Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
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American Journal of Microbiological Research
Biomedical Science and Engineering

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Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

An Unusual Case of Bowel Evisceration after Sneezing

Jason Jones*, Alicia Buck, Jeffrey Adams, Anthony Meyer

Department of Emergency Medicine, University of Florida, Gainesville, FL, USA

Abstract: Evisceration is a rare complication of abdominal surgery. This case report describes small bowel evisceration through a healed cystectomy surgical site after sneezing and coughing. Perspectives from the emergency responders, the patient, and his surgeons are discussed. When evisceration occurs, patients may be unsure of how to protect their exposed intestines. First medical responders may experience anxiety with initial management due to a distressing presentation and unfamiliarity with the condition. Surgeons must carefully protect the bowel, reduce it into the abdomen, inspect it for injury, prevent infection, and repair the dehisced wound

Keywords: Bowel evisceration, cystectomy, complication, emergency medical services, sneezing, coughing

Received April 20, 2024; Revised May 21, 2024; Accepted May 28, 2024

Citation: Jason Jones, Alicia Buck, Jeffrey Adams, Anthony Meyer, An Unusual Case of Bowel Evisceration after Sneezing. American Journal of Medical Case Reports, 12 (6). 85-86. January 2024. doi:10.12691/ajmcr-12-6-1

1. Introduction

Cystectomy is a surgical procedure to remove the entire urinary bladder, typically performed for bladder cancer, which accounts for 3% of all cancers worldwide [1,2]. A 2019 Cochrane review described radical cystectomy with urinary diversion as “the gold standard surgical treatment” for invasive bladder cancer [3]. An estimated 5 to 8% of cystectomy cases are performed for non-cancer reasons, including radiation cystitis and refractory incontinence [4]. Open radical cystectomy is a complex procedure, with one study reporting a complication rate of 64% within 90 days [5]. Though wound dehiscence is a known post-operative complication, bowel evisceration through the abdominal wall after cystectomy has rarely been reported.

In this case report, we describe a spontaneous bowel evisceration through a cystectomy incision site occurring 15 days after surgical closure.

2. Case Presentation

A 63-year-old man was eating breakfast with his wife at a diner. He had a history of prostate cancer treated with robotic-assisted laparoscopic prostatectomy 9 years prior to the event. Despite the surgery, he was found to have biochemical recurrence (persistent elevation of Prostate Specific Antigen), which was treated with several months of salvage radiation therapy. This therapy induced radiation cystitis, causing episodes of gross hematuria resulting in bilateral hydronephrosis. Fifteen days prior, the patient underwent operative treatment for these conditions: open cystectomy with bilateral uretoileal conduit diversion. The surgery was successful, and he was discharged home in good condition. On the morning of the event, he returned to Urology clinic, where his wound appeared well-healed and the overlying staples were removed. He and his wife went to breakfast to celebrate.

During breakfast, the man sneezed forcefully, followed by coughing. He immediately noticed a “wet” sensation and pain in his lower abdomen. Looking down, he observed several loops of pink bowel protruding from his recent surgical site. He later related that he was unsure of how to proceed, so he covered the exposed intestines with his shirt. He initially decided to drive himself to the hospital, but concerned that changing his position might injure his bowel, his wife requested an ambulance.

An advanced life support ambulance arrived at the diner 4 minutes after being requested for a “laceration with exposed bowel.” After removing a fluid-soaked shirt, the paramedic noted an approximately 3 inch (7.6 cm) vertical laceration with “large amounts of bowel” protruding through it (Figure 1). Only minimal bleeding was seen.

Figure 1. Illustration of initial abdominal examination

The paramedic described that she was initially unsure of the best treatment, as her medical protocols did not have specific guidelines for treating evisceration. She briefly considered manually reducing the exposed bowel back into his abdomen under sterile technique, but declined due to concerns that this might injure the bowel. She remembered watching two lectures about penetrating trauma and gastroschisis that both recommended keeping exposed bowel moist. In response, she covered the intestines with an abdominal pad moistened with saline, securing it in place by wrapping gauze roll around the entire abdomen. She inserted an IV and administered fentanyl and ondansetron before arriving at the hospital.

In the Emergency Department, the Urology service was consulted immediately. Vital signs were within normal limits. Pre-operative blood tests were obtained and noted to be unchanged from recent comparisons. A nasogastric tube was inserted, and the patient consented to receive an exploratory laparotomy.

In the operating room, the patient received pre-operative antibiotics (vancomycin and piperacillin / tazobactam) and general anesthesia with endotracheal intubation. The patient was placed supine, prepped, and draped. Three Urologic surgeons carefully reduced the eviscerated bowel back into the abdominal cavity. They inspected the full length of the small bowel and noted no evidence of injury. The peritoneal cavity was irrigated with normal saline and a gentamicin solution. The suture line was noted to have dehisced at its center and was closed with a variety of sutures, including: interrupted, figure-of-eight, vertical mattress, and internal retention sutures. Two Jackson-Pratt surgical drains were placed into the abdominal cavity for fluid collection. The skin was then closed with staples, and a negative-pressure wound vacuum was applied.

The patient was weaned from sedation and extubated in the post-anesthesia care unit. Over several days, the patient’s pain was controlled with IV analgesia, his wound vacuum and tubes were removed, and his diet was slowly advanced to a regular diet. He was discharged on post-operative day 6 in good condition, with a reassuring abdominal examination (Figure 2). The final discharge diagnosis from his surgeons was “evisceration.”

Figure 2. Illustration of abdominal examination after surgical repair

3. Discussion

Wound dehiscence is a well-described complication of open cystectomy. A 2023 meta-analysis of 772 radical cystectomy cases reported an overall post-operative wound dehiscence rate of 6.9%, with individual studies ranging between 0% and 27% [6]. A 2016 review of 1,776 open cystectomy cases identified chronic obstructive pulmonary disease (COPD) and a high body mass index as the two independent predictors of wound dehiscence [7]. Our patient has neither of these conditions. Nevertheless, in that study, COPD was felt to be a risk factor because it causes coughing, which can induce wound dehiscence or evisceration by forcefully raising intraabdominal pressure. Coughing was likely the cause in our case.

While wound dehiscence is a well-known complication, this case is important because evisceration through the abdominal surgical site after cystectomy is poorly described in the medical literature. A PubMed search for “cystectomy AND evisceration” performed in May 2024 provided only 7 results related to evisceration through the abdominal wall after cystectomy.

In this case, the responding paramedic did not have a protocol for treating evisceration. Emergency Medical Services medical directors might consider incorporating the guidelines for abdominal evisceration published by Tactical Combat Casualty Care, including: control visible bleeding, address gross contamination by rinsing the bowel with sterile saline or sterile water, cover the exposed bowel with a "moist, sterile dressing or a sterile water-impermeable covering," and irrigate these dressings as needed with additional sterile fluid [8].

References

[1]   | Aminoltejari, K. and Black, P.C., “Radical cystectomy: a review of techniques, developments and controversies,” Translational Andrology and Urology. 9 (6). 3073-3081. Dec 2020.
[2]   | Ferlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., Parkin, D.M., Forman, D. and Bray, F. “Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.” International Journal of Cancer. 136 (5). 359-386. Mar 2015.
[3]   | Rai, B.P., Bondad, J., Vasdev, N., Adshead, J., Lane, T., Ahmed, K., Khan, M.S., Dasgupta, P., Guru, K., Chlosta, P.L. and Aboumarzouk, O.M. “Robotic versus open radical cystectomy for bladder cancer in adults.” Cochrane Database of Systematic Reviews. 4 (4). Apr 2019.
[4]   | Aftreth, O.P., Tenggardjaja, C.F. and Reyblat, P. “Cystectomy for Benign Indications.” Current Urology Reports. 23(9). 195-201. Sep 2022.

[5]  
Shabsigh, A., Korets, R., Vora, K.C., Brooks, C.M., Cronin, A.M., Savage, C., Ganesh, R., Bochner, B.H., Dalbagni, G., Herr, H.W. and Donat, S.M. “Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology.” European Urology. 55(1). 164-174. Jan 2009.

[6]   | Xue, G., Liu, Y., Ji, X. and Zhang, H. “Wound dehiscence in enhanced recovery after open radical cystectomy: A meta-analysis.” International Wound Journal. 20 (7). 2634-2639. Sep 2023.

[7]  
Meyer, C.P., Rios Diaz, A.J., Dalela, D., Hanske, J., Pucheril, D., Schmid, M., Trinh, V.Q., Sammon, J.D., Menon, M., Chun, F.K., Noldus, J., Fisch, M. and Trinh, Q.D. “Wound dehiscence in a sample of 1776 cystectomies: identification of predictors and implications for outcomes.” BJU International. 117 (6B). E95-E101. Jun 2016.

[8]  
Riesberg, J.C., Gurney, J.M., Morgan, M., Northern, D.M., Onifer, D.J., Gephart, W.J., Remley, M.A., Eickhoff, E., Miller, C., Eastridge, B.J., Montgomery, H.R., Butler, F.K. and Drew, B. “The Management of Abdominal Evisceration in Tactical Combat Casualty Care: TCCC Guideline Change 20-02.” Journal of Special Operations Medicine. 21 (4). 138-142. Winter 2021.