Complicated appendiceal diverticulitis a extremely rare cause of acute abdomen: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Appendiceal diverticulitis (AD) represents a rare cause of acute abdomen. Diagnosis of AD is a challenge because of its rarity and resemblance to other ileocecal diseases like as cecal diverticulitis (CD) and acute appendicitis (AA). Preoperative imaging can be useful to aid diagnosis. Surgery represents the correct treatment of AD. CASE PRESENTATION: A 48-year-old Caucasian male presented to the Emergency Department with a two-day history of right lower quadrant (RLQ) abdominal pain and fever. Physical examination revealed RLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal computed tomography(CT) scan showed findings of AA and a thin-walled 5 mm appendiceal diverticulum. The patient underwent laparoscopic appendectomy. The postoperative course was uneventful, the patient was discharged on the 5th postoperative day in a stable condition. Gross anatomy confirmed the presence of appendiceal diverticulum in the distal appendix on the mesenteric border. Histopathological examination revealed an inflamed and perforated appendiceal pseudo-diverticulum with surrounding AA and peri-appendicitis. CLINICAL DISCUSSION: Appendiceal diverticulosis is an uncommon entity, classified as congenital or acquired based on the number of appendiceal layers herniating through the normal wall. Two thirds of diverticula will develop acute or chronic diverticulitis that can lead to several complications some of which can be life-threatening. CONCLUSION: AD is a rare surgical emergency and represents often an overlooked diagnosis. Early diagnosis and treatment are crucial for reducing morbidity and mortality Appendectomy represents a safe and appropriate treatment of AD.

Accidentally ingested wooden toothpick, perforation of a sigmoid diverticulum and mimicking acute colonic diverticulitis: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Ingested wooden toothpick (WT) represents a rare cause of acute abdomen. Preoperative diagnosis of ingested WT is a challenge because of its unspecific clinical presentation, the low sensitivity rate of radiological investigations and the patient's inability to often recall the event of swallowing a WT. Surgery represents the main treatment in case of ingested WT-induced complications. CASE PRESENTATION: A 72-year-old Caucasian male presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting and fever. Physical examination revealed LLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography (CECT) showed colonic diverticulosis, wall thickening of the sigmoid colon, pericolic abscess, regional fatty infiltration, a suspicion of sigmoid perforation secondary to a foreign body. The patient underwent diagnostic laparoscopy: a sigmoid diverticular perforation caused by an ingested WT was noticed and a laparoscopic sigmoidectomy with end-to-end Knight-Griffen colorectal anastomosis, partial omentectomy and protective loop ileostomy were performed. The postoperative course was uneventful. CLINICAL DISCUSSION: The ingestion of a WT represents a rare but potentially fatal condition which may cause GI perforation with peritonitis, abscesses and other rare complications if it migrates out of the GI tract. CONCLUSION: Ingested WT may cause serious GI injuries with peritonitis, sepsis or death. Early diagnosis and treatment are crucial for reducing morbidity and mortality. Surgery is mandatory in case of ingested WT-induced GI perforation and peritonitis.

Increased rate of cholecystectomies performed with doubtful or no indications after laparoscopy introduction: a single center experience.

BACKGROUND: During recent years laparoscopic cholecystectomy has dramatically increased, sometimes resulting in overtreatment. Aim of this work was to retrospectively analyze all laparoscopic cholecystectomies performed in a single center in order to find the percentage of patients whose surgical treatment may be explained with this general trend, and to speculate about the possible causes. METHODS: 831 patients who underwent a laparoscopic cholecystectomy from 1999 to 2008 were retrospectively analyzed. RESULTS: At discharge, 43.08% of patients were operated on because of at least one previous episode of biliary colic before the one at admission; 14.08% of patients presented with acute lithiasic cholecystitis; 14.68% were operated on because of an increase in bilirubin level; 1.56% were operated on because of a previous episode of jaundice with normal bilirubin at admission; 0.72% had gallbladder adenomas, 0.72% had cholangitis, 0.36% had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. By excluding all these patients, 21.18% were operated on without indications. CONCLUSIONS: The broadening of indications for laparoscopic cholecystectomy is undisputed and can be considered a consequence of new technologies that have been introduced, increased demand from patients, and the need for practice by inexperienced surgeons. If not prevented, this trend could continue indefinitely.

A new technique for spleen autotransplantation.

PURPOSE: Although the efficacy of spleen autotransplantation is debated, this approach remains the only possibility for preserving splenic function after traumatic splenectomy. This report describes an alternative method for splenic autotransplantation in case of splenic trauma. METHODS: After splenectomy, the organ was weighed and the undamaged part was cut transversely to prepare a segment of approximately 4 × 3 × 2 cm in size and of 35 g of weight to be transplanted. The greater omentum was pedunculated in its left lateral portion, and the previously prepared splenic tissue was implanted in a pouch created at the lower edge of the omentum. The omental peduncle containing the splenic tissue was fixed to the parietal peritoneum of posterior left upper quadrant of the abdomen where the native spleen was previously located. RESULTS: This technique was performed in 4 patients after informed consent had been obtained. The functionality of the splenic implant was assessed after 3 months by abdominal computed tomography and scintigraphy. These exams showed the functioning of the trasplanted splenic tissue in all patients. CONCLUSION: This new technique needs further evaluation, but it appears to be an easy and safe alternative for spleen autotransplantation.

Health-related quality of life in patients with hepatocellular carcinoma after hepatic resection, transcatheter arterial chemoembolization, radiofrequency ablation or no treatment.

BACKGROUND: Aim of this work was to compare quality of life (QoL) of patients affected by HCC and submitted to hepatic resection (HR), transarterial chemoembolization (TACE), radiofrequency ablation (RFA), or no treatment (NT). METHODS: Patients affected by HCC between 2001 and 2009 were considered for this study. Gender, diabetes, hepatitis status, Child grade, tumor size, and recurrence were analyzed. QoL was assessed before treatment and 3, 6, 12, and 24 months after, using a FACT-Hep questionnaire. P value was considered significant if <0.01 and highly significant if <0.001. RESULTS: Fourteen patients (27.45%) were treated with HR, 15 patients (29.41%) underwent TACE, RFA was performed in 9 patients (17.65%), and 13 patients (25.49%) were not treated. Physical well-being, social/family well-being, emotional well-being, functional well-being and additional concerns 24 months after HR were significantly higher compared to all other treatments. CONCLUSIONS: Hepatic resection provides the best QoL at 24 months. RFA provides a worse QoL compared to HR, but a higher QoL compared to TACE or NT.

Localized fluid collection after carrier-bound fibrin sealant application on liver: complication or proof of efficacy? A long-term clinical observational study.

BACKGROUND/AIMS: This study was intended to evaluate the incidence and the long-term outcome of fluid collecting between the hepatic resection surface and a collagen patch. To our knowledge, this is the first study to analyze these aspects. METHODOLOGY: All patients undergoing hepatic resection with patch application from February 2006 to September 2008 were included. At followup, all patients found to have a collection between the liver surface and the patch underwent a CT scan every three months. RESULTS: Ten patients underwent hepatic resection with the patch application. No mortality occurred and the morbidity rate was 10%. No biliary leaks or free abdominal fluid collection occurred. At follow-up, fluid collections were detected in 60% of cases. The collected fluid did not increase in volume and in 66.6% of the cases the fluid spontaneously reabsorbed after a mean of 5.5 +/- 1.9 months from the operation. CONCLUSION: The high incidence, lack of symptoms, favorable evolution and constant stability should be considered a display of patch tightness rather than a complication.

Parenchymal compression and new devices for hepatic resections: re-visitation of an old technique.

BACKGROUND/AIMS: This reports on the modification of a technique of parenchymal compression ideated to reduce blood loss during liver transection, favorably affecting patient's outcome by reducing the need of Pringle maneuver and operative time through the active role of the second surgeon. METHODOLOGY: After echographic examination a water-cooled, high-density, monopolar dissecting sealer is introduced into the hepatic parenchyma allowing pre-coagulation of liver tissue. After coagulation of the traced line, a small Kelly forceps is used to fracture the liver parenchyma. As the transection proceeds, the hemostatic efficacy of the dissecting sealer reduces. At this step, where the Pringle maneuver is usually requested to stop bleeding, bimanual compression determines the occlusion of all the afferent vessels, bleeding is effectively stopped with a limited amount of residual backflow arising from the opposite plane. RESULTS: During a three-year period this approach was used in 9 patients affected by HCC. The Pringle maneuver was not necessary in any patient. The median blood loss was 200mL. The median transection time was 120 min, with a median operative time of 180 min. No mortality occurred. CONCLUSION: Compression during the transection represents a valid support not only for the dissecting sealer, but also in all cases in which similar devices are used, and by avoiding the need of further devices there is an unquestionable reduction of costs.

Seizure attack and Morgagni diaphragmatic hernia: incidental diagnosis or direct correlation?

Asymptomatic Morgagni hernia can be discovered in adults as an incidental finding or because of acute gastrointestinal symptoms. We report a case of a 76-year-old man with an incidental diagnosis of seizure attack. Obesity and the increased abdominal pressure caused by abdominal muscles contraction during seizure could have contributed to the clinical presentation. The omentum, small bowel, and transverse colon were found in the right side of the chest using an open transabdominal approach. The hernia sac was excised and the diaphragmatic defect closed by direct suturing. The postoperative period was uneventful and the shortness of breath attributed to obesity disappeared.

Could antibiotic prophylaxis be not necessary to implant totally implantable venous access devices? Randomized prospective study.

BACKGROUND: The growing use of totally implantable venous access devices (TIVAD) has caused the simultaneous increase of various complications. Among these, one of the most encountered is the infection of the subcutaneous pocket in which the device is positioned, or the infection of TIVAD itself. The aim of this study is to evaluate the role of the antibiotic in the prevention of the infection of both the surgical site and the TIVAD within 30 days after the implant. METHODS: The authors enrolled one hundred eight consecutive patients divided into two randomized arms each of 54 patients: group A (antibiotic), group B (no antibiotic). All patients were affected by solid tumors needing chemotherapy continuously. TIVADs were implanted surgically in cephalic vein. On the first, third, and seventh postoperative days, the following manifestations were considered as signs or symptoms of infection: pain, localized swelling, redness, and heat; white blood cell count was performed in the in-hospital laboratory. Body temperatures were checked twice a day for 7 days. A statistical analysis of the results was performed. RESULTS: No sign of infection was recorded in both groups. Body temperatures and white blood cell counts remained within normal limits in both groups. One month after the procedure no patients recorded any sign of skin infection or body temperature increase. CONCLUSIONS: The study suggests that, following strict methods of pre- and postoperative care, TIVADs in patients with solid tumors may be surgically implanted without any antibiotic prophylaxis.

An update on indications for treatment of solid hepatic neoplasms in noncirrhotic liver.

During recent years, we have experienced an increased detection of previously unsuspected liver masses in otherwise asymptomatic patients owing to the widespread application of imaging techniques. Regardless of the malignant or cystic tissues, a remarkable percentage of these masses are represented by benign solid neoplasms. Treatment of benign liver tumors still represents a major concern in the hepatic surgery field. Indications for surgery have remained unchanged for many years, but the laparoscopic approach could determine in some cases a broadening of indications, which may result in overtreatment. In this article, the main surgical indication for hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma are discussed with regard to the most recent advancements in literature. In addition, a separate section deals with the role of laparoscopy in the treatment of benign liver neoplasms.

Laparoscopic versus open restoration of intestinal continuity after Hartmann procedure.

BACKGROUND/AIMS: To present the initial experience with laparoscopic technique of restoration after Hartmann procedure compared to open surgery. METHODOLOGY: All patients submitted to Hartmann procedure from 2003 to 2008 were considered. The following parameters were evaluated: age, gender, comorbidities, American Society of Anesthesiologists score, indication for the procedure, Hinchey scale, interval between Hartmann and reversal procedure, total operative time of Hartmann reversal, pain management, delay in renewal of peristalsis, start of alimentation, length of hospital stay, morbidity, and mortality. RESULTS: Six patients were divided into groups A and B. Patients in group A underwent open Hartmann reversal and patients in group B underwent laparoscopic Hartmann reversal. Mean operative time was 136,6 min for group A and 95,6 min for group B. Mean postoperative duration of nasogastric tube placement was 2 days for group A and 1 day for group B. Group B showed a earlier return of bowel function and earlier restart of alimentation. Group B had shorter length of stay. There was no mortality or morbidity. CONCLUSIONS: Laparoscopic approach showed a shorter mean postoperative nasogastric tube time of placement and a shorter mean hospital stay, with faster resumption of bowel movements and early solid diet alimentation.

May the method of hepatic parenchymal transection influence early results of liver surgery?

BACKGROUND/AIMS: Aim of this work was to analyze retrospectively two groups of patients who underwent hepatic resection using two different techniques, to determine whether exists a difference in hepatic tolerance and in the early outcome. METHODOLOGY: We retrospectively analyzed seventy-one patients divided into group 1, treated with kellyclasia and Pringle maneuver, and group 2 treated with a radiofrequency device. The following parameters were analyzed: age; sex; type of disease, number of major/minor resections; total operative time and transection time; number and time of clampings; blood loss; pre- and postoperative transaminases and total bilirubin; length of hospitalization; morbidity and mortality. RESULTS: Median total operative time and median hospital stay were similar in both groups but median median blood loss was higher in group 1. ALT levels in group 1 were higher than in group 2. Morbidity and mortality were observed only in group 1. CONCLUSIONS: Kelly-crush is related to a lower parenchymal tolerance as shown by the higher increase in postoperative alanine aminotransferase levels.

Is laparotomy the unavoidable step to diagnose caecal volvulus?

Caecal volvulus is the axial twist of the caecum, ascending colon and terminal ileum around the mesenteric pedicle. This infrequently encountered clinical entity is responsible for 1-1.5% of all intestinal obstruction with a mortality of 10-40% depending on the presence of colon viability or intestinal gangrene. Many factors have been referred as correlated to caecal volvulus development, mainly anatomical predisposition and previous abdominal operations. Pre-operative diagnosis plays an important role in the management of such patients. Unfortunately, clinical signs, symptoms and laboratory tests are never specific enough to lead to a prompt diagnosis. Abdominal radiography and computed tomography may allow a diagnosis if typical signs are present. However, up to 30% of patients do not show these radiographic peculiarities, making the diagnosis difficult or impossible. Moreover, the low incidence of this disease is often responsible of a wrong or imprecise diagnosis, especially for radiologists who work with low volume of patients. We report a case of a patient with caecal volvulus, in which laparotomy was unavoidable to reach a diagnosis.

Adenoma or atypical hepatic focal nodular hyperplasia: role of preoperative imaging and laparoscopic treatment.

Differentiation of focal nodular hyperplasia (FNH) and other hypervascular liver lesions, such as hepatocellular adenoma (HCA), is important because of the drastically different therapeutic approach. However, FNH can be well distinguished only if it shows a typical aspect; alternatively, in the case of atypical FNH, imaging findings are not specific enough to provide a secure diagnosis and histologic verification of the lesion is required. In addition, HCA cannot be identified conclusively by any current available imaging technique and it can be at best suspected strongly, and this suspicion may lead to liver resection. Herein we report a case of a patient with an unusual FNH nodule presenting at ultrasonographic scanning as an isoechoic mass arising from hepatic segment 4b; the diagnostic indecision between FNH and HCA was not definitively solved even after computed tomography scan and magnetic resonance imaging and the patient was scheduled for a laparoscopic resection. The pathologic examination diagnosed an atypical FNH nodule. The clinical doubt between FNH and HCA remains a problem affecting the clinicians, and more effort should be made in the direction of a better preoperative differentiation of such different conditions. Surgical resection should not be considered as the failure of the preoperative diagnostic attempt, but as the mainstay for a definitive and sure diagnosis.

Sacroplasty in a patient with bone metastases from hepatocellular carcinoma. A case report.

Bone metastases account for 10% to 30% of secondary tumors in all cancer types. In patients with primary hepatocellular carcinoma (HCC), bone metastases are usually treated by nonoperative procedures including pain medication, radiotherapy, hormone therapy, chemotherapy, and bisphosphonates. Surgical treatments include vertebrectomy, reconstruction with a cage or polymethylmethacrylate bone cement, and stabilization with pedicle screws. Sacroplasty to treat bone metastases from HCC has been rarely reported in the literature. We describe the case of a patient with vertebral metastases of HCC treated by this approach. A 65-year-old man had undergone a hepatic segmentectomy in 2004. In May 2008, after several weeks of back pain and bed rest, the patient underwent computed tomography and magnetic resonance imaging of the abdominal and pelvic spine, which revealed metastatic lesions in S1-S5 on the right and S1-S2 on the left. Sacroplasty was performed on all lesions without complications. The patient was discharged from the hospital the same day of the procedure. Two months later, he reported pain relief and improvement in walking. Due to the technical feasibility, low complication rate, and immediate relief of symptoms, sacroplasty for HCC metastases of the sacrum may be considered a valid therapeutic option.

An unusual association of diffuse adenomyomatosis with dysplastic adenoma in chronic calculous cholecystitis: case presentation.

BACKGROUND: Gallbladder adenomyomatosis is an epithelial proliferation and hypertrophy of the muscularis mucosae of the gallbladder. Rokitansky-Aschoff sinuses are a characteristic of this condition. The segmental adenomyomatosis has a higher risk of developing into gallbladder carcinoma, especially in the fundal region of elderly patients.We report the case of a patient affected by chronic calculous cholecystitis with diffuse adenomyomatosis associated with dysplastic adenoma. CASE PRESENTATION: An 81-year-old woman presented at our hospital with a 1-year history of intermittent pain localized at the right upper abdominal quadrant, without diffusion to any other body part. On physical examination the abdomen was soft, not distended, and tender to palpation in the right upper quadrant. Murphy sign was negative. Laboratory tests were normal. The patient was scheduled for a laparoscopic cholecystectomy, and neither endoscopic ultrasonographic scan nor magnetic resonance imaging was performed. The operation, performed after obtaining informed consent, was uncomplicated and the intra-operative pathological examination showed no malignancy. The definitive pathological examination of the gallbladder showed: multiple stones of cholesterol origin; diffuse mucosal adenomyomatosis; and a 1.1 cm pedunculated mass localized at the fundus, whose surface was lumpy. This mass was diagnosed as an adenoma with multiple areas of severe dysplasia. CONCLUSIONS: The adenoma of the gallbladder, together with the dysplasia, represents a biological carcinogenetic model. Carcinoma has rarely been reported in adenomyomatosis. Degenerative risk suggests surgery should be mandatory when there is a concomitant presence of large adenoma and adenomyomatosis.