Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis.

BACKGROUND: Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. METHODS: This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. RESULTS: Age as a continuous variable, WBC count ≥ 12.4 × 103/µl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. CONCLUSIONS: Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes.

Jejuno-jejunal invagination due to intestinal melanoma.

Cutaneous melanoma is one of the most studied neoplastic lesions in biology and clinical oncology. It has been well documented that this type of neoplasm presents a high metastatic rate, and is able to involve nearly every tissue. Non-cutaneous melanoma represents an unusual pattern of melanoma, and the small intestine is an uncommon anatomic localization. Herein we report an extremely rare clinical case of a young woman affected by a bleeding jejunal melanoma, whose early clinical presentation was an intestinal invagination.

A rare diaphragmatic hernia with a delayed presentation of intestinal symptoms following spleno-distal pancreatectomy: a case report.

Acquired diaphragmatic hernia, non-related to trauma, is a very rare condition. It can constitute a therapeutic problem and the surgical solution is not always immediately clear. We report the case of a 73-year-old woman with a history of spleno-distal pancreatectomy for a neuroendocrine tumour performed in 2009, who came back to Emergency Room 2 years later, complaining of abdominal pain. Chest radiography and computed tomography were performed; they showed a diaphragmatic hernia with visceral migration into the thorax. The diaphragmatic defect was surgically repaired and the patient had an uneventful post-operative recovery.

The surgical approach to near-total small bowel infarction in a patient with massive portomesenteric thrombosis. Case report.

AIM: To describe an acute portomesenteric venous thrombosis, with massive small bowel infarction, which is managed with small bowel resection, primary anastomosis, and open abdomen management (OAM). CASE REPORT: A 76-year-old male patient was admitted to the surgical ward, complaining spread abdominal pain. Contrast Enhanced Computed Tomography (CECT) diagnosed massive bowel ischemia, caused by portomesenteric thrombosis. He had negative coagulation tests for thrombophilia, while he presented concomitant risk factors (cancer, previous venous thrombosis, obesity). Surgery was performed, including open abdomen management, and the patient was discharged one month after surgery. No recurrences of portal thrombosis were found in one-year follow-up. DISCUSSION: Mesenteric venous thrombosis (MVT) diagnosis could be difficult to establish and it often presented itself late with peritonitis. Currently, CECT scanning is considered the gold standard for MVT, because it identifies not only filling defects in the portomesenteric system, but also possible complications, such as bowel ischemia. Standard initial treatment of MVT included heparin anticoagulation alone or in combination with surgery. When peritoneal signs initially are present, immediate surgery is indicated. During laparotomy, assessment of bowel viability and of the border between ischemia and vivid bowel could be more difficult to define. A planned "second-look" operation remains the gold standard for final bowel viability assessment. CONCLUSIONS: OAM strategy could possibly play an important role, also in case of resection for bowel ischemia, in improving survival in critically patients with increased risks of complications of re- anaesthesia and re-laparotomy. KEY WORDS: Acute Mesenteric Ischemia, Open Abdomen, Portal vein, Venous Thrombosis.

Benign multicystic mesothelioma of peritoneum complicating acute appendicitis in a man: a case report.

BACKGROUND: Benign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon. CASE PRESENTATION: We describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation. CONCLUSIONS: We showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply.

Asymptomatic and early pseudoaneurysm of posterior superior pancreaticoduodenal artery and right gastric artery complicating acute pancreatitis: A case report.

INTRODUCTION: Arterial pseudoaneurysm is a rare and life-threatening complication of pancreatitis, seen more often in chronic than in acute pancreatitis. It involves mostly the splenic artery, while only in 10% of the case it appears in pancreaticoduodenal and gastric artery. This case report described an asymptomatic pseudoaneurysm of the posterior superior pancreaticoduodenal artery and of the right gastric artery, which occurred after 13days from the episode of acute pancreatitis and, then it was treated with vascular angioembolization. PRESENTATION OF CASE: A 71 year-old female was admitted to the Emergency Surgery Department for severe acute pancreatitis. After 13days from the onset, pseudoaneurysms were detected with a control contrast-enhanced computed tomography and they were localized in a branch of the right gastric artery and in a branch of the posterior superior pancreaticoduodenal artery. The patient underwent angiography and the pseudoaneurysms were treated with platinum coil embolization, without complications or further bleeding. DISCUSSION: This is an unusual case because of the low incidence of arterial pseudoaneurysm as acute pancreatitis complication (1.3-10%), and the uncommon localization in the pancreaticoduodenal arteries. CONCLUSION: It is important to be aware of pancreatitis-related arterial pseudoaneurysms, as they have a mortality of 90% if not recognized and treated, not only in chronic but also in acute pancreatitis, and to work out a scheduled follow-up with abdominal computed tomography or pancreatic contrast-enhanced ultrasound in order to control and prevent late onset complications.

Solitary fibrous tumour of gluteus: a case report about an uncommon localization of a rare neoplasm.

Solitary fibrous tumour (SFT) is a rare benign tumour that occurs most frequently in the pleura. It is considered rare in soft tissues. We report a case of a middle-aged woman that presented a solitary fibrous tumor of gluteus. The tumour was composed of mesenchymal spindle-shaped cells positive for CD34 and bcl-2. Although rare, SFT should be included in the differential diagnosis of mesenchymal soft tissue tumours. The clinical presentation and imaging can be helpful for a better pre-operative diagnosis.

Delayed diagnosis of blunt carotid trauma in a seat belt syndrome with associated abdominal wall injury A case report.

The aim of this case report is to be aware of occult carotid lesions in thoracic- abdominal trauma because, carotid artery injury consequent to blunt trauma is rare, affecting less than 1% of patients as reported in literature. A 45-years-old female, involved in a traffic accident, arrived to Emergency Room hemodynamically stable, with a Glasgow Coma Scale of 15, complaining abdominal pain, without any neurological signs. She underwent Computed Tomography (CT) scan that showed a complete disruption of left abdominal wall muscles, associated with massive bowel loops herniation. No free air nor other visceral injuries were found. The radiological brain evaluation was negative for neurological injuries. Considering the nature of the trauma, an explorative laparotomy was performed. During the fifth postoperative day, the patient presented neurological side signs with right facial-brachial-crural hemiparesis and expressive aphasia. Head and neck CT scan revealed a lesion of the left common carotid artery with distal embolization of the internal carotid. A left-carotid-axis revascularization procedure and a surgical endarterectomy were immediately performed. Patient was discharged after 20 days without neurological consequences. Physicians should be aware of neck vascular injuries when evaluating patients with multiple trauma, even in neurological asymptomatic patients without seatbelt abrasions of the neck skin. KEY WORDS: Abdominal Hernia, Carotid artery, Seat belt, Surgery.

An approach to complicated diverticular disease. A retrospective study in an Acute Care Surgery service recently established.

AIM: Acute diverticulitis is a frequent disease in the Western Countries. The increase number of patients admitted in the Surgery Departments led the necessity of new Scores and Classifications in order to clarify, in absence of clear guidelines, the best treatments to offer in the different situations. METHODS: A retrospective study of ninety-nine patients treated in our Department from June 2010 and March 2015. RESULTS: In our study 41 patients were treated conservatively, the remaining 58 were operated, 56 laparotomic and 2 laparoscopic. 5 patients submitted US guided drainage of abscess which failed in 2 cases. 25 submitted Hartmann's Procedure (HP), 29 Primary Resection and Anastomosis (PRA), 3 Contemporary Closure of Perforated Diverticula (CC) and just 2 Laparoscopic Peritoneal Lavage and Drainage (LPL). We related different Hinchey groups and up-groups with the treatments approached, identifying patients risk factors, ASA score and complications. DISCUSSION: The treatment of perforated diverticulitis is debated. CT scan is becoming an useful instrument to make a correct diagnosis. Hinchey I and II patients are preferentially treated conservatively except in cases of complicated presentations. Hinchey III and IV are necessarily treated with surgical approach. We analyze the different types of intervention currently approached. CONCLUSION: We believe in PRA in Hinchey III and IV selected patients, HP is the gold standard in higher ASA scores patients but the low number of stoma reversal remains an open problem. Many studies are ongoing concerning LPL and now there are insufficient data to think of a widespread use of this technique. Key words: CT scan, Diverticular Disease, Hartmann's Procedure, Intr-abdominal abscess, Laparoscopic Peritoneal Lavage and Drainage (LPL), Peritonitis, Primary Resection and Anastomosis (PRAHinchey Classification, US and CT guided drainage.

Management of blunt splenic injuries Retrospective cohort study of early experiences in an Acute Care Surgery Service recently established.

AIM: To identify patients with splenic injuries, who should benefit from a conservative treatment, and to compare inhospital follow-up and hospital length of stay (LOS), in patients treated by non-operative management (NOM) versus immediate-splenectomy (IS). MATERIAL OF STUDY: A retrospective cohort study on consecutive patients, with all grade of splenic injuries, admitted between November 2010 and December 2014 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara. Patients were offered NOM or IS. RESULTS: Fifty-four patients were enrolled; 29 (53.7%) underwent IS and 25 (46.3%) were offered NOM. Splenic artery angioembolization was performed in 9 patients (36%) among this latter group. High-grade splenic injuries (IVV) were more represented in IS group (65.5% vs 8%), while low grade (I-II) were more represented in NOM group (64% vs 10.3%). Failure of NOM occurred in 4 patients (16%). Hospital LOS was longer in IS group (p=0.044), while in-hospital and 30-day mortality were not statistically significant different between the two groups. CONCLUSIONS: Hemodynamically stable patients, with grade I to III of splenic injuries, without other severe abdominal organ injuries, could benefit from a NOM; the in-hospital follow-up should be done, after a control CECT scan, with US. Observation and strictly monitoring of splenic injuries treated with NOM do not affect patients' hospital los. KEY WORDS: Non-operative management, Splenic Rupture, Surgery.

Adenocarcinoma arising in an elderly patient's large ileal duplication.

Bowel duplications are rare congenital anomalies commonly found in pediatric patients; few cases may remain undetected until adulthood. Malignant carcinomatous changes are rare complications in intestinal duplications. An 88-year-old female patient was referred to our surgical unit with the diagnosis of a large abdominal mass. An explorative laparotomy was performed, revealing a large (22 × 11 cm) neoplasm strictly connected to the lowest ileal segment and completely filling the pelvis. Definitive histology revealed a moderately differentiated adenocarcinoma developing in a duplication of the terminal ileum. The hypothesis of a gastrointestinal duplication should be evaluated in the differential diagnosis of large, complex, indeterminate masses located in or near the bowel; the possibility of neoplasm within the duplication should be considered.