We saved 3 patients from gangrenous ischemic enteritis. Patient 1; a 57-year-old woman in shock 24 hours after her first admission was found in an emergency laparotomy to have intestinal necrosis from the ileum to the descending colon, necessitating subtotal ileocolectomy. Three days later, intraoperative endoscopy in a second-look operation showed that the necrotic area extended to the small intestine, and a resection of the necrotic intestine and a ileosigmoidstomy were done. Patient 2; a 78-year-old man found with necrosis of the rectal mucosa during colonoscopy, underwent emergency laparotomy showing transmural necrosis from the descending colon to the upper rectum. The necrotic colon was resected and a tube colostomy was established in the cecum. Five days later, intraoperative endoscopy showed partial mucosal necrosis of the ileum end, and a stoma was formed in the cecum preserving the Bauhin valve. Patient 3; a 72-year-old woman who developed shock and diagnosed with gangrenous ischemic colitis based on computed tomography had serosa of the entire colon normal in color, but mucosal necrosis of the colon was identified by intraoperative colonoscopy. The necrotic colon was resected and a stoma formed in the ascending colon. All 3 patients survived with a fair quality of life, including diarrhea control. Total resection of an intestine with mucosal necrosis is for short-term life but may ruin the quality of life due to short bowel syndrome. Necrosis of the intestine may progress after the first operation. Careful therapic strategy including secondlook operation is required for patients with gangrenous ischemic enteritis. Intraoperative endoscopy is helpful for evaluating the resection.
A 54-year-old woman with tympanitis admitted for confusion and high fever was found in a spinal tap to have an initial pressure of 39cm H2O. Cerebrospinal fluid (CSF) contained 141900/mm3 cells, 0mg/dl glucose, and 1004.3mg/dl protein. The causative bacterium was identified as penicillin-resistant Streptococcus pneumoniae (PRSP). Under a diagnosis of PRSP meningitis, we emplaced a lumbar drainage catheter and bolus-injected intrathecal vancomycin (VCM) 5mg/day via the catheter. Her high fever continued, however, and her consciousness waned. We emplaced an intraventricular drainage catheter and continuously infused intrathecal VCM via the catheter. VCM solution was made by adding 50mg of VCM 500ml of saline, and was infused at 4ml/hr (about 10mg/day) for 5 days. CSF cells decreased dramatically via continuous VCM infusion. In the final spinal tap, CSF contained 5/mm3 cells. Three months after onset, she was discharged with good recovery. Treatment with continuous intrathecal VCM infusion may thus be more effective in serious meningitis when the causative bacterium is resistant to multiple antibiotics.