David Aranovich

Reversed Intestinal Rotation Presented as Bowel Obstruction in a Pregnant Woman

A rare case of complete large bowel obstruction in a pregnant woman, without previous surgical history, due to previously undiagnosed reversed intestinal rotation is presented. The young woman was admitted with progressive nausea and vomiting which did not respond to conventional therapy. Her plain abdominal film revealed signs of small bowel obstruction. On laparotomy, her transverse colon was found to be located beneath the root of small bowel mesentery and completely obstructed by congenital fibrous bands. Postoperative recovery was unremarkable. Surgery for this unusual developmental anomaly is discussed.

Intraoperative ultrasound in colorectal surgery.

To assess the accuracy of intraoperative ultrasound (IOUS) as a localizing technique for colorectal resections, and its impact on surgical management.

Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography

Background All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission. Methods From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n=56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n=45), and Group B had stones in the CBD (n=11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP. Results The cumulative rate of choledocholithiasis was 19.7% (Group B, n=11). Forty-five patients (Group A, n=45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n=11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p=0.016). Conclusions Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones.

Incarcerated Femoral Hernia Repair with Ventralex™ Hernia Patch through Same Skin Incision and Suprainguinal Laparotomy

Purpose To report our experience with incarcerated femoral hernia procedure, which allows laparotomy through same inguinal skin incision, inspection and resection of compromised bowel, and preperitoneal tension-free transabdominal repair with Ventralex™ Hernia Patch. Materials and Methods The suprainguinal laparotomy was performed via same groin incision without compromising iliopubic tract. The femoral ring was sealed with Ventralex™ Hernia Patch pulled through the abdominal cavity and secured outside. Five consecutive patients diagnosed with incarcerated femoral hernias were operated. All of them required laparotomy, either for bowel resection (n = 3) or for inspection of viability (n = 2). Results All patients tolerated the procedure well. There were no wound or mesh infections, incisional hernias, or recurrences during follow-up. Conclusions Our easy-to-master operative approach to incarcerated femoral hernia allows easy access to abdominal cavity through same groin incision without compromising iliopubic tract or midline laparotomy. Reduction of incarcerated bowel and its inspection and resection can be safely performed. The femoral ring defect can be effectively obliterated with Ventralex™ Hernia Patch.

Ocular Melanoma Metastasizing to Intra-Abdominal Lymph Nodes

Background. Visceral metastatic spread of ocular melanoma most commonly occurs via hematogenous route to the liver. Lymphatic spread of ocular melanoma into abdominal lymph nodes has not been reported previously. Case Presentation. A 47-year-old man with a history of ocular melanoma presented with a soft tissue mass on CT scan. The mass encased the portal structures of the hepaticoduodenal ligament. Image-guided biopsy revealed it to be a metastatic melanoma to lymph nodes. The patient underwent surgery with the intent to prolong disease-free survival. On final pathological examination, two lymph nodes were found harboring metastatic melanoma. Conclusion. Extrahepatic lymphatic intra-abdominal spread of ocular melanoma is not impossible. Since this mode of spread is rare, the oncologic significance of surgical resection of isolated intra-abdominal nodal with metastatic ocular melanoma is difficult to determine at the present time.

Hydrocolonic technique facilitates intraoperative sonographic localization of colorectal polyps and cancers

On May, 2007 the Surgical Endoscopy published an article entitled ‘‘Intraoperative fluoroscopy vs. intraoperative laparoscopic ultrasonography for early colorectal cancer localization in laparoscopic surgery’’ (Nagata K et al). Intraoperative localization of colorectal polyps and early cancers may be extremely problematic during laparoscopic and open procedures as well. The absence of tactile sense during laparoscopy and the inability to palpate small lesions during open procedures both call for an effective and simple method of intraoperative localization. The available techniques are far from ideal. On-table colonoscopy is cumbersome, and submucosal dye injection may be misleading due to migration of the colorants. In the aforementioned article the authors compared two intraoperative techniques for localization of early colonic cancers, namely fluoroscopy and ultrasound. The authors concluded that ultrasound was a good and reliable localization technique. During the past two years we have also utilized intraoperative ultrasonography in open procedures for the localization of nonpalpable lesions, which are not amenable to colonoscopic removal. One of the drawbacks of this method mentioned in the article is intracolonic gas. To overcome this obstacle we use retrograde instillation of saline solution, and direct scanning of saline-filled bowel with a linear 7.5 MHz probe. This method creates an excellent acoustic window and allows visualization of small polyps and cancers (Fig. 1). Moreover, the resolution permits clear distinction of invasive from noninvasive lesions according to the degree of penetration into the sonographic layers. Our experience was published in the International Journal of Colorectal Diseases [1]. As mentioned, this method was tested in open procedures only, and I do not know whether fluid-filled bowel would compromise the intra-abdominal compartment during laparoscopy. I think that the method merits testing in laparoscopy.

Should Echogenic Material in the Urinary Bladder Noticed on FAST Preclude Urinary Catheter Insertion in a Trauma Patient Until Further Evaluation

Background:Serious urethral and bladder injuries are most often associated with severe blunt trauma. The most common diagnostic tool used to assess lower urinary tract injuries is a retrograde urethrogram. However, the decision to place a Foley catheter is often made on clinical grounds during initial stabilization phase of a trauma victim. If there is a clinical suspicion of a urethral injury, a Foley catheter should not be introduced until further evaluation is made. Focused abdominal sonography for trauma (FAST) is a major tool for primary evaluation of trauma victims. Treating trauma patients, we encountered an unusual “pick up”, namely, blood clots in the urinary bladder in two patients.Case Report:We report on two cases of severely traumatized patients on which FAST examination detected an echogenic material in the bladder. This correlated with severe injuries to the urethra and urinary bladder. Moreover, ignorance of this finding in a patient without obvious clinical signs of urethral injury (Patient 1) led to a Foley catheter insertion, and as a consequence, a complex jatrogenic injury to the urethra. On the basis of this study, we hypothesize that the presence of an echogenic material on FAST examination should be considered blood until proven otherwise, and a urinary bladder catheter should not be passed, even in the absence of clinical signs of urethral injury. Since urogenital trauma is rare, this concept should be validated in the prospective study in a high-volume trauma center.