Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer

AIM:To evaluate the main factors associated with mortality in patients undergoing surgery for perforated peptic ulcer referred to an academic department of general surgery in a large southern Italian city. METHODS:One hundred and forty-nine consecutive patients (M:F ratio=110:39,mean age 52 yrs,range 16-95) with peptic ulcer disease were investigated for clinical history (including age,sex,previous history of peptic ulcer,associated diseases,delayed abdominal surgery,ulcer site,operation type,shock on admission,postoperative general complications, and intra-abdominal and/or wound infections),serum analyses and radiological findings. RESULTS:The overall mortality rate was 4.0%.Among all factors,an age above 65 years,one or more associated diseases,delayed abdominal surgery,shock on admission, postoperative abdominal complications and/or wound infections,were significantly associated (x^2) with increased mortality in patients undergoing surgery (0.0001<P<0.03). CONCLUSION:Factors such as concomitant diseases,shock on admission,delayed surgery,and postoperative abdominal and wound infections are significantly associated with fatal outcomes and need careful evaluation within the general workup of patients admitted for perforated peptic ulcer.

Hepatic abscess secondary to a rosemary twig migrating from the stomach into the liver

The ingestion of a foreign body that penetrates the gastric wall and migrates to the liver,where it causes an abscess is uncommon. A case of an ingested rosemary twig perforating the gastric antrum,then migrating to the liver,complicated by hepatic abscess and Staphylococcus aureus sepsis is reported. A 59-year-old man without a history of foreign body ingestion was admitted to our hospital because of sepsis and epigastralgia,which had progressively worsened. No foreign body was identified at preoperative imaging,but a rosemary twig was discovered during laparotomy. The liver abscess and sepsis were controlled successfully with surgery and antibiotics. This unusual condition should be kept in mind when dealing with cases of hepatic abscess,or even sepsis of unknown origin. Despite the improvement of non-surgical techniques such as percutaneous drainage and interventional endoscopy,surgery still remains important in the treatment of hepatic abscess caused by an ingested foreign body.

Gut perforation after orthotopic liver transplantation in adults

AIM： To describe cases of gut perforation after orthotopic liver transplantation.METHODS： Data were colleted from our center database and medical records. Six of 187 patients （3.2%）who underwent orthotopic liver transplantation from January to December 2005 developed gut perforation.All patients were male with an average age of 46 years.Modified piggyback liver transplantation was performed at the Organ Transplantation Center, First Affiliated Hospital, Sun Yat-Sen University.RESULTS： Previous operation, steroid therapy, and prolonged portal venous cross clamp time, poor nutritional status and iatrogenic injury were found to be its ecological factors. The patients with gut perforation were found to have fever, increased leukocytes, mild abdominal pain and tenderness. The median portal venous clamp time was 63 min （range 45-72 min）,median cold ischaemia time was 11.3 h （range 7-15 h）.Median intraoperative blood loss was 500 mL （range 100-1200 mL） and median operation time was 8.8 h （range 6-12 h）. None of the six patients developed acute cellular rejection. White cell count was above 18 × 10^9/L in five patients （neutrophilic leukocytes were above 90%） and 1.5 × 10^9/L in one patient. Bacterial culture in drainage liquid revealed enterococci in five patients. Of the 6 patients undergoing orthotopic liver transplantation, 3 survived and 3 died after modified piggyback liver transplantation.CONCLUSION： Gut perforation occurs after orthotopic liver transplantation in adults. A careful and minimal dissection during OLT, longer retention of the stomach tube, and reducing the portal clamp time and steroid dose should be taken into consideration. If gut perforation is not prevented, then early diagnosis,preferably through detection of enterococci may ensure better survival.