Acute Colonic Pseudo-Obstruction (Ogilvieʼs Syndrome) after Hip Arthroplasty

Ogilvieʼs syndrome is a clinical entity that occurs with signs of excessive dilatation of the colon and obstruction, despite the absence of a mechanical obstruction. Although its etiology remains uncertain, anticholinergic drugs, metabolic disorders, diabetes mellitus, hyperparathyroidism, Parkinsonʼs disease, major orthopedic interventions, or blunt abdominal trauma are considered to be possible causes. Imbalance in sympathetic innervation plays a role in the pathogenesis. The characteristic feature of the syndrome is the presence of a major trauma or surgical history. Although this is an uncommon complication, especially after hip and knee arthroplasty, it is an important cause of mortality and morbidity. Conservative or surgical colonic decompression and anticholinergic agents play a role in the treatment of Ogilvieʼs syndrome, which is defined as acute colonic pseudo-obstruction (ACPO). In this case report, we present the postoperative process of an elderly patient with comorbid diseases who underwent hemiarthroplasty due to a hip fracture as a result of a domestic fall. We will discuss the diagnosis of ACPO and the approach to multidisciplinary management of the treatment in a case that is frequently encountered in daily practice and starts as a normal report. We aim to remind surgeons that they may encounter ACPO in the postoperative period and to emphasize that mortality and morbidity can be reduced with early diagnosis and a multidisciplinary approach. We would like to emphasize that Ogilvieʼs syndrome should be included in the differential diagnosis portfolio of all orthopedic surgeons.

Asystole Following Concomitant Intravenous Administration of Neostigmine and Dexmedetomidine in a Patient With Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a condition characterized by acute dilation of the large bowel without evidence of mechanical obstruction that occurs in a variety of hospitalized patients with many predisposing factors. Management includes supportive care and limitation of offending medications with mainstays of treatment of neostigmine administration and colonic decompression. We report the case of a critically ill patient with ACPO who experienced bradycardia and a brief episode of asystole when receiving concomitant dexmedetomidine and neostigmine infusions but who later remained hemodynamically stable when receiving propofol and neostigmine infusions. The bradycardia and associated hemodynamic instability experienced while on dexmedetomidine and neostigmine infusions were rapidly corrected with atropine and cessation of offending agents. Because ACPO is encountered frequently and the use of dexmedetomidine as a sedative agent in the ICU is increasing, practitioners should be aware of the additive risk of bradycardia and potential for asystole with the combination of neostigmine and dexmedetomidine. Electronic drug interaction databases should be updated and drug information sources should include a drug-drug interaction between dexmedetomidine and neostigmine to reduce the likelihood of concomitant administration.

Self-Expanding Metal Stent Insertion by Colorectal Surgeons Using a Two-Person Approach Colonoscopy Without Fluoroscopic Monitoring in the Management of Acute Colorectal Obstruction: A 14-Year Experience

Background Placement of a self-expanding metal stent (self-expanding metal stent, SEMS) in patients presenting with kinds of colorectal disease as an acute colorectal obstruction (acute colorectal obstruction, ACO) may obviate emergency surgery(emergency surgery, ES), potentially effectively palliating incurable tumours, acting as a bridge to surgery (bridge to surgery, BTS) in patients with operable or potentially operable tumours and achieving effective decompression of other colorectal obstruction diseases. We present our experience with SEMS insertion by colorectal surgeons without fluoroscopic monitoring for ACO especially for acute malignant colorectal obstruction (acute malignant colorectal obstruction, AMCO) nearly a 14-year period (2007–2020).Methods We retrospectively reviewed the medical records of patients to identify all patients presenting to our unit with ACO especially with AMCO who had stenting carried out to achieve colonic decompression. All 434 procedures were performed by colorectal surgeons using a two-person approach colonoscopy and a conventional endoscope without fluoroscopic monitoring. Results The overall technique success rate by SEMS insertion was (428/434, 98.6%), the overall clinic success rate by SEMS insertion was (412/434, 94.9%), and the overall incidence of complications was (19/434, 4.4%). The complications included clinical perforation (6/434, 1.4%), stent migration (2/434, 0.5%), one of which re-stent; stent detachment (fell off)(3/434, 0.7%), none of them with re-stent; stool impaction (6/434, 1.4%), 1 of which re-stent; abdominal pain or anal pain (2/434, 0.5%). There was no hemorrhage in any of the 434 patients. Conclusions SEMS insertion is a relative safe and effective technique for colonic decompression in the dealing with ACO as either a bridge to subsequent resection surgery or as palliative measure, or solution to other causes such as recurrent tumor、benign diseases or extra-luminal compression. Therefore, ES was largely avoided.

Transmesocolon internal hernia masking as simple sigmoid volvulus

Transmesocolon internal hernias are very rare causes of bowel obstruction. Transmesenteric internal hernias normally associated with small bowel. It can be challenging to diagnose transmesocolon internal hernia hence we present a 93-year-old patient who was misdiagnosed with simple sigmoid volvulus on CT abdomen. She underwent endoscopic colonic decompression. Patient continued to deteriorate in the ward, and CT abdomen was repeated; it revealed the cause of the sigmoid volvulus was due to a defect through transverse mesocolon resulting in internal hernia. Patient was diagnosed with transmesocolic internal hernia with sigmoid volvulus. Patient underwent emergency laparotomy and Hartmann procedure. Transmesocolic internal hernia can be easily missed and needs to be considered when diagnosing patients with large bowel volvulus or obstruction.

Safety and Efficacy of Intermittent Bolus and Continuous Infusion Neostigmine for Acute Colonic Pseudo-Obstruction

Purpose: To compare clinical response of intermittent bolus versus continuous infusion neostigmine for acute colonic pseudo-obstruction (ACPO). Acute colonic pseudo-obstruction occurs due to reduced colonic parasympathetic activity. Neostigmine is an acetylcholinesterase inhibitor that increases frequency of smooth muscle contraction by increasing acetylcholine at autonomic nervous system synapses. Although these administration modalities have been studied separately, they have never been compared. Methods: This retrospective study compared bolus versus continuous infusion neostigmine for ACPO. The primary outcome was initial clinical response, defined as bowel movement (BM) within 4 hours of bolus dose or 24 hours of initiation of continuous infusion. Secondary outcomes included time to BM, bowel diameter reduction at 24 hours, incidence of bradycardia, additional neostigmine requirements, and need for colonic decompression or surgical intervention. Results: Seventy-five patients were included (bolus n = 37; infusion n = 38). Median total 24-hour neostigmine dose was 2.0 mg (interquartile range [IQR]: 2.0-2.6) with bolus and 9.6 mg (IQR: 6.3-9.6) with continuous infusion. Initial clinical response was similar (infusion 81.6% vs bolus 62.2%, P = .06), but continuous infusion was associated with greater bowel diameter reduction (73.7% vs 40.5%, P = .004). Bolus administration had shorter time to BM (1.4 vs 3.5 hours, P = .0478) and increased need for colonic decompression (67.6% vs 39.5%, P = .0148). Bolus dosing was associated with less bradycardia (13.5% vs 39.5%, P = 0.011), with no difference in atropine usage (10.8% vs 5.3%, P = .43). Conclusion: Initial clinical response was similar between groups; however, continuous infusion neostigmine was associated with greater bowel diameter reduction at 24 hours. Bolus administration resulted in less bradycardia; however, given the lack of difference in atropine use, clinical significance is unknown. This study is the first to compare bolus versus continuous infusion neostigmine for ACPO. Further studies are needed to confirm findings.

From Endoscopic Detorsion to Sigmoid Colectomy—The Art of Managing Patients with Sigmoid Volvulus: A Survey of the Members of the American Society of Colon and Rectal Surgeons

This study queried American Society of Colon and Rectal Surgeons members for management of sigmoid volvulus and aimed to determine whether surgeon experience impacts decision-making. American Society of Colon and Rectal Surgeons members received a 16-item survey in March, 2017. Items included endoscopic detorsion technique and colonic decompression, preoperative dietary considerations, surgical approach, and respondents’ demographics. Respondents were separated into low experience (LE; ≤10 years in practice) and high experience (HE; >10 years in practice). Of 1996 survey recipients, 10 per cent (197) responded; 124 were HE and 73 were LE. Most were fellowship-trained (93.8%) and primarily in colorectal surgery practice (74.6%), however only 27.4 per cent managed >20 sigmoid volvulus cases as attendings. Fifty-two per cent use rectal tubes for continued colonic decompression after successful endoscopic detorsion; 81.2 per cent would perform sigmoid colectomy on the index admission after successful detorsion, but within a variable timeframe (one to seven days postdetorsion) and with variable dietary restrictions in the interval period; 49.7 per cent would perform a laparoscopic colectomy and 68.3 per cent would perform a stapled colorectal anastomosis. LE surgeons reported a higher proportion of gastrointestinal-performed endoscopic detorsions (P = 0.015), were more likely allow regular diet in the interval period (P = 0.031), and were more inclined to use laparoscopy (P = 0.008), versus HE surgeons. There remains controversy among many of the components in the management of sigmoid volvulus after successful endoscopic detorsion.