI perforations, additional treatment strategies may be needed. Adjuvant chemotherapy or immunotherapy may be required in various GI neoplasms such as adenocarcinoma, lymphoma or gastrointestinal stromal tumor. Inflammatory bowel disease is a chronic disease repeating cycle of intermittent, thus appropriate medical treatment and periodic follow-up are also required. Moreover, vascular intervention may have a role in some cases of mesenteric ischemia associated with mesenteric artery occlusion. Recently, computed tomography (CT) has been the first choice for patients with suspected GI perforations, because CT plays an important role in the accurate assessment of the perforation site, the pathology causing the perforation and the ensuing complications. This review will illustrate characteristic CT findings that differentiate underlying pathologies causing GI perforations to help clinicians decision-making regarding an optimal treatment plan.

We present a case of a 58-year-old female with anti-PD-1 immunotherapy-related small bowel perforation. The patient was on long-term therapy with nivolumab for metastatic non-small cell lung cancer. She presented to the emergency department with acute abdominal pain, in which the CT revealed a short segment of dilated distal ileum proximal to a very short segment of bowel with mural thickening and a perforation near the transition point. The patient underwent subsequent laparotomy, which confirmed the CT findings and revealed a short-segment of friable and dilated loop of distal ileum proximal to a stricture and a small perforation at the transition point. Pathological analysis revealed mural thickening at the site of stricture without evidence of malignancy with focal necrosis and perforation at the transition point. Bowel perforation in the setting of anti-PD-1 immunotherapy is rare, but life-threatening complication, and should be considered in oncology patients on immunotherapy presenting with severe abdominal pain.

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Background Whether surgery can improve the prognosis of patients with primary pediatric gastrointestinal lymphoma (PPGL) who experienced bowel perforation remains controversial. This study aimed to evaluate the prognosis of such patients. Methods Nine patients pathologically diagnosed with PPGL who experienced perforation at our center between January 2010 and December 2020 were enrolled and divided into two groups: those with perforation during (n = 4) and before (n = 5) chemotherapy. Their medical records were reviewed, and long-term follow-up was conducted by telephone in February 2021. Results All patients with perforation during chemotherapy were diagnosed with PPGL in the outpatient department. The mean time from outpatient visit to chemotherapy was 17.3 ± 6.1 days. Two patients experienced perforation during the first chemotherapy regimen and received conservative treatment, while the others developed perforation after multiple chemotherapy regimens and underwent surgery. All of the patients received regular chemotherapy and survived for a mean follow-up time of 3.8 ± 1.9 years. No patient with perforation before chemotherapy had a definite diagnosis in the outpatient department. Among these patients, 4 experienced perforation and underwent surgery, of whom 3 developed perforation-related complications and died; the other recurred after chemotherapy. Only the patient who received conservative treatment was diagnosed with PPGL before chemotherapy, received regular chemotherapy, and survived without a recurrence for 1.0 year. Conclusion Prompt diagnosis and chemotherapy improve the prognosis of PPGL. Surgery does not affect the prognosis of patients with perforation during chemotherapy but may accelerate disease progression in patients with perforation before chemotherapy.

Background Ehlers–Danlos syndrome is a clinically and genetically heterogeneous group of heritable connective tissue disorders caused by a defect in collagen synthesis and structure. The vascular subtype (Ehlers–Danlos syndrome IV) is reported to be associated with a higher incidence of gastrointestinal perforations. The most reported site of perforation is the colon, followed by the small bowel. Perforation of the stomach is very rare, and there are no reported cases to date of classic types I and II. Case presentation We present the case of a 14-year-old Saudi girl who visited our emergency department with abdominal pain and vomiting. Initially, she was diagnosed with gastroenteritis and discharged once her condition stabilized. After 48 hours, she developed severe abdominal pain with recurrent vomiting and peritonitis evident on clinical examination. Initial abdominal x-ray failed to show any free air; however, enhanced computed tomography revealed free air and contrast extravasation in the proximal gut. During exploratory laparotomy, a large perforation was found on the anterior wall of the stomach due to the underlying ischemia. The posterior wall had ischemic mucosa with an intact healthy serosa. A free-hand partial gastrectomy was performed to resect all ischemic parts of the stomach. Detailed examinations and laboratory workup were carried out after the surgery to figure out the possible underlying cause. The clinical findings during the physical examination supported marfanoid features. Marfan’s syndrome and related disorders sequencing panel was requested, and Deoxyribonucleic acid (DNA) samples were sent. Given results were supporting the diagnosis of classical Ehlers–Danlos syndrome, the patient was labeled as a case of Ehlers–Danlos syndrome. During the postoperative period, she developed a wound infection that was managed successfully with vacuum-assisted closure dressing. She recovered well without gastrointestinal sequelae in the 4 years of follow-up. Conclusions Heritable systemic connective tissue diseases must be given serious consideration in young patients with unusual spontaneous perforation. Such patients might develop life-threatening conditions that require immediate intervention. Hence, correct and timely diagnosis is important to prepare for the anticipated complications.

Background Coagulopathy induced by COVID-19 has received much attention. Arterial and venous thrombosis of multiple organs due to COVID-19-related coagulopathy is associated with a poor outcome. Case presentation A 67-year-female was transferred to our hospital in need of intensive care for severe COVID-19 pneumonia. On day 7 after admission, despite the treatments, her respiratory and hemodynamic status deteriorated. Computed tomography revealed massive ascites and free air as well as wall defects of the transverse colon. An emergency laparotomy was undertaken in the intensive-care unit, and 17 cm of the transverse colon was resected. Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter, necrosis of the intestinal mucosa around the perforation sites, and the microcirculatory thrombosis in the mesentery vessels which was suspected of having been induced by COVID-19-related coagulopathy. Conclusions The case highlights the risk of intestinal ischemia and perforation induced by COVID-19 coagulopathy. Physicians treating COVID-19 should recognize the risk and evaluate patients carefully.

Endoscopic migration of plastic biliary stents is performed by endoscopic retrograde cholangiopancreatography (ERCP) for biliary and pancreatic diseases. This plays an increasingly important role. Intestinal perforation caused by stent migration is one of the complications. Although sigmoid colon perforation caused by stent migration is rare, it can be life-threatening. This case shows us that we should increase awareness of sudden abdominal pain after ERCP. We provide a review of the clinical manifestations, imaging data of this case, and the literature related to the perforation caused by stent migration. A male patient had a history of choledocholithiasis, cholecystolithiasis, and biliary pancreatitis treated with ERCP and a pancreatic stent. After the operation, the patient developed cholangitis and was treated with ERCP and a plastic biliary stent. This patient was admitted to the emergency department with sudden lower abdominal pain. A CT scan showed sigmoid colon perforation by a foreign body and infra-diaphragmatic free air. An emergency surgery confirmed that the stent had caused the perforation. The patient was then treated with sigmoid colectomy and sigmoidostomy. Biliary stent migration after ERCP is rare, but intestinal perforation caused by migration should be considered in cases of abdominal pain of unknown cause.

We describe a term infant who experienced recurrent apnea associated with intracranial hemorrhage and later, developed colonic perforation. Plasma protein C activity was below detectable limits and a heterozygous PROC mutation was identified. Neonatal colonic perforation is rare, and this case report highlights the importance of considering congenital Protein C deficiency.

A 77-year-old woman presented with the chief complaint of large amounts of hematochezia. Contrast-enhanced computed tomography (CT) revealed extravasation of contrast medium from the diverticula in the sigmoid colon; therefore, upon diagnosis of sigmoid colonic diverticular hemorrhage, she was immediately admitted to our hospital. Emergency colonoscopy revealed active bleeding from the diverticula in the sigmoid colon; hemostasis was achieved with endoscopic band ligation (EBL). However, 4 days later, she suddenly developed severe abdominal pain while defecation, prompting the requirement for obtaining a CT scan, which revealed intraabdominal free air, and delayed perforation after EBL was diagnosed. Emergency surgery was immediately performed; the perforation site was closed with sutures. EBL is useful in achieving hemostasis for colonic diverticular hemorrhage; however, it carries the risk of serious complications, such as delayed perforation, which require surgery. Although EBL is useful to achieve hemostasis for diverticular hemorrhage in the colon, it is preferable to carefully judge its indication owing to the risk of serious complications.

Laparoscopic primary anastomosis (PA) without diversion for diverticulitis has historically been confined to the elective setting. Hartmann’s procedure is associated with high morbidity rates that might be reduced with less invasive and one-step approaches. The aim of this study was to analyze the results of laparoscopic PA without diversion in Hinchey III perforated diverticulitis. We performed a retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic sigmoidectomy for diverticular disease during the period 2000–2018. The sample was divided in two groups: elective laparoscopic sigmoid resection for recurrent diverticulitis (G1) and emergent laparoscopic sigmoidectomy for Hinchey III diverticulitis (G2). Demographics, operative variables, and postoperative outcomes were compared between groups. A total of 415 patients underwent laparoscopic sigmoid resection for diverticular disease. PA without diversion was performed in 351 patients; 278 (79.2%) belonged to G1 (recurrent diverticulitis) and 73 (20.8%) to G2 (perforated diverticulitis). Median age, gender, and BMI score were similar in both groups. Patients with ASA III score were more frequent in G2 (p: 0.02). Conversion rate (G1: 4% vs. G2: 18%, p

Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004–2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52–54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.

Endoscopic transmural drainage is performed for symptomatic peripancreatic fluid collections (PPFCs). Long-term transmural double-pigtail stent (DPS) placement is useful in preventing recurrences. There are few reports on the long-term safety of DPS placement. Thus, this study aimed to examine the complications of long-term indwelling DPS for PPFCs. Among 53 patients who underwent endoscopic ultrasound-guided transmural drainage for symptomatic PPFCs between April 2006 and March 2017, those followed up for over one year were included. Complications of long-term indwelling DPS were examined retrospectively. This study enrolled 36 patients [30 men, median age 54 years (range 22–82)]. Walled-off necrosis was present in 22 cases (including 9 disconnected pancreatic duct syndrome cases) and pancreatic pseudocysts, in 14 cases. The median stenting period was 20.9 (range 0.8–142.3) months, and median observation period was 56.2 (range 12.4–147.1) months. Colon perforation due to DPS occurred in 3 cases (8.3%), at 5.8, 17.1, and 33.7 months after indwelling DPS placement; 2 cases developed perforation from the serosal side. In 1 case, the patient was treated surgically, and in 2 cases, the patients underwent endoscopic removal of the stent and showed improvement with conservative treatment. Long-term indwelling transmural DPS for symptomatic PPFCs poses a risk of intestinal perforation. Thus, if possible, it may be better to avoid long-term placement.

Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis. Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy). The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group. The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).

Undetected bowel perforations occur in 0.3–1% of laparoscopic surgical procedures with an associated mortality rate of 5.3%. The purpose of the study was to evaluate the clinical feasibility of a novel medical device to accurately detect bowel gas, specifically hydrogen (H2) and methane (CH4), from a sample of gas from the abdominal cavity during laparoscopic surgery when a known bowel wall perforation has occurred. Setting: University (Academic) Hospital. A prospective single arm study was composed of 8 patients undergoing a standard laparoscopic roux-en-y gastric bypass. At seven time points during the operation intra-abdominal gas was pulled from the abdominal cavity and analyzed using the novel device for H2 and CH4. The time points included after insufflation (T1), after first jejunotomy (T2), after closure of jejunotomy (T3), after recycle of carbon dioxide gas (T4), after gastrostomy (T5), after jejunotomy (T6), at procedure end (T7). Eight patients were enrolled in the study; in 7 (87.5%) patients data from all 7 time points were obtained. After the first opening of the small bowel (T2) mean hydrogen levels were significantly increased compared to baseline hydrogen levels (T1, T4, T7) (p

Ingestion of jujube pits is a common clinical problem, which can be difficult to diagnose and life-threatening if accompanied with intestinal perforation and peritonitis. In this study, 18 cases of intestinal perforation caused by ingestion of jujube pits were reviewed and summarized to discuss the clinical characteristics, diagnosis and treatments. From 2012 to 2018, a total of 18 patients diagnosed as intestinal perforation due to ingested pits of jujube in our center were retrospectively reviewed and the manifestations, laboratory tests, imaging examinations and treatment strategies were summarized. The patients comprised of 11 males and 7 females with an average age of 63.5 years. The main clinical manifestation was abdominal pain. Twelve patients (67%) presented to the emergency department with signs of localized peritonitis. CT imaging revealed positive findings in 17 (94%) patients. Conservative treatments were attempted in 3 patients, and the other 15 patients received emergency surgical exploration, where 7 patients had more than one perforation identified during surgery. Five patients were admitted in the surgical intensive care unit after surgery. The average length of stay of all 18 patients was 9.8 days (range 5–24 days). Ingestion of jujube pits is a common clinical problem and potentially leads to intestinal perforation and peritonitis. CT imaging is the first imaging modality of choice. Patients with milder symptoms might be managed with cautious conservative treatment, and patients with more than one perforation can be identified during surgery.

Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7–10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association. We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review. A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02–0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01–0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not. Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.

Background Thromboangiitis obliterans or Buerger’s disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2% of the cases, when they may present as acute abdomen due to mesenteric ischemia. The uncommonness of the condition makes it a less suspected differential diagnosis, leading to a delay in appropriate management, thereby increasing chances of morbidity or mortality. Cessation of smoking is known to stall the disease progression including visceral involvement, but may not always be the case as happened in the case being presented. Case presentation Our Indian Hindu male patient, a known smoker, presented with diffuse abdominal pain along with bouts of vomiting and loose motions. He had a prior history of amputation of the right foot, 4 years before. At presentation he had abdominal distension with diffuse tenderness and guarding. An omental band attached to the tip of the appendix was discovered at the initial exploration along with dilated proximal bowel loops, for which a release of the omental band along with appendectomy was done. He developed an enterocutaneous fistula on the 6th postoperative day for which he had to be reexplored, and multiple jejunal perforations were found. Segmental jejunal resection and a Roux-en-Y gastrojejunostomy with distal ileostomy were done along with a feeding jejunostomy. The patient however again had feculent discharge from the wound for which a third exploration was done. The gastrojejunostomy and feeding jejunostomy sites were leaky, both of which were repaired primarily. The patient developed septicemia which progressed to refractory septic shock, and he ultimately succumbed to his illness on the 23rd postoperative day of the index surgery. Conclusion Acute abdomen in a young man who is a chronic smoker and having an antecedent history of amputation of some part of an extremity for a nontraumatic cause should raise the suspicion of Buerger’s disease of the intestine. Although it is a progressive disease and the situation has already progressed by the time intestinal symptoms manifest, early detection may give some scope of salvage and decrease the morbidity and mortality.

Background Peritoneal dialysis (PD) is a safe and home-based treatment for end-stage renal disease (ESRD) patients. The direct thermal damage of abdominal organs is very rare. Case presentation We report a peritoneal dialysis patient presented abdominal pain and feculent effluent 3 weeks after he instilled hot dialysis solution. In spite of emergency exploratory laparotomy and active treatment, the patient died of septic shock. Biopsy revealed necrosis and perforation of the intestines. Conclusions Delayed bowel perforation by hot fluid is very rare. Standardized performance is of the first importance for peritoneal dialysis patients.

Background Stercoral perforation (SP) is a rare surgical condition that is associated with high morbidity and mortality. Most of these patients undergo emergent surgery, including colostomy, and some undergo colostomy takedown after recovery. Stercoral re-perforation after colostomy takedown followed by colostomy for SP has not yet been reported. Case presentation A 79-year-old woman presented with abdominal pain for one day. Abdominal-pelvis computed tomography revealed pneumoperitoneum with diffuse mesenteric fat haziness of the left abdomen. During laparoscopic exploration, a 3-cm-sized perforated site was found at the sigmoid-descending colon, with fecal material and reactive fluid outside the colon. Loop colostomy formation was performed, and a takedown was completed after 3 months. Two years 4 months after the initial procedure, the patient was re-admitted to our hospital with abdominal pain. She underwent a second laparoscopic colostomy formation and was discharged, although the postoperative clinical course was poorer than that after the first surgery. Conclusions This case of stercoral re-perforation after colostomy takedown followed by colostomy formation for SP has important clinical implications and can be a reference for physicians. When the first colostomy formation was performed for SP, the decision on performance of a colostomy takedown should be made after carefully considering several factors.

Background Cushing’s syndrome occurs due to overproduction of cortisol from adrenal glands. Endogenous hypercortisolemia can occur secondary to adrenocorticotropic hormone (ACTH) dependent as well as independent causes. The presence of non-specific symptoms and signs contributes to a delay in diagnosis. Early identification and prompt definitive management is crucial. It is important to be alert about the post-operative complications including multiple thrombotic phenomena, which can add to the mortality. We report a case of Cushing’s disease in a young female managed with trans-sphenoidal surgery, followed by a challenging post-operative period complicated with multiple thrombotic phenomena, ultimately succumbed. Case presentation A 32-year-old Sri Lankan female presented with overt features of Cushing’s syndrome and diagnosed to have ACTH dependent Cushing’s disease with pituitary microadenoma. She underwent trans-sphenoidal surgery, following which she developed fatal multiple complications including diverticular rupture and ischemic colitis, needing hemicolectomy, followed by a parieto-occipital infarction. Conclusion This case highlights important and aggressive complications associated with Cushing’s syndrome giving rise to a challenging post-operative course. Diverticular rupture had been described in association with hypercortisolemia and this case adds to the existing literature. Post-operative ischemic colitis and stroke which contributed to the death of this patient could have been due to the procoagulant state associated with Cushing’s syndrome, with a high risk during the immediate post-operative period. This emphasizes the need to consider post-operative thromboprophylaxis in patients undergoing surgery for Cushing’s syndrome.

Background Migration of fish bones into abdominal para-aortic tissue after penetrating the junction of 3rd and 4th part of duodenum is incredibly rare. Case presentation A 68-year-old man was admitted to our hospital with persistent colic in the lower abdomen after eating fish two weeks ago. Abdominal computed tomography (CT) scan showed High density streaks along the anterior and lower edges of the 3rd part of duodenum with peripheral exudation and localized peritonitis. Esophagogastroduodenoscopy didn’t find foreign bodies and perforations in the digestive tract. Laparoscopic surgery and intraoperative endoscopy were made to detect foreign bodies and perforation site was found. After transition to open surgery, the fish bone was found in abdominal para-aortic tissue and removed without complications. Postoperative recovery is smooth, and the patient resumed normal diet and was discharged. Conclusions It is difficult to choose a treatment plan for foreign bodies at the 3rd part of the duodenum, because it is difficult to judge the damage caused by the foreign body to the intestine and the positional relationship with the surrounding important organs. Conservative treatment or surgical treatment both have huge risks. The handling of this situation will extremely test the psychology, physical strength and professional experience of the surgeon.

Background Free air after laparoscopic hysterectomy is a common finding; in rare cases, free air represents gastrointestinal perforation, requiring emergency laparotomy. Ectopic air localizations after pneumoperitoneum have been reported in various laparoscopic surgical techniques. Delayed diagnosis of visceral perforation is associated with high mortality rates. Case presentation We present a white Caucasian female in which dysphonia due to air entrapment in the cervical area, pneumomediastinum and pneumothorax, occured afterlaparoscopic hysterectomy. Conclusions Upon mobilization of the patient, air from sigmoid perforation moved cephalad. Through the same path, pneumoperitoneum, causes subcutaneous emphysema in the neck and face, pneumomediastinum and pneumothorax.

Background Gastrointestinal lymphomas like diffuse large B-cell lymphoma (DLBCL) are rare complications of ulcerative colitis (UC), and only a few studies have reported intestinal ulcers caused by DLBCL, which got perforated during the treatment of UC. Case presentation A 43-year-old man with severe lower abdominal pain and an 8-year history of UC was admitted in our hospital. He was diagnosed UC since 8 years and received a maintenance oral dose of 5-aminosalicylic acid, and no other immunosuppressive drugs. A deep rectal ulcer was endoscopically diagnosed 10 months before admission, no malignancy or cytomegalovirus infection was detected on biopsy. After 7 months a further endoscopy with biopsies confirmed the finding and the absence of malignancy. Three months later the patient developed sudden abdominal pain and was admitted in our hospital. Rectal perforation was suspected on X-ray and computed tomography imaging, and an emergency surgery was performed. Surgical exploration revealed a perforation on the anterior wall of the rectum. A subtotal colectomy with temporary ileostomy was performed. Pathology examinations showed lymphocyte infiltration of all of the layers of the perforated site and an immunohistochemical evaluation revealed DLBCL. Clinical staging was stage IV, and the patient received a 6-months regimen of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. Positron emission tomography restaging revealed disappearance of distant uptake and a slight uptake in the residual rectum, and completion proctectomy with ileal pouch-anal anastomosis was performed. No residual tumor in the specimen was found, and the patient was disease-free at 2 years follow-up. Conclusions DLBCL may increase the frequency of perforation and is a poor prognostic risk factor for patients with UC. This case study emphasizes the importance of careful medical surveillance and repeated endoscopic biopsies during the treatment of UC.