Mechanisms linking bariatric surgery to adipose tissue, glucose metabolism, fatty liver disease and gut microbiota.

PURPOSE: In the last 20 years, bariatric surgery has achieved an important role in translational and clinical research because of obesity comorbidities. Initially, a tool to lose weight, bariatric surgery now has been shown to be involved in several metabolic pathways. METHODS: We conducted a narrative review discussing the underlying mechanisms that could explain the impact of bariatric surgery and the relationship between obesity and adipose tissue, T2D, gut microbiota, and NAFLD. RESULTS: Bariatric surgery has an impact in the relation between obesity and type 2 diabetes, but in addition  it induces the white-to-brown adipocyte trans-differentiation, by enhancing thermogenesis. Another issue is the connection of bariatric surgery with the gut microbiota and its role in the complex mechanism underlying weight gain. CONCLUSION: Bariatric surgery modifies gut microbiota, and these modifications influence lipid metabolism, leading to improvement of non-alcoholic fatty liver disease.

Microbiome Dysbiosis: A Pathological Mechanism at the Intersection of Obesity and Glaucoma.

The rate at which obesity is becoming an epidemic in many countries is alarming. Obese individuals have a high risk of developing elevated intraocular pressure and glaucoma. Additionally, glaucoma is a disease of epidemic proportions. It is characterized by neurodegeneration and neuroinflammation with optic neuropathy and the death of retinal ganglion cells (RGC). On the other hand, there is growing interest in microbiome dysbiosis, particularly in the gut, which has been widely acknowledged to play a prominent role in the etiology of metabolic illnesses such as obesity. Recently, studies have begun to highlight the fact that microbiome dysbiosis could play a critical role in the onset and progression of several neurodegenerative diseases, as well as in the development and progression of several ocular disorders. In obese individuals, gut microbiome dysbiosis can induce endotoxemia and systemic inflammation by causing intestinal barrier malfunction. As a result, bacteria and their metabolites could be delivered via the bloodstream or mesenteric lymphatic vessels to ocular regions at the level of the retina and optic nerve, causing tissue degeneration and neuroinflammation. Nowadays, there is preliminary evidence for the existence of brain and intraocular microbiomes. The altered microbiome of the gut could perturb the resident brain-ocular microbiome ecosystem which, in turn, could exacerbate the local inflammation. All these processes, finally, could lead to the death of RGC and neurodegeneration. The purpose of this literature review is to explore the recent evidence on the role of gut microbiome dysbiosis and related inflammation as common mechanisms underlying obesity and glaucoma.

Traumatic limb wounds management: Efficacy of silver and hyaluronic acid-containing dressings.

Traumatic limb wound management represents a common and challenging health problem. Conservative treatment can be a good option when surgery fails or surgical reconstruction is planned. Wound healing is a complex process that involves several factors and can be delayed if wound details are not noticed. So, expert healthcare professionals should take care of these delicate patients to obtain satisfactory outcomes in terms of cosmesis and functionality of the residual scar. Thanks to the description of three patients with traumatic limb injuries, this article emphasizes the importance of respecting what we call the three golden rules of wound management: correct cleaning of the wound, its accurate inspection and choose the appropriate dressing according to the wound aspect.

Folate levels in hepatocellular carcinoma patients with portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) occurs frequently in hepatocellular carcinoma (HCC) and is often diagnosed in the course of a routine patient evaluation and surveillance for liver cancer. The purpose of this study is to investigate the relationship between folate status and portal vein thrombosis. METHODS: HCC with PVT patients were 78, HCC without PVT were 60 and control subjects were 70 randomly selected. We evaluate serum and red blood cellular folate, homocysteine, alpha fetal protein cholesterol, triglycerides, prothrombin time. RESULTS: HCC patients with PVT showed lower levels of serum folate, respect HCC patients without PVT, with an average difference of 1.6 nmol/l p < 0.01 (95% CI - 2.54 to - 0.66), red cell folate 33.6 nmol/l p < 0.001 (95% CI - 43.64 to - 23.55) and albumin 0.29 g/dl p < 0.001 (95% CI - 0.42 to - 0.15); PVT patients displayed higher levels of bilirubin 0.53 mg/dl p < 0.001 (95% CI 0.23 to 0.78), INR 0.91 p < 0.001 (95% CI 0.72 to 1.09), γGT 7.9 IU/l (95% CI 4.14 to 11.65) and homocysteine 4.6 µmol/l p < 0.05 (95% CI 0.32 to 8.87) CONCLUSION: The low folate concentration and higher levels of homocysteine are associated with the loss of antithrombotic function, and with a more aggressive course of HCC and with a higher change of complications related to portal vein thrombosis.

Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site.

Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

PURPOSES: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG. PATIENTS AND METHODS: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management. RESULTS: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery. CONCLUSION: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.

Near-infrared fluorescent cholangiography - real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.

BACKGROUND: The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy. METHODS: Fifty consecutive elective laparoscopic cholecystectomies were performed with fluorescent cholangiography. FC was performed at three time points: following exposure of Calot's triangle, prior to any dissection; and after partial and complete dissection of Calot's triangle. RESULTS: The cystic duct (CD) was identified successfully by FC in 43 of 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot's dissection respectively (p > 0.05). The common hepatic duct (CHD) and the common bile duct (CBD) were identified successfully in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before Calot's dissection respectively and in 26 of 50 patients (52%) and in 47 of 50 patients (94%) after complete Calot's dissection (p = 0.007 and p = 0.001, respectively). Significant differences were observed for CBD visualization rate, in relation to BMI after Calot's dissection (p < 0.05) and history of cholecystitis, before Calot's dissection (p = 0.017). No bile duct injuries were reported. CONCLUSION: Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies.

Value of 3D printing for the comprehension of surgical anatomy.

BACKGROUND: In a preliminary experience, we claimed the potential value of 3D printing technology for pre-operative counseling and surgical planning. However, no objective analysis has ever assessed its additional benefit in transferring anatomical information from radiology to final users. We decided to validate the pre-operative use of 3D-printed anatomical models in patients with solid organs' diseases as a new tool to deliver morphological information. METHODS: Fifteen patients scheduled for laparoscopic splenectomy, nephrectomy, or pancreatectomy were selected and, for each, a full-size 3D virtual anatomical object was reconstructed from a contrast-enhanced MDCT (Multiple Detector Computed Tomography) and then prototyped using a 3D printer. After having carefully evaluated-in a random sequence-conventional contrast MDCT scans, virtual 3D reconstructions on a flat monitor, and 3D-printed models of the same anatomy for each selected case, thirty subjects with different expertise in radiological imaging (10 medical students, 10 surgeons and 10 radiologists) were administered a multiple-item questionnaire. Crucial issues for the anatomical understanding and the pre-operative planning of the scheduled procedure were addressed. RESULTS: The visual and tactile inspection of 3D models allowed the best anatomical understanding, with faster and clearer comprehension of the surgical anatomy. As expected, less experienced medical students perceived the highest benefit (53.9% ± 4.14 of correct answers with 3D-printed models, compared to 53.4 % ± 4.6 with virtual models and 45.5% ± 4.6 with MDCT), followed by surgeons and radiologists. The average time spent by participants in 3D model assessing was shorter (60.67 ± 25.5 s) than the one of the corresponding virtual 3D reconstruction (70.8 ± 28.18 s) or conventional MDCT scan (127.04 ± 35.91 s). CONCLUSIONS: 3D-printed models help to transfer complex anatomical information to clinicians, resulting useful in the pre-operative planning, for intra-operative navigation and for surgical training purposes.

Lipoprotein(a) in patients with hepatocellular carcinoma and portal vein thrombosis.

BACKGROUND: The mechanism for hypercoagulability in malignancy is not entirely understood. Although several studies report contrasting finding about the link between elevated plasma levels of the lipoprotein(a) [Lp(a)] and the possible recurrence of venous thromboembolism, we perform a study to evaluate the impact of the Lp(a) in the development of portal vein thromboembolism (PVT) in patients with HCC. METHODS: We compared 44 PVT patients with 50 healthy subjects and 50 HCC patients. RESULTS: The comparison between PVT patients and HCC showed in the former the mean value of serum lipoprotein levels was higher than 37.3 mg/dl (p = 0.000). The comparison between PVT versus healthy controls showed that in the former, mean value of serum lipoprotein levels was higher than 75 mg/dl (p = 0.000). The predictive value test of serum lipoprotein(a) on PVT was 0.72 and on HCC was 0.83. The odds ratio of lipoprotein(a) was 9.21 on PVT and 6.33 on HCC. CONCLUSION: Patients with PVT and HCC showed a statistical significant serum lipoprotein(a) level higher than the subjects with HCC and no PVT or the healthy subject. So we assume a role of lipoprotein(a) as predictor of venous thromboembolism in neoplastic patients.

Role of Perturbated Hemostasis in MASLD and Its Correlation with Adipokines.

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to rise, making it one of the most prevalent chronic liver disorders. MASLD encompasses a range of liver pathologies, from simple steatosis to metabolic dysfunction-associated steatohepatitis (MASH) with inflammation, hepatocyte damage, and fibrosis. Interestingly, the liver exhibits close intercommunication with fatty tissue. In fact, adipose tissue could contribute to the etiology and advancement of MASLD, acting as an endocrine organ that releases several hormones and cytokines, with the adipokines assuming a pivotal role. The levels of adipokines in the blood are altered in people with MASLD, and recent research has shed light on the crucial role played by adipokines in regulating energy expenditure, inflammation, and fibrosis in MASLD. However, MASLD disease is a multifaceted condition that affects various aspects of health beyond liver function, including its impact on hemostasis. The alterations in coagulation mechanisms and endothelial and platelet functions may play a role in the increased vulnerability and severity of MASLD. Therefore, more attention is being given to imbalanced adipokines as causative agents in causing disturbances in hemostasis in MASLD. Metabolic inflammation and hepatic injury are fundamental components of MASLD, and the interrelation between these biological components and the hemostasis pathway is delineated by reciprocal influences, as well as the induction of alterations. Adipokines have the potential to serve as the shared elements within this complex interrelationship. The objective of this review is to thoroughly examine the existing scientific knowledge on the impairment of hemostasis in MASLD and its connection with adipokines, with the aim of enhancing our comprehension of the disease.

Exploring public interest in gut microbiome dysbiosis, NAFLD, and probiotics using Google Trends.

Scientific interest related to the role of gut microbiome dysbiosis in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) has now been established and is constantly growing. Therefore, balancing dysbiosis, through probiotics, would be a potential therapy. In addition to scientific interest, on the other hand, it is important to evaluate the interest in these topics among the population. This study aimed to analyze, temporally and geographically, the public's interest in gut microbiome dysbiosis, NAFLD, and the use of gut probiotics. The most widely used free tool for analyzing online behavior is Google Trends. Using Google Trends data, we have analyzed worldwide volume searches for the terms "gut microbiome", "dysbiosis", "NAFLD" and "gut probiotic" for the period from 1, January 2007 to 31 December 2022. Google's relative search volume (RSV) was collected for all terms and analyzed temporally and geographically. The RSV for the term "gut microbiome" has a growth rate of more than 1400% followed, by "gut probiotics" (829%), NAFLD (795%), and "dysbiosis" (267%) from 2007 to 2012. In Australia and New Zealand, we found the highest RSV score for the term "dysbiosis" and "gut probiotics". Moreover, we found the highest RSV score for the term "NAFLD" in the three countries: South Korea, Singapore, and the Philippines. Google Trends analysis showed that people all over the world are interested in and aware of gut microbiome dysbiosis, NAFLD, and the use of gut probiotics. These data change over time and have a geographical distribution that could reflect the epidemiological worldwide condition of NAFLD and the state of the probiotic market.

The surgical treatment of Morgagni hernias in adults: a systematic review for the standardization of laparoscopic surgical repair.

A Morgagni hernia is a congenital diaphragmatic hernia that is rarely diagnosed in adults, and the technique for its repair has not yet been standardized. This review will give an overview of the different laparoscopic methods reported by other authors, highlighting the key points indicating a good repair to help standardize the technique. A systematic review of the available articles on PubMed was conducted according to PRISMA 2020 by two authors independently in May 2022. Only articles written in English were included. A total of 180 case reports of laparoscopic Morgagni's hernia repair procedures were found; direct repair was performed in 59 patients, mesh was used in 119 patients, and mesh was not used in 2 patients. The hernia sac was removed in 71 patients, and the defect was closed before mesh placement in 49 patients. Nonabsorbable, dual or biologic mesh was used. The mean operative time was 92.65 min for direct repair and 84.11 min for mesh repair. One recurrence was reported in the direct repair series. The optimal method of repair has not yet been identified. The laparoscopic approach is associated to fewer complications and facilitates a faster recovery than the open approach. Several manoeuvres have been reported to help surgeons, who are not trained in laparoscopic knotting, perform extracorporeal knotting. Mesh should be placed when tension is too high after a direct repair or when primary closure cannot be achieved.

The impact of bariatric surgery on colorectal cancer risk.

Obesity is considered a risk factor for different types of cancer, including colorectal cancer (CRC). Bariatric surgery has been associated with improvements in obesity-related co-morbidities and reductions in overall cancer risk. However, given the contradictory outcomes of several cohort studies, the impact of bariatric surgery on CRC risk appears controversial. Furthermore, measurement of CRC biomarkers following Roux-en-Y gastric bypass (RYGB) has revealed hyperproliferation and increased pro-inflammatory gene expression in the rectal mucosa. The proposed mechanisms leading to increased CRC risk are alterations of the gut microbiota and exposure of the colorectum to high concentrations of bile acids, both of which are caused by RYGB-induced anatomical rearrangements. Studies in animals and humans have highlighted the similarities between RYGB-induced microbial profiles and the gut microbiota documented in CRC. Microbial alterations common to post-RYGB cases and CRC include the enrichment of pro-inflammatory microbes and reduction in butyrate-producing bacteria. Lower concentrations of butyrate following RYGB may also contribute to an increased risk of CRC, given the anti-inflammatory and anticarcinogenic properties of this molecule. Laparoscopic sleeve gastrectomy appears to have a more moderate impact than RYGB; however, relatively few animal and human studies have investigated its effects on CRC risk. Moreover, evidence regarding the impact of anastomosis gastric bypass on one is even more limited. Therefore, further studies are required to establish whether the potential increase in CRC risk is restricted to RYGB or may also be associated with other bariatric procedures.

Gut Microbiome in the Progression of NAFLD, NASH and Cirrhosis, and Its Connection with Biotics: A Bibliometric Study Using Dimensions Scientific Research Database.

There is growing evidence that gut microbiota dysbiosis is linked to the etiopathogenesis of nonalcoholic fatty liver disease (NAFLD), from the initial stage of disease until the progressive stage of nonalcoholic steatohepatitis (NASH) and the final stage of cirrhosis. Conversely, probiotics, prebiotics, and synbiotics have shown promise in restoring dysbiosis and lowering clinical indicators of disease in a number of both preclinical and clinical studies. Additionally, postbiotics and parabiotics have recently garnered some attention. The purpose of this bibliometric analysis is to assess recent publishing trends concerning the role of the gut microbiome in the progression of NAFLD, NASH and cirrhosis and its connection with biotics. The free access version of the Dimensions scientific research database was used to find publications in this field from 2002 to 2022. VOSviewer and Dimensions' integrated tools were used to analyze current research trends. Research into the following topics is expected to emerge in this field: (1) evaluation of risk factors which are correlated with the progression of NAFLD, such as obesity and metabolic syndrome; (2) pathogenic mechanisms, such as liver inflammation through toll-like receptors activation, or alteration of short-chain fatty acids metabolisms, which contribute to NAFLD development and its progression in more severe forms, such as cirrhosis; (3) therapy for cirrhosis through dysbiosis reduction, and research on hepatic encephalopathy a common consequence of cirrhosis; (4) evaluation of diversity, and composition of gut microbiome under NAFLD, and as it varies under NASH and cirrhosis by rRNA gene sequencing, a tool which can also be used for the development of new probiotics and explore into the impact of biotics on the gut microbiome; (5) treatments to reduce dysbiosis with new probiotics, such as Akkermansia, or with fecal microbiome transplantation.

Awake laparoscopic cholecystectomy: A case report and review of literature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the most widely practiced surgical procedures in abdominal surgery. Patients undergo LC during general anaesthesia; however, in recent years, several studies have suggested the ability to perform LC in patients who are awake. We report a case of awake LC and a literature review. CASE SUMMARY: A 69-year-old patient with severe pulmonary disease affected by cholelithiasis was scheduled for LC under regional anaesthesia. We first performed peridural anaesthesia at the T8-T9 level and then spinal anaesthesia at the T12-L1 level. The procedure was managed in total comfort for both the patient and the surgeon. The intra-abdominal pressure was 8 mmHg. The patient remained stable throughout the procedure, and the postoperative course was uneventful. CONCLUSION: Evidence has warranted the safe use of spinal and epidural anaesthesia, with minimal side effects easily managed with medications. Regional anaesthesia in selected patients may provide some advantages over general anaesthesia, such as no airway manipulation, maintenance of spontaneous breathing, effective postoperative analgesia, less nausea and vomiting, and early recovery. However, this technique for LC is not widely used in Europe; this is the first case reported in Italy in the literature. Regional anaesthesia is feasible and safe in performing some types of laparoscopic procedures. Further studies should be carried out to introduce this type of anaesthesia in routine clinical practice.

Gut-Liver Axis and Non-Alcoholic Fatty Liver Disease: A Vicious Circle of Dysfunctions Orchestrated by the Gut Microbiome.

Non-alcoholic fatty liver disease (NAFLD) is a prevalent, multifactorial, and poorly understood liver disease with an increasing incidence worldwide. NAFLD is typically asymptomatic and coupled with other symptoms of metabolic syndrome. The prevalence of NAFLD is rising in tandem with the prevalence of obesity. In the Western hemisphere, NAFLD is one of the most prevalent causes of liver disease and liver transplantation. Recent research suggests that gut microbiome dysbiosis may play a significant role in the pathogenesis of NAFLD by dysregulating the gut-liver axis. The so-called "gut-liver axis" refers to the communication and feedback loop between the digestive system and the liver. Several pathological mechanisms characterized the alteration of the gut-liver axis, such as the impairment of the gut barrier and the increase of the intestinal permeability which result in endotoxemia and inflammation, and changes in bile acid profiles and metabolite levels produced by the gut microbiome. This review will explore the role of gut-liver axis disruption, mediated by gut microbiome dysbiosis, on NAFLD development.

Recurrent aortoduodenal fistula.

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Quantifying the scientific interest in surgical training and education: numerical evidence of a PubMed analysis.

The scientific interest (SI) for a given field can be ascertained by quantifying the volume of published research. We quantified the SI in surgical education to clarify the extent of worldwide efforts on this crucial factor required to improve health-care systems. A set of Medical Subject Headings (MeSH) was defined for the PubMed search. The number of Pubmed Indexed Papers (nPIP) relevant to the SI was extracted from database conception to December 2016 and their distribution and evolution by country were analyzed at 10-year intervals. Population Adjusted Index (PAI) and Medical School Adjusted Index (MSAI) analyses were performed for countries with the nPIP > 30. We identified 51,713 articles written in 33 different languages related to surgical education; 87.6% of these were written in English. General surgery was the leading surgical specialty. The overall nPIP doubled every 10 years from 1987 (from 6009 to 13,501, to 26,272) but stabilized at 3707, 3800 and 3433 in the past 3 years, respectively. The PAI and MSAI analyses showed that the USA, United Kingdom, New Zealand, Canada, Australia and Ireland are top producers of published research in surgical education, constituting a combined 62.88% of the nPIP. Our quantification of the change in SI in surgical education and training gives a clear picture of evolution, efforts and leadership worldwide over time. This picture mirrors an international academic society that should encourage all those involved in surgical education to improve efforts in educational research.

Corrigendum to "Iatrogenic nerve lesion following laparoscopic surgery. A case reportË® [Ann. Med. Surg. 28 (2018) 34-37].

[This corrects the article DOI: 10.1016/j.amsu.2018.02.002.].

Traumatic perforated diverticulum of the fourth duodenal portion: First case report and literature review.

INTRODUCTION: Duodenal rupture following blunt abdominal trauma is rare, and traumatic rupture of duodenal diverticula is exceptional. However, duodenum is the second most frequent location of intestinal diverticula following colon. Duodenal diverticula are common but only in few cases they are symptomatic due to the onset of complications such as inflammation, hemorrhage, or perforation. Perforation, although rare, especially post-trauma, is the most serious life threatening complication. CASE PRESENTATION: We report the case of a patient who, 24 hours after a blunt trauma secondary to a car accident, complained symptoms related to the perforation of a diverticulum of the fourth portion of the duodenum. A computed tomography was performed and extraluminal fluid-air collection was identified. During emergent laparotomy, a fourth portion perforated duodenal diverticulum was diagnosed, and resected. The recovery was uneventful. DISCUSSION: Diagnosis of perforated duodenal diverticulum represents a challenge in diagnosis and few guidelines exist about the management of this rare occurrence, especially in a traumatic setting. The present case is the first report of traumatic perforated diverticulum of the fourth duodenal portion. CONCLUSION: Surgery still remain the most common approach in the treatment of this pathology, including diverticulectomy and primary repair.