Ulusal Cer Derg 2014; 30: 214-218 DOI: 10.5152/UCD.2014.2643
Original Investigation / Özgün Araştırma
Isolated cecal necrosis: our surgical experience and a review of the literature İzole çekum nekrozu: cerrahi deneyimlerimiz ve literatürün gözden geçirilmesi Ekrem Çakar1, Feyzullah Ersöz1, Murat Bag2, Savaş Bayrak1, Şükrü Çolak1, Hasan Bektaş1, M. Emin Güneş1, Emel Çakar3 ABSTRACT
Objective: Isolated cecal necrosis is a rare cause of ischemic colitis. Ischemic colitis is further divided into two groups: occlusive mesenteric ischemia and non-occlusive mesenteric ischemia. The aim of this study was to investigate the cause of isolated cecal necrosis. Material and Methods: We operated on 3 male and 3 female patients with a mean age of 60.3±18.7 (38-85) years with a preliminary diagnosis of acute appendicitis between 2007 and 2012. Four of these patients were on hemodialysis, 1 patient had an aortofemoral bypass, and 1 patient had coronary artery disease with atrial fibrillation. Results: The diagnosis was made intraoperatively in all cases. Five patients died postoperatively. One patient survived. Conclusion: In the case of right lower quadrant pain, the possibility of isolated cecal necrosis should be kept in mind, especially in patients on hemodialysis, elderly patients with diabetes, and heart disease; surgical strategies should be planned accordingly, and it should be understood that a high mortality rate will be inevitable. Key Words: Isolated cecal necrosis, non-occlusive mesenteric ischemia, appendicitis
ÖZET
Amaç: İzole çekum nekrozu iskemik kolitin nadir görülen bir nedenidir. İskemik kolit ise oklüziv ve non-oklüziv mezenterik iskemi olmak üzere ikiye ayrılır. Bu çalışmanın amacı izole çekum nekrozunun nedenlerini araştırmaktır. Gereç ve Yöntemler: 2007-2012 tarihleri arasında yaş ortalamaları 60,3±18,7 (38-85) yıl olan 3 erkek ve 3 kadın hasta akut apandist ön tanısı ile ameliyat edildi. Bu hastaların 4’ü hemodiyaliz hastası, 1’i aortofemoral bypasslı, 1’i atriyal fibrilasyonlu koroner hastalığı olan hastalardı.
Clinic of General Surgery, İstanbul Training and Research Hospital, İstanbul, Turkey 1
Clinic of General Surgery, Kocaeli State Hospital, Kocaeli, Turkey 2
Department of Nursing, İstanbul Gelişim University, İstanbul, Turkey
Bulgular: Tüm olgularda tanı intraoperatif olarak konuldu. Beş hasta postoperatif dönemde kaybedildi. Bir hasta yaşadı. Sonuç: Özellikle hemodiyaliz, diyabet ve kalp hastalığı olan yaşlı hastalarda sağ alt kadran ağrısı olması durumunda izole çekum nekrozu olasılığı akılda tutulmalı, ameliyat stratejileri buna göre planlanmalı ve yüksek mortalitenin kaçınılmaz olacağı bilinmelidir. Anahtar Kelimeler: İzole çekum nekrozu, non-oklüziv mezenter iskemisi, apandisit
3
Address for Correspondence Yazışma Adresi Ekrem Çakar Clinic of General Surgery, İstanbul Training and Research Hospital, İstanbul, Turkey Phone: +90 505 578 40 57 e-mail: [email protected] Received / Geliş Tarihi: 10.01.2014 Accepted / Kabul Tarihi: 05.04.2014 ©Copyright 2014 by Turkish Surgical Association Available online at www.ulusalcerrahidergisi.org ©Telif Hakkı 2014 Türk Cerrahi Derneği
214
Makale metnine www.ulusalcerrahidergisi.org web sayfasından ulaşılabilir.
INTRODUCTION Isolated cecal necrosis is a rare condition that occurs secondary to multiple causes. It develops especially when the anterior and posterior cecal arteries do not originate from a vascular arcade but from the colic branch of ileocolic artery. Vaso-occlusive infarcts have been reported to occur after atheroembolic or thromboembolic occlusions of the cecal arteries in this anatomical variation (1, 2). On the other hand, non-occlusive cecal infarction has also been reported to be associated with shock, open-heart surgery, chronic heart disease, certain drugs, and hemodialysis (3-8). Isolated cecal necrosis generally presents with right lower quadrant abdominal pain, and with these manifestations, it may mimic acute appendicitis. Due to high rates of morbidity and mortality, it must be considered in the differential diagnosis of pain in the right lower quadrant of the abdomen. The aim of this study is to remind that less common causes should be considered in the differential diagnosis of right lower quadrant pain and to examine 6 cases of isolated cecal necrosis seen at our clinic within a 5-year period in light of the literature. MATERIAL AND METHODS Six cases of isolated cecal necrosis presented to the emergency department of İstanbul Training and Research Hospital General Surgery Clinic between 2007 and 2012 with acute abdominal pain mimicking physical examination findings of acute appendicitis were evaluated. Written informed consent was obtained from patients who participated in this study. Six patients were analyzed retrospectively. Data were obtained from hospital records. Data regarding their age, sex, diagnosis on admission, comorbid diseases, clinical and laboratory findings, and imaging techniques were reviewed according to the surgical procedures and postoperative follow-up performed (Table 1, 2). The cases consisted of 3 male and
Ulusal Cer Derg 2014; 30: 214-218
3 female patients with a mean age of 60.3±18.7 (38-85) years at diagnosis. All patients had a preliminary diagnosis of acute appendicitis at diagnosis. The medical histories of these 6 patients revealed that 4 were chronic hemodialysis patients, 1 Table 1. Clinical and laboratory findings of the patients with isolated cecal necrosis Findings Number of cases Abdominal pain
6
Defense in the right lower quadrant of the abdomen
6
Vomiting 2 Arterial hypotension episodes during hemodialysis
4
Fever >37.5°C
2
Shock (Max. blood pressure
Original Investigation / Özgün Araştırma
Isolated cecal necrosis: our surgical experience and a review of the literature İzole çekum nekrozu: cerrahi deneyimlerimiz ve literatürün gözden geçirilmesi Ekrem Çakar1, Feyzullah Ersöz1, Murat Bag2, Savaş Bayrak1, Şükrü Çolak1, Hasan Bektaş1, M. Emin Güneş1, Emel Çakar3 ABSTRACT
Objective: Isolated cecal necrosis is a rare cause of ischemic colitis. Ischemic colitis is further divided into two groups: occlusive mesenteric ischemia and non-occlusive mesenteric ischemia. The aim of this study was to investigate the cause of isolated cecal necrosis. Material and Methods: We operated on 3 male and 3 female patients with a mean age of 60.3±18.7 (38-85) years with a preliminary diagnosis of acute appendicitis between 2007 and 2012. Four of these patients were on hemodialysis, 1 patient had an aortofemoral bypass, and 1 patient had coronary artery disease with atrial fibrillation. Results: The diagnosis was made intraoperatively in all cases. Five patients died postoperatively. One patient survived. Conclusion: In the case of right lower quadrant pain, the possibility of isolated cecal necrosis should be kept in mind, especially in patients on hemodialysis, elderly patients with diabetes, and heart disease; surgical strategies should be planned accordingly, and it should be understood that a high mortality rate will be inevitable. Key Words: Isolated cecal necrosis, non-occlusive mesenteric ischemia, appendicitis
ÖZET
Amaç: İzole çekum nekrozu iskemik kolitin nadir görülen bir nedenidir. İskemik kolit ise oklüziv ve non-oklüziv mezenterik iskemi olmak üzere ikiye ayrılır. Bu çalışmanın amacı izole çekum nekrozunun nedenlerini araştırmaktır. Gereç ve Yöntemler: 2007-2012 tarihleri arasında yaş ortalamaları 60,3±18,7 (38-85) yıl olan 3 erkek ve 3 kadın hasta akut apandist ön tanısı ile ameliyat edildi. Bu hastaların 4’ü hemodiyaliz hastası, 1’i aortofemoral bypasslı, 1’i atriyal fibrilasyonlu koroner hastalığı olan hastalardı.
Clinic of General Surgery, İstanbul Training and Research Hospital, İstanbul, Turkey 1
Clinic of General Surgery, Kocaeli State Hospital, Kocaeli, Turkey 2
Department of Nursing, İstanbul Gelişim University, İstanbul, Turkey
Bulgular: Tüm olgularda tanı intraoperatif olarak konuldu. Beş hasta postoperatif dönemde kaybedildi. Bir hasta yaşadı. Sonuç: Özellikle hemodiyaliz, diyabet ve kalp hastalığı olan yaşlı hastalarda sağ alt kadran ağrısı olması durumunda izole çekum nekrozu olasılığı akılda tutulmalı, ameliyat stratejileri buna göre planlanmalı ve yüksek mortalitenin kaçınılmaz olacağı bilinmelidir. Anahtar Kelimeler: İzole çekum nekrozu, non-oklüziv mezenter iskemisi, apandisit
3
Address for Correspondence Yazışma Adresi Ekrem Çakar Clinic of General Surgery, İstanbul Training and Research Hospital, İstanbul, Turkey Phone: +90 505 578 40 57 e-mail: [email protected] Received / Geliş Tarihi: 10.01.2014 Accepted / Kabul Tarihi: 05.04.2014 ©Copyright 2014 by Turkish Surgical Association Available online at www.ulusalcerrahidergisi.org ©Telif Hakkı 2014 Türk Cerrahi Derneği
214
Makale metnine www.ulusalcerrahidergisi.org web sayfasından ulaşılabilir.
INTRODUCTION Isolated cecal necrosis is a rare condition that occurs secondary to multiple causes. It develops especially when the anterior and posterior cecal arteries do not originate from a vascular arcade but from the colic branch of ileocolic artery. Vaso-occlusive infarcts have been reported to occur after atheroembolic or thromboembolic occlusions of the cecal arteries in this anatomical variation (1, 2). On the other hand, non-occlusive cecal infarction has also been reported to be associated with shock, open-heart surgery, chronic heart disease, certain drugs, and hemodialysis (3-8). Isolated cecal necrosis generally presents with right lower quadrant abdominal pain, and with these manifestations, it may mimic acute appendicitis. Due to high rates of morbidity and mortality, it must be considered in the differential diagnosis of pain in the right lower quadrant of the abdomen. The aim of this study is to remind that less common causes should be considered in the differential diagnosis of right lower quadrant pain and to examine 6 cases of isolated cecal necrosis seen at our clinic within a 5-year period in light of the literature. MATERIAL AND METHODS Six cases of isolated cecal necrosis presented to the emergency department of İstanbul Training and Research Hospital General Surgery Clinic between 2007 and 2012 with acute abdominal pain mimicking physical examination findings of acute appendicitis were evaluated. Written informed consent was obtained from patients who participated in this study. Six patients were analyzed retrospectively. Data were obtained from hospital records. Data regarding their age, sex, diagnosis on admission, comorbid diseases, clinical and laboratory findings, and imaging techniques were reviewed according to the surgical procedures and postoperative follow-up performed (Table 1, 2). The cases consisted of 3 male and
Ulusal Cer Derg 2014; 30: 214-218
3 female patients with a mean age of 60.3±18.7 (38-85) years at diagnosis. All patients had a preliminary diagnosis of acute appendicitis at diagnosis. The medical histories of these 6 patients revealed that 4 were chronic hemodialysis patients, 1 Table 1. Clinical and laboratory findings of the patients with isolated cecal necrosis Findings Number of cases Abdominal pain
6
Defense in the right lower quadrant of the abdomen
6
Vomiting 2 Arterial hypotension episodes during hemodialysis
4
Fever >37.5°C
2
Shock (Max. blood pressure
