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Rationale: Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands installed after a surgical procedure. However, SBO caused by surgical staples used in a previous operation is unusual. Herein, we report a rare case of adhesive ileus induced by surgical staples., Patient's Concerns: A 58-year-old woman visited our Emergency Department with right lower quadrant (RLQ) pain and vomiting. The patient had undergone laparoscopic total hysterectomy with the Endo GIA stapler for uterine myoma 6 years prior., Diagnoses: Computed tomography (CT) revealed a closed-loop obstruction with volvulus involving the distal ileum., Interventions: After suspected failure of conservative therapy with fluid resuscitation and Levin tube decompression, emergency laparoscopic surgery was performed. A fibrous band around the surgical staples considered to have been used in a previous operation was observed which extended to the greater omentum, through which a segment of the bowel formed a closed-loop obstruction around the right ovary., Outcomes: The patient's symptoms resolved and a follow-up on post-operative day 14 showed no symptoms., Lessons: Surgeons using surgical staples should be aware that adhesion may occur when the staples are exposed to the abdominal cavity, which can lead to the risk of SBO several years after surgery. Thus, staples should not be exposed to the abdominal cavity, or anti-adherent substances should be used to minimize the possibility of such complications.

Rationale: Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disorder; prompt diagnosis is vital. Surgical treatment is often required, but some cases can be treated conservatively. We herein report an extremely rare case wherein protein-losing enteropathy (PLE) developed after conservative treatment of NOMI., Patient Concerns: The patient was a 66-year-old man. He underwent laparoscopic super low anterior resection and temporary ileostomy for sigmoid colon cancer and rectum cancer. During the postoperative course, he developed ileus. Subsequently, he developed shock. On examination, the possibility of NOMI could not be denied, but intestinal necrosis was absent. Conservative treatment was initiated. His general condition improved, but the ileus persisted. Therefore, we performed a stoma closure. Ten days after stoma closure, he developed continuous unexplained diarrhea. The serum albumin and total protein levels were low. The symptoms improved after administration of an antidiarrheal drug, but the root cause was yet untreated., Diagnosis: The patient's alpha-1 antitrypsin clearance was increased. A CT scan revealed an enhanced hypertrophied wall of the short segment of the small intestine, and 99m Tc-labeled human serum albumin scintigraphy revealed protein leakage into the thickened wall of the small intestine. We arrived at a definitive diagnosis of PLE secondary to NOMI., Interventions: Partial resection of the affected small intestine was performed., Outcomes: The patient recovered uneventfully and was discharged on the 30th postoperative day., Lessons: NOMI has a high mortality rate, often requiring intestinal resection immediately after onset. To our knowledge, there is no report of PLE developing after conservative treatment, as in our case. Further study of cases is necessary to determine the reversibility of the condition, which will influence the therapeutic plan. We herein present an extremely rare case of PLE after conservative treatment for NOMI. The possibility of PLE also needs to be considered when hypoalbuminemia occurs after conservative treatment of NOMI.

Rationale: Gallstone ileus is a rare complication of cholecystolithiasis. It has a female predominance and can result in high mortality rates., Patient Concerns: A 71-year-old woman complaining of recurrent vomiting and vague epigastralgia for > 2 weeks presented to our department., Diagnosis: Based on her physical examination, laboratory test results and radiographic findings (the typical Rigler's triad), she was diagnosed with gallstone ileus caused by multiple ectopic stones., Interventions: After correction of electrolyte imbalances through parenteral nutrition and fluid management, the patient's condition improved and she underwent enterolithotomy. A 5.3-cm stone located 40 cm from the ligament of Treitz was extracted, and a second ectopic stone, not detected on any imaging modality, was found during laparotomy. Given her comorbidities and overall poor condition, cholecystectomy and fistula repair were not performed., Outcomes: The patient gradually recovered postoperatively., Lessons: Clinical symptoms including epigastralgia with nausea and vomiting, and abdominal CT findings of Rigler's triad (ectopic gallstone, bowel obstruction, and pneumobilia) may lead to early diagnosis of gallstone ileus and enterolithotomy may be the preferred treatment for this condition in the elderly. Laparotomy should involve a systematic and meticulous search for the presence of additional ectopic enteric stones.

Objective: To identify clinical hallmarks associated with recovery of gastrointestinal transit., Background: Impaired gastrointestinal transit or postoperative ileus largely determines clinical recovery after abdominal surgery. However, validated clinical hallmarks of gastrointestinal recovery to evaluate new treatments and readiness for discharge from the hospital are lacking., Methods: Gastric emptying and colonic transit were scintigraphically assessed from postoperative day 1 to 3 in 84 patients requiring elective colonic surgery and were compared with clinical parameters. The clinical hallmark that best reflected recovery of gastrointestinal transit was validated using data from a multicenter trial of 320 segmental colectomy patients., Results: Seven of 84 patients developed a major complication with paralytic ileus characterized by total inhibition of gastrointestinal motility and were excluded from further analysis. In the remaining patients, recovery of colonic transit (defined as geometric center of radioactivity ≥2 on day 3), but not gastric emptying, was significantly correlated with clinical recovery (ρ = -0.59, P < 0.001). Conversely, the combined outcome measure of tolerance of solid food and having had defecation (SF + D) (area under the curve = 0.9, SE = 0.04, 95% CI = 0.79-0.95, P < 0.001), but not time to first flatus, best indicated recovery of gastrointestinal transit with a positive predictive value of 93% (95% CI = 78-99). Also in the main clinical trial, multiple regression analysis revealed that SF + D best predicted the duration of hospital stay., Conclusions: Our data indicate that the time to SF + D best reflects recovery of gastrointestinal transit and therefore should be considered as primary outcome measure in future clinical trials on postoperative ileus.(Netherlands National Trial Register, number NTR1884 and NTR222).

Ileus development has been associated with a wide range of complications among hospitalized patients, ranging from increased patient pain and discomfort to malnutrition, aspiration, delayed rehabilitation, and sepsis. This article examines factors that appeared to correlate with an increase in ileus development among patients in a trauma/surgical intensive care unit, with the goal of preventing the condition through nursing practice changes., (© 2011 Lippincott Williams & Wilkins.)

Objectives: : Considering the hazards of pulmonary aspiration of oral contrast material (OCM) during general anesthesia, we investigated the gastric emptying time (GET) of OCM in children and adolescents undergoing abdominal computed tomography (CT)., Patients and Methods: : Included in the study were 101 consecutive patients ages 3.1 to 17.9 years (mean age 12.2 +/- 3.3 years), who underwent contrast-enhanced abdominal CT for suspected acute appendicitis (n = 90), abdominal trauma (n = 10), or suspected ileus (n = 1). Oral iodinated ioxithalamate was given for bowel opacification. Background data (age, sex, weight, chronic diseases, and medication intake), time of initiation and completion of OCM, and time of CT scanning were recorded. To estimate the GET of OCM, CT images were reviewed to examine whether the stomach was empty or full of OCM at the time of imaging., Results: : The Kaplan-Meier curve showed that 75% of the patients had OCM in the stomach 48 +/- 5.2 minutes after its completion, 50% after 74 +/- 7.9 minutes, and 25% after 135 +/- 32.5 minutes; 1 patient still had OCM after 162 minutes. Except for the length of time taken to drink the contrast material (< or =90 minutes was associated with slower empting of the stomach; log rank, P = 0.03), GET of OCM was not correlated with sex (P = 0.16), age (P = 0.15), weight (P = 0.13), or type of diagnosis (P = 0.41)., Conclusions: : Given the variability of GET of OCM and if clinically feasible, we advocate waiting at least 3 hours between completion of OCM ingestion and general anesthesia induction.

Gallstone ileus is an uncommon cause of mechanical obstruction due to a biliary stone that wedges the intestinal lumen. It is a surgical emergency representing a clinical and diagnostic challenge: the clinical manifestations are rarely specific, often causing diagnostic delay that can adversely affect the prognosis. Emergency ultrasound could be useful in assessing the level and identifying the cause of bowel obstruction. We report a case of a 74-year-old patient with a 6-day history of constipation and crampy abdominal pain without previous history of abdominal diseases. Emergency ultrasound led to an early diagnosis showing dilated small bowel loops with a shadowing mass inside consistent with an ileal stone, in the absence of aberrant located stone on plain abdominal film.