The principles and art of plastic surgery

Purpose of reviewThis review focuses on recent publications concerning medical complications in patients with eating disorders, including anorexia nervosa and bulimia nervosa.Recent findingsRecent literature continues to reflect that multiple organ systems are frequently affected by eating disorders

Medical complications of anorexia nervosa and bulimia nervosa.

Actinomycosis: a great pretender. Case reports of unusual presentations and a review of the literature

Surgical Treatment − Evidence‐Based and Problem‐­Oriented

Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis. The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier. During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group. Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

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Acute appendicitis in the elderly: risk factors for perforation.

Acute massive gastric dilatation is a rare event and though it can occur in a multitude of medical conditions, its pathogenesis is still debated. It leads almost invariably to gastric necrosis with or without perforation which calls for emergency surgical treatment. We present the case of a 22 year-old male patient of normal weight with acute massive gastric dilatation due to a binge eating episode leading to gastric parietal ischemia with mucosal necrosis. Abdominal computed tomography established the diagnosis of acute massive gastric dilatation. After partial decompression of the stomach, the patient emptied his stomach by vomiting. Eight hours after gastric decompression, an upper endoscopy was performed showing ischemia with areas of necrotic gastric mucosa in the fundus and along the greater curvature. Despite presence of ischemia and gastric necrosis, conservative treatment was successful. Psychiatric assessment revealed a borderline mentally retarded young man, but no current diagnosis of a typical eating disorder. Physicians should be aware that binge eating habits may cause acute massive gastric dilatation in patients of normal weight who are not diagnosed as having a typical eating disorder. Prompt diagnosis of acute gastric dilatation and decompression of the stomach even when gastric ischemia and mucosal necrosis is present, may avoid unnecessary laparotomy.

Acute massive gastric dilatation: severe ischemia and gastric necrosis without perforation.

Background and aims Acute appendicitis (AA) in the elderly (over 60 year-old) continues to pose diagnostic problems and carries a high morbidity and mortality rate. The aim of this article is to present our experience and outcomes and to evaluate influencing factors. Methods During a period of 5 years 63 patients with a definitive pathological diagnosis of AA were retrospectively analyzed. Results The primary admission diagnosis was established correctly in 44 patients (69.8%). Nineteen patients (30.1%) required further diagnostic investigations and the mean time to final diagnosis was 26 hours. For 3 patients (4.8%), the final diagnosis was established intra-operatively. The perforation rate was 31.8% (20 patients). Thirty-eight patients (63.3%) had associated co-morbidities. The overall mean duration of pre-hospitalization symptoms was 2.7 days, 2.3 days for non-perforated cases and 3.8 days for perforated AA (p=0.0025). The complication rate was 34.9% (22 patients), complications occurred in 75% of perforated appendicitis and in 16.2% of non-perforated cases (p=0.00001). Overall mortality rate was 6.3%, 15% in the perforated case group and 2.3% in the group with non-perforated appendicitis (p=0.0003). The mean hospital stay was significantly longer for cases with perforated AA (7.2 days) than non-perforated AA (5.1 days) (p=0.0056), and for patients developing complications (9.6 days) than those without complications (5.6 days) (p=0.0031). Conclusions Advanced age adversely affects clinical diagnosis, the stage of the disease and the outcomes. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with a poor outcome from surgery.

Acute appendicitis in the elderly patient: diagnostic problems, prognostic factors and outcomes.

Background: Emphysematous cholecystitis is a rare condition caused by ischemia of the gallbladder wall with secondary gas-producing bacterial proliferation. The pathophysiology and epidemiology of this condition differ from that in gallstone-related acute cholecystitis. This report illustrates a case of emphysematous cholecystitis successfully treated by laparoscopic surgery. Methods: An 83-year-old female patient was admitted to the hospital with acute abdominal syndrome. Clinical examination and blood tests suggested acute cholecystitis. Plain radiography revealed a circular gas pattern in the right upper quadrant suggestive of emphysematous cholecystitis. Subsequent computed tomography confirmed the presence of gas in the gallbladder wall and a gas-fluid level within the organ. Results: Emergency laparoscopic cholecystectomy was successfully performed during which bubbling of the gallbladder wall was observed. Intraoperative cholangiography revealed no bile duct stones or biliary obstruction. The patient made an unremarkable recovery from surgery with no postoperative complications or admission to the intensive care unit. Pathological analysis revealed fullthickness infarctive necrosis of the gallbladder. Bacterial cultures grew Clostridium perfringens. Conclusions: This case illustrates a typical case of emphysematous cholecystitis successfully treated by laparoscopic surgery. It contributes to suggestions from other reports that this condition can be safely treated by the laparoscopic approach.

A case of emphysematous cholecystitis managed by laparoscopic surgery.

The relationship between pelvic actinomycosis and the presence of an intrauterine device is well known. Abdominal wall actinomycosis with no involvement of pelvic organs in the presence of an intrauterine device is extremely rare. We report a case of a 32-year-old woman with a long-standing intrauterine device who developed abdominal wall actinomycosis. The diagnosis was established late by histopathological examination after an initial surgical procedure during which the abscess was evacuated and all the necrotic tissue was excised. Postoperatively, the patient developed two intra-abdominal abscesses, which were treated by surgical drainage. The combination of long-term high-dose antibiotic therapy with surgery led to successful management of the condition. We highlight the difficulty in diagnosis, necessity for an early postoperative diagnosis, and the importance of high-dose intravenous antibiotic therapy to prevent recurrence. Abdominal wall actinomycosis should be considered in intrauterine device users who present with abdominal abscesses of unknown origin.

Abdominal wall actinomycosis associated with prolonged use of an intrauterine device: a case report and review of the literature.

One of the most significant complications of the gastric banding procedure is gastric prolapse. However, pouch necrosis after gastric prolapse is an extremely rare complication. We present the case of a morbidly obese 41-year-old woman who had had a laparoscopic adjustable gastric banding procedure 3 years before. She developed a pouch necrosis after a late gastric prolapse. After failure of conservative treatment, a diagnostic laparoscopy was performed. This resulted in removal of the band and the diagnosis of pouch necrosis. A laparotomy was indicated and a sleeve gastrectomy was performed. A delay in the diagnosis of gastric prolapse can lead to major complications. Initial referral to a specialized center is necessary for proper care of this complication. Failure of conservative treatment mandates early operative intervention.

Sorinel Lunca

Papers

Acute massive gastric dilatation: severe ischemia and gastric necrosis without perforation.

Acute appendicitis in the elderly patient: diagnostic problems, prognostic factors and outcomes.

A case of emphysematous cholecystitis managed by laparoscopic surgery.

Abdominal wall actinomycosis associated with prolonged use of an intrauterine device: a case report and review of the literature.

Late gastric prolapse with pouch necrosis after laparoscopic adjustable gastric banding.