Nadko G. Velitchkov

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.

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.

Abdominoperineal resection and perineal colostomy for low rectal cancer

PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2–4 times per week), and in five patients the self-administration of enemas (2–4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.

Stercoral perforation of the normal colon: report of five cases.

A series of five consecutive patients with stercoral perforation of the colon is presented. Four of the patients had free perforation and one had an abscess between the splenic flexure, spleen and surrounding organs, a yet unreported entity. All patients underwent emergency surgery including laparostomy with repeated explorations and lavages in two of them. The ethiology, pathophysiology and treatment of the condition are updated. A graphic algorithm for decision-making in appropriately dealing with stercoral perforation of the colon is proposed.