We report an unusual case of a 76-year-old woman with a necrotic perforated excluded gastric pouch who had stomach partitioning gastrojejunostomy 20 years earlier for morbid obesity. The necrotic mucosa of the excluded gastric pouch was seen on gastroscopy with retrograde cannulation from the pylorus. Laparotomy revealed a distended excluded stomach with full-thickness ischaemia of the posterior wall with perforation into the lesser sac. Partial gastrectomy with Roux-en-Y gastrojejunostomy was performed. We strongly suggest early surgical exploration for these patients when they are hemodynamically unstable or do not have a precise diagnosis despite imaging to prevent potentially life-threatening gastric pouch necrosis. We advocate for avoiding risk factors like alcohol, nicotine, and nonsteroidal anti-inflammatory drugs (NSAIDs) and implement preoperative Helicobacter pylori testing and its eradication to reduce the incidence of perforation in the excluded pouch.
Background
Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence.
Methods
All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two‐year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed.
Results
The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re‐presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one‐third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%.
Conclusion
Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after‐hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.
Objective: Obstetric anal sphincter injuries (OASIS) occur in
approximately 3-6% of vaginal deliveries and are the leading risk
factor for late onset faecal incontinence. We aimed to assess the effect
of irritable bowel syndrome (IBS) on severity of faecal incontinence
after immediate primary repair of major OASIS (Grade IIIb-IV). Design:
Prospective cohort study Setting: Zaans Medisch Centrum, Zaandam, The
Netherlands Population: Women who underwent a primary repair of major
OASIS over a 2-year period (Group A), a control group consisting of
primigravid women (Group B), and another control group who underwent
elective Caesarean section (Group C). Methods: Participants were
assessed with ultrasonography within 12 weeks, then a follow-up
questionnaire after at least 12 months. Main outcome: Wexner faecal
incontinence scores and presence of IBS based on Rome IV criteria.
Results: There were 211 total patients included, and mean follow-up time
was 26 months after sphincter repair. Ultrasonographic sphincter defects
were detected in 37% but did not affect faecal incontinence score
(p=0.16). Patients with IBS had significantly worse faecal incontinence
(p<0.001), and interestingly in women with OASIS those without
IBS had comparable symptoms to the control groups. Inability to defer
defaecation for 15 minutes was also associated with worse faecal
incontinence (p=0.003). Conclusion: After OASIS repair faecal
incontinence was significantly worsened by the presence of IBS, or in
women with an inability to defer defaecation. Presence of
ultrasonographic sphincter defects did not correlate to a clinical
difference in faecal incontinence scores. Funding: Nil. Keywords: OASIS,
sphincter, irritable bowel syndrome, incontinence
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