Kirien T. Kjossev

Ingested Foreign Bodies of the Gastrointestinal Tract: Retrospective Analysis of 542 Cases

Abstract. Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69.9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%;n = 410). Endoscopic removal was possible in 19.5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

RECONSTRUCTIVE RENAL SURGERY USING A WATER JET

PURPOSE We describe the successful application of a water jet to reconstructive renal surgery. MATERIALS AND METHODS Two consecutive patients underwent reconstructive renal surgery using a waterjet apparatus for a 4.0x6.5 cm. well encapsulated tumor of the lower pole of the left kidney and a 4.5x2.5 cm. staghorn calculus of the left kidney, respectively. The water jet apparatus (Parenchimotom 01) consists of a pressure generating pump and a flexible hose connected to the hand piece, and a nozzle with a pinhole opening of 0.3 mm. RESULTS Both patients underwent surgery through a left lumbar incision. Partial nephrectomy was performed in 1 patient and anatrophic nephrotomy for stone removal in the other. Dissection time was 25 and 12 minutes, with blood loss of 150 and 100 ml., respectively. No temporary vascular clamping or local hypothermia was necessary. Both patients were discharged home 10 days after surgery and at followup no negative sequelae were attributable to the procedure. CONCLUSIONS The operative procedures proved easy, fast and effective. No temporary vessel clamping or hypothermia was required. Using a water jet is a novel approach that is helpful in renal surgery.

Classification of hydatid liver cysts

Abstract  A number of investigations advocate various classification systems for liver hydatid cysts. However, none permits predicting the treatment outcome or making clinical decisions regarding medical treatment; open surgery; punction, aspiration, injection, reaspiration (PAIR); or laparoscopy. An international hydatid disease registry employing an uniform nomenclature and consistent reporting methods would allow more rational comparison of different management strategies. TN(R)C (topography, nature, recurrent, complication) classification is a comprehensive system based on four criteria: location (T), natural history (N), recurrence (R) and complications (C) of the cyst. This pictorial review illustrates the classification and puts accent of its clinical usefulness. The TN(R)C classification provides a standardized description formula of every liver hydatid cyst, permitting multiple comparisons and analyses.

Palisade dorsoventral lavage for neglected peritonitis

A modification of the procedure of laparostomy with palisade dorsoventral lavage for treating neglected peritonitis is described. It consists of adding a polyethylene foil to cover the intestines and thus avoiding the direct contact between them from one side, and the suction drains and the palisade laparostomy screen from the other. Between 1988 and 1995, 19 patients with neglected peritonitis (APACHE II scores from 12 to 42; mean 22.3) were managed using this modified technique. A total of 81 reexplorations were done (average, 4.3 reexplorations per patient). The technique proved effective (21% mortality, n = 4). No intestinal perforations, fistulas, or residual pus collections occurred among survivors or among those who died. Primary fascial closure was achieved in all survivors and during an 18-months followup, no incisional hernia occurred. Based on these results, we believe this technique is extremely useful when both laparostomy and continuous peritoneal irrigations are considered in patients with neglected peritonitis.

Gastrointestinal "crosses": an indication for surgery.

Background We present our experience with a unique type of foreign body that was specifically designed to arrest in its passage and cause perforation of the gastrointestinal tract. Study Between 1994 and 1999, nine male prisoners from the same jail presented after ingestion of “crosses.” A cross is constructed from the two halves of a standard paperclip that are tied together with a rubber band. The resulting construction is elastic: the two branches can be pulled to lie parallel, but they assume their original position once released. The cross is wrapped into paper with its branches parallel and ingested. After release from the wrapper, it “opens” and causes bowel perforations. Results All patients underwent emergency surgery for foreign body removal and treatment of peritonitis. A total of 19 crosses were removed from the patients. Six (32%) were found in the stomach; five, in the duodenum (28%); three, in the jejunum and ileum (16%); and one, in the pylorus and colon. There was no morbidity or mortality. Conclusions Foreign bodies of this type never pass distally. The ultimate key to success in the management of patients who have ingested crosses is emergency surgical intervention.

Posttraumatic intra-gallbladder hemorrhage

We read with interest the article by Nishiwaki and colleagues1 on posttraumatic intra-gallbladder hemorrhage which appeared in the April 1999 issue of the Journal. This is an impressive first case report of a massive intragallbladder clot occuring after blunt trauma and requiring surgery because of persisting abdominal pain. Nishiwaki and colleagues1 should be congratulated for their excellent review of other causes of hemorrhage into the gallbladder—a rare but important entity. In the Introduction section of their article, Nishiwaki and colleagues1 state that gallbladder injuries include laceration, avulsion, and contusion. In general, this may be true; however, this is not a detailed listing of all known types of gallbladder injury. A detailed classification system of all known types of traumatic gallbladder injury, recently appeared, under our authorship, in the English-language literature2 (Table 1). As seen from the Table, to date there are five different types (divided into ten subtypes) of gallbadder injury, which may lead to a myriad of presentations. We were pleased to realize that the report of Nishiwaki and colleagues1 presented a new, as yet undescribed type of gallbladder injury; in this respect their report further broadens readers’ knowledge regarding this rare type of injury. We believe that the injury they described could possibly be classified as subtype 1C or 4C according to the recent classification we proposed,2 or possibly, as type 6. We would greatly appreciate the opinion of Nishiwaki and colleagues regarding whether they agree with this idea.

Open abdomen and VAC® in severe diffuse peritonitis

Background Currently, the open abdomen technique is the widely recognised method for treatment of life-threatening trauma, intra-abdominal sepsis, abdominal compartment syndrome and wound dehiscence. The techniques for temporary closure using negative pressure have gained increasing popularity. Although negative pressure wound therapy has been proved as an effective method in trauma, the results in diffuse peritonitis are contradictory. Methods Overall, 108 patients with diffuse peritonitis and open abdomen were prospectively enrolled from January 2006 to December 2013—69 treated with mesh-foil laparostomy without negative pressure and 49 with vacuum-assisted closure (VAC®) The primary endpoints were the rate of primary fascial closure and mortality. The secondary outcomes were the rate of complications—enteroatmospheric fistulas, intra-abdominal abscesses, wound infection and necrotising fasciitis, intensive care unit (ICU) and overall hospital stay. Results VAC was associated with higher overall (73% vs 53%) and late primary fascial closure rates (31% vs 7%), lower rates of necrotising fasciitis (2% vs 15%, p=0.012), intra-abdominal abscesses (10% vs 20%), enteroatmospheric fistulas (8% vs 19%), overall mortality (31% vs 53%, p<0.05), shorter ICU (6.1 vs 10.6 days, p=0.002) and hospital stay (15.1 vs 25.9 days, p=0.000). Conclusions The results clearly suggest the obvious advantage of VAC in comparison to the temporary abdominal closure without negative pressure in the cases with severe diffuse peritonitis. However, to a large extent, our results might be attributed to the combination of VAC with dynamic fascial closure.

Eosinophilic enterocolitis and visceral neuropathy with chronic intestinal pseudo-obstruction

A patient is described who was found to have both eosinophilic enterocolitis and visceral neuropathy with chronic idiopathic intestinal pseudo-obstruction. The etiology and pathogenesis of this rare combined disorder of the gastrointestinal tract are discussed. Although eosinophilic enterocolitis is amenable to conservative treatment, surgery may be necessary for palliation in selected patients with pseudo-obstruction due to visceral neuropathy.

Zoophilia: a rare cause of traumatic injury to the rectum

A 62-year-old farmer presented with generalized abdominal pain of eight hour’s duration. Past medical history was negative. Physical examination revealed marked abdominal distension with diffuse rebound. Digital rectal examination was unremarkable. Chest and abdominal X-ray film revealed free gas below the diaphragm and multiple gas-fluid levels consistent with paralytic ileus. Laboratory findings were significant for peripheral leukocytosis of 16,500 mm3. Laparotomy revealed diffuse feculent peritonitis and a 0.5 cm anterior tear of the rectum located 5 cm above the pelvic peritoneal reflection. The edges of the tear were ragged but without necrosis. No other pathology or foreign body was found. The abdomen was cleaned and the perforation closed. Intraoperative anoscopy and sigmoidoscopy were unremarkable except for several minute mucosal hematomas on the luminal aspect of the tear. A diverting transverse colostomy was constructed. The abdomen was irrigated copiously with warm saline, drained and closed in layers. Post-operative treatment consisted of nasogastric suction, total parenteral nutrition and broad-spectrum antibiotics. The patient recovered uneventfully.

Toxic shock syndrome and necrotizing fasciitis complicating neglected sacrococcygeal pilonidal sinus disease

PURPOSE: This study was conducted to report the rare combination of necrotizing fasciitis and toxic shock syndrome, which both complicated neglected sacrococcygeal pilonidal sinus disease. METHODS: A case report is presented. RESULTS: We describe the rare case of a previously healthy adult male patient who developed necrotizing fasciitis and toxic shock syndrome associated withStreptococcus pyogenesandBacteroides fragilis.Patients response to emergency surgery followed by repeated debridements of necrotic tissue, together with aggressive fluid resuscitation, broad-spectrum antibiotic coverage, and hyperbaric oxygenation was good. CONCLUSION: This case serves again as a clear reminder that neglected pilonidal sinus disease can lead to unusual and life-threatening consequences.