Gastrointestinal bleeding as a result of entero-iliac fistula due to intestinal foreign body.

Ingested toothpicks are a relatively rare event, but they may cause serious gut injuries and can be listed among rare causes of perforation, peritonitis, sepsis or death. Unless the foreign bodies were intentionally swallowed, many patients who ingested them fail to remember the event and they do not refer it during the medical history collection; this makes diagnosis problematic. In this work, a case of perforation of the sigmoid colon is described, caused by a toothpick ingestion. The patient had to be surgically treated because of a complication: the formation of an entero-iliac fistula with subsequent development of a pseudoaneurysm of the right external iliac artery. Vascular perforation due to toothpick ingestion has rarely been reported. In similar cases, it could be difficult to establishing the correct diagnosis because of the low sensitivity and accuracy rates of diagnostic investigations. The ingestion of foreign bodies should be kept in mind as an important differential diagnosis in patients with acute abdomen or chronic abdominal pain of unknown origin.

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity.

OBJECTIVES: The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG. METHODS: One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases. RESULTS: Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal). CONCLUSION: This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Hypovolemic shock after pelvic radiotherapy. A rare combination leading to a devastating complication.

BACKGROUND: Radiotherapy currently plays a key role in pelvic malignancies' management. Excellent outcomes have been reported on its association with chemotherapy for the treatment of the anal carcinoma. Despite that, the combined use of chemo- and radiotherapy and the high doses administered seem to be strongly associated with early and late onset side effects. METHODS: We reported a case of a 72 years old woman, affected by anal squamous cell carcinoma. She underwent chemotherapy, and then radiotherapy, with good results. RESULTS: During a regular MR control, the patient developed anaphylactic reaction to Gadolinium, and after that a rectosigmoid ischemia with total necrosis of the posterior rectal wall was diagnosed and surgically treated with Hartmann procedure. CONCLUSION: In our case we faced with the rapid and severe degeneration of pelvic anatomy determined by the sum of vascular alterations following hypovolemic shock and pelvic tissues alteration after radiotherapy. It seems essential not to underestimate the exponential outcome of a similar unusual combination of events. KEY WORDS: Anal carcinoma, Hypovolemic shock, Pelvic radiotherapy, Rectal necrosis.

Malignant obstructive jaundice: comparison of MRCP and ERCP in the evaluation of distal lesions.

PURPOSE: To compare the diagnostic accuracy of MR cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of malignant stenosis of the distal common bile duct. MATERIALS AND METHODS: Twenty-one patients (12 males and 9 females, mean age 62 years) with a clinical suspicion of malignancy of the distal biliary tract and pancreatic head underwent tomographic RM evaluation and diagnostic MRCP, followed by diagnostic and, where possible, therapeutic ERCP. The images obtained with ERCP and MRCP were reviewed blind by two experts who evaluated the presence, site, signal features and locoregional extension of the tumours. Histology performed by brushing or biopsy during ERCP and after surgical resection provided the standard of reference for all 21 patients. RESULTS: CPRM correctly identified the presence and site of the distal biliary stenosis in 21/21 (100%) cases, as well as allowing evaluation of the upper abdomen by associating it with conventional MRI. ERCP, instead, allowed detection of the presence and site of biliary stenosis in 20/21 (95%) cases. DISCUSSION AND CONCLUSIONS: ERCP may have some limitations as regards identification of distal bile duct stenosis in cases of critical stenosis. The non-invasive nature and panoramic capabilities of MRCP and the fact that no contrast material is needed make MRCP the examination of reference in the diagnosis of malignant stenosis of the distal bile duct, also thanks to its ability to visualise the entire biliary tree in the presence of critical strictures of the common bile duct. The rationale for the use of ERCP lies in the possibility of taking histological samples and performing minimally invasive surgical interventions.