Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study.

ABSTRACT: The CIAO Study ("Complicated Intra-Abdominal infection Observational" Study) is a multicenter investigation performed in 68 medical institutions throughout Europe over the course of a 6-month observational period (January-June 2012).Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.2,152 patients with a mean age of 53.8 years (range: 4-98 years) were enrolled in the study. 46.3% of the patients were women and 53.7% were men. Intraperitoneal specimens were collected from 62.2% of the enrolled patients, and from these samples, a variety of microorganisms were collectively identified.The overall mortality rate was 7.5% (163/2.152).According to multivariate analysis of the compiled data, several criteria were found to be independent variables predictive of patient mortality, including patient age, the presence of an intestinal non-appendicular source of infection (colonic non-diverticular perforation, complicated diverticulitis, small bowel perforation), a delayed initial intervention (a delay exceeding 24 hours), sepsis and septic shock in the immediate post-operative period, and ICU admission.Given the sweeping geographical distribution of the participating medical centers, the CIAO Study gives an accurate description of the epidemiological, clinical, microbiological, and treatment profiles of complicated intra-abdominal infections (IAIs) throughout Europe.

Familial occurrence of an association of multiple intestinal atresia and choanal atresia: a new syndrome?

We report on two familial cases from a non-consanguineous marriage, presenting multiple intestinal and choanal atresia. Massive hydramnios and dilatation of the bowel were observed at 29 weeks of gestation during routine ultrasound scan of a healthy mother. The fetal karyotype was normal and cystic fibrosis screening was negative. Regular scans were performed throughout the pregnancy. The child was born at 34 weeks gestation. Choanal atresia was diagnosed at birth and abdominal investigations showed multiple atresia interesting both the small bowel and the colon. Further interventions were necessary because of recurrent obstructions. During the following pregnancy, a dilatation of the fetal intestinal tract was detected by ultrasonography at 27 weeks of gestation. Pregnancy was interrupted. Post-mortem examination of the fetus confirmed the stenosis of long segments of the small intestine associated with areas of colonic atresia. In both cases, histology and distribution were consistent with those reported in hereditary multiple intestinal atresia (HMIA). An association between multiple intestinal and choanal atresia has never been reported. We suggest it could correspond to a new autosomal recessive entity for which cytogenetic investigations and high-resolution array CGH revealed no visible anomalies.

Enhanced-reality video fluorescence: a real-time assessment of intestinal viability.

OBJECTIVE: Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model. MATERIALS AND METHODS: A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification. RESULTS: Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments. CONCLUSIONS: Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.

Jejunojejunal intussusception after Roux-en-Y gastric bypass: a review.

Small bowel intussusception is a rare long-term complication after Roux-en-Y gastric bypass, the etiology of which remains unclear. Except for one series reporting on 23 patients, case reports represent the vast majority of all cases reported so far. With this complete review of the world literature, based on a total of 63 patients including 2 of our own cases, we provide an extensive overview of the subject. The origin of intussusception after gastric bypass is different from that of intussusception of other causes, in that there is usually no lead point. It is likely related to motility disorders in the divided small bowel, especially in the Roux limb. This rare condition may cause obstruction and lead to bowel necrosis if not recognized and treated promptly. Clinical presentation is not specific. Computerized tomography scan represents the diagnostic test of choice, but surgery is sometimes the only way to establish the diagnosis. Treatment may be limited to reduction if the small bowel is viable, but resection of the affected segment is recommended on the basis of this review, since it seems to result in fewer recurrences. Knowledge of this entity and a high index of suspicion are required to make the correct diagnosis and offer appropriate treatment in a timely fashion.

Consolidation whole abdomen irradiation following adjuvant carboplatin-paclitaxel based chemotherapy for advanced uterine epithelial cancer: feasibility, toxicity and outcomes.

BACKGROUND: To evaluate feasibility and preliminary outcomes associated with sequential whole abdomen irradiation (WAI) as consolidative treatment following comprehensive surgery and systemic chemotherapy for advanced endometrial cancer. METHODS: We conducted a retrospective analysis of patients treated at our institution from 2000 to 2011. Inclusion criteria were stage III-IV endometrial cancer patients with histological proof of one or more sites of extra-uterine abdomen-confined disease, treated with WAI as part of multimodal therapy. Endpoints were feasibility, acute toxicity, late effects, recurrence-free survival (RFS) and overall survival (OS). Twenty patients were identified. Chemotherapy consisted of 3 to 6 cycles of a platinum-paclitaxel regimen in 18 patients. WAI was delivered using conventional technique to a median total dose of 27.5 Gy. RESULTS: No grade 4 toxicities occurred during chemotherapy or radiotherapy. No radiation dose reduction was necessary. Three patients developed small bowel obstruction, all in the context of recurrent intraperitoneal disease. Kaplan-Meier estimates and 95% confidence intervals for RFS and OS at one year were 63% (38-80%) and 83% (56-94%) and at 3 years 57% (33-76%) and 62% (34-81%), respectively. On univariate Cox analysis, stage IVB and serous papillary (SP) histology were found to be statistically significantly (at the p = 0.05 level) associated with worse RFS and OS. The peritoneal cavity was the most frequent site of initial failure. CONCLUSIONS: Consolidative WAI following chemotherapy is feasible and can be performed without interruption with manageable acute and late toxicity. Patients with endometrioid adenocarcinoma, especially stage FIGO III, had favorable outcomes possibly meriting prospective evaluation of the addition of WAI following chemotherapy in selected patients. Patients with SP do poorly and do not routinely benefit from this approach.

Heterotaxy syndrome: a case report

Heterotaxy syndrome is defined as an abnormal arrangement of some organs and vessels in association with dysmorphism. The authors describe the case of a patient with heterotaxy syndrome with poliesplenia incidentally diagnosed during imaging evaluation (computed tomography and small bowel barium study) of unrelated pathological condition.

Síndrome da alça aferente com necrose simulando pseudocisto de pâncreas

Afferent loop obstruction after gastrectomy and Billroth II reconstruction is an uncommon problem. Complete acute obstruction requires emergent laparotomy. We describe a patient who developed acute abdominal pain, hyperamylasemia, and palpable abdominal mass, five years after Billroth II gastrectomy. At laparotomy the patient was found to have a complete stricture of the afferent limb with evidence of strangulation and necrosis. There was no evidence of pancreatitis or pancreatic pseudocyst. The patient underwent pancreaticoduodenectomy plus degastrectomy and died 18 hours after the procedure in the ICU. The mass was initially inte1preted as pancreatic pseudocyst. Ultrasonography may provide enough evidence to differentiate a pancreatic pseudocyst. from an obstructed afferent loop, by the presence of a peripancreatic cystic mass or debris within the mass or the absence of the keyboard sign, suggesting effacement of the valvulae conniventes of the small bowel. Howewer, CT scan of the abdomen has been suggested to be highly characteristic, if not pathognomonic, for an obstructed afferent loop and should be considered first in patients with pancreatitis after Billroth II gastrectomy. A history of previous gastrectomy, recurrent or severe abdominal pain, hyperamylasemia with characteristic tomography, and endoscopic findings will establish the diagnosis and necessitate surgical evaluation and intervention.

Trombose mesentérica como complicação da colecistectomia videolaparoscópica

Intestinal complications after laparoscopic cholecystectomy are rare and usually caused by direct injury sustained on trocar insertion. However, intestinal ischaemia has been reported as an unusual complication of the pneumoperitoneum. We describe a 55-years-old patient who underwent an uneventful laparoscopic cholecystectomy after an episode of acute cholecystitis. Initial recovery was complicated by development of increasing abdominal pain which led to open laparotomy on day 2. Gangrene of the distal ileum and right-sided colon was detected and small bowel resection with right colectomy and primary anastomosis was performed. Histological examination of the resected ileum showed features of venous hemorragic infarction and trombosis. In view of the proximity of the operation it is assumed that ileal ischaemia was precipitated by carbon dioxide pneumoperitoneum. Some studies have been demonstrated that, within 30 minutes of establishing a pneumoperitoneum at an intraabdominal pressure of 16 mmHg, cardiac output, blood flow in the superior mesenteric artery and portal vein decrease progressively. Carbon dioxide pneumoperitoneum may lead to mechanical compression of the splanchnic veins and mesenteric vasoconstriction as a result of carbon dioxide absortion. The distribution of the ischaemic segment of intestine is also unusual as the most precarious blood supply is traditionally at the splenic flexure of the colon. It has been suggested that intermittent decompression of the abdomen reduces the risk of mesenteric ischaemia during penumoperitoneum especially in patients with predisposing clinical features for arteriosclerosis intestinal. In present patient was observed intestinal venous infarction what remains unclear but we think the carbon dioxide pneumoperitoneum have been related to it.

Tumor estromal gastrointestinal de intestino delgado

Stromal tumors of the gastrointestinal tract (gists) represent relatively rare lesions that arise from connective tissue elements located along the entire length of the gut. They were initially identified by immunohistochemical investigation, proving their origin from nondifferentiated mesenchymal cells. Only a minority of this lesions, mainly those confined to the esophagus and rectum, have been shown to correspond to mature, well-differentiated types of neoplasms such as leiomyoma or leiomyosarcoma. The majority of gists corresponds to a heterogeneous group of lesions that have as their common denominator an immature proliferation of epithelioid or spindle cells arising from its muscle layers, or between them, showing partial or incomplete myoide, neural, ganglionic, or mixed features of differentiation. This case report intends to show a gist of small bowel in a male, 46 years old, with a two-year of evolution.

Leiomiossarcoma de jejuno

We describe a case of leiomyosarcoma of the jejunum in which abdominal computed tomography showed an intestinal tumor with a "sui generis" metalic artefact inside, which made us think of a benign disease (foreign body granuloma), because the patient lived in the rural area and he had a manioc flour mill, which is one the basic foods of the majority of the population of the north in Brazil. Because of the aspect of the tumor, we decided on a large scale resection, considering the possibility of a malignant tumor since we don't have frozen sections. This assured us of an adequate treatment for the tumor. This type of pathology should be remembered even though it only accounts for 0,2-2% of the intestinal tract tumors.

Videolaparoscopia no trauma abdominal

Despite the use of laparoscopy in abdominal trauma for several decades, it was only after the advent of video chip camera that an explosion of interest ocurred, giving rise to possibilities and perspectives not only in diagnosis but also in therapeutics. In trauma, its use has been gradually defined and experience has shown the benefits of the method in early diagnosis of visceral injuries as well as avoiding unnecessary laparotomies. Trauma laparoscopy is a safe method, can reduce negative and nontherapeutic laparotomies. The worrisome failure of laparoscopy to detect gastrintestinal injuries, specially small bowel lesions can be avoided with a mandatory and apropriated "run bowel" exploration. We believe that in hemodinamically stable patients, video laparoscopy is safely indicated in some situations in trauma, such as evaluation of diaphragmatic injuries in thoraco abdominal stab wounds and tangential gunshot wounds of anterior abdominal wall.

Adenocarcinoma primário de duodeno

Primary adenocarcinoma of the duodenum is an extremely rare disease, and represents only 0.35% of all gastrointestinal malignancies. Early detection of the disease may be difficult because of the absence of pathognomonic symptoms. The authors relate one case of a adenocarcinoma of the duodenum in a 61-year-old white man with a history of abdominal pain for a six-month period, associated with postprandial fullness, vomiting and weight loss. Contrasted x-ray and computerized tomography showed a tumor in the fourth segment of the duodenum, with partial obstruction of the lumen. Histological study revealed a moderate differentiated adenocarcinoma. Treatment consisted of resection of the fourth portion of duodenum. The authors comment on the most important aspects of this pathology.

Megacólon chagásico associado a pneumatose cística difusa do delgado e úlcera péptica duodenal

Diffuse intestinal pneumatosis appears as gaseous cysts in the intestinal wall in the submucosal layer or, more frequently, sub-serous layer. It affects more the jejunum than the ileum, can be diffuse and may extend into the colon. It's diagnosis is established during a small bowel transit examination, necropsy examination or during surgical exploration of the peritoneal cavity.

Hérnia encarcerada em orifício de trocarte lateral diagnosticada por tomografia computadorizada

Incisional hernia is an uncommon complication in laparoscopic surgery. The majority of the hernias are located in the umbilical site. Nevertheless, they can occur in the lateral trocar site, although they are rarely diagnosed. We report a case of a 55 year-old patient who underwent a videolaparoscopic hysterectomy and developed small bowel obstruction on the third postoperative day. This initially gave rise to the diagnosis of paralytic ileum. The definitive diagnosis of incarcerated hernia in the lateral trocar site was established after an abdominal computed tomography was performed.

Obstrução intestinal após uso de infliximab no tratamento de fístula êntero-cutânea na doença de Crohn

Crohn's disease is often complicated by the development of fistulas. Infliximab, a monoclonal antibody that binds tumor necrosis factor a have shown to be successful in the treatment of fistulizing Crohn's disease. It's possible complications and side effects have not been completely elucidated. Our objective is to report a case of a patient who developed intestinal obstruction after treatment of fistulizing Crohn's disease with infliximab. A 50 years-old female with Crohn's disease presented with spontaneous enterocutaneous fistula. She was successfully treated with the infusion of 5mg/kg infliximab at weeks 0, 2, and 6, with complete closure of the fistula after the first infusion. Eight weeks after treatment she developed small bowel obstruction secondary to stenosis of the ileum. She was subjected to exploratory laparotomy and resection of the stenotic ileum. The patient had good recovery, with no complications, and was discharged on the 5th postoperative day. Although a faster and complete healing of enterocutaneous fistula was induced by infliximab, this treatment may have caused intestinal obstruction in this case.