Jejunal volvulus within an inguinal hernia sac like as an extremely rare cause of acute mechanical gastrointestinal obstruction in adults: First literature report.

INTRODUCTION AND IMPORTANCE: Small bowel volvulus (SBV) represents a rare and life-threatening cause of gastrointestinal obstruction among adults. SBV can be classified as primary and secondary subtypes. Preoperative diagnosis of SBV is a challenge because of the absence of pathognomonic clinical, radiographic and laboratory findings. Surgery represents the correct treatment of SBV. CASE PRESENTATION: A 69-year-old Caucasian male presented to the Emergency Department with a two-day history of abdominal pain, inability to pass gas or stool, nausea, vomiting. Physical examination revealed abdominal distension, generalized abdominal pain without guarding or rebound tenderness, a partially reducible and painless right inguinal hernia. Laboratory tests reported neutrophilic leukocytosis. Abdominal computed tomography revealed massive gastroduodenal dilatation with pneumoperitoneum and small bowel loops in the right inguinal sac. The patient underwent exploratory laparotomy: a jejunal volvulus (JV) located within the right inguinal hernia sac, causing gastrointestinal obstruction, was devolvulated and a right prosthetic inguinal hernia repair was also performed. The patient was discharged on the 10th postoperative day. CLINICAL DISCUSSION: Secondary SBV is due to any congenital or acquired lesions and rarely occurs among adults in Western countries. This is the first literature report of a JV located within an inguinal hernia sac causing gastrointestinal obstruction. CONCLUSION: Secondary JV represents an extremely rare abdominal emergency necessitating early diagnosis to prevent the development of intestinal ischemia, bowel necrosis and peritonitis. Diagnosis of JV needs a high index of suspicion and may be facilitated by imaging, often it is made intraoperatively. Surgery represents the appropriate treatment of JV.

Left-sided acute appendicitis in a patient with situs viscerum inversus totalis: A case report.

INTRODUCTION AND IMPORTANCE: Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as situs viscerum inversus (SVI) and midgut malrotation (MM). Preoperative diagnosis of LSAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of LSAA. CASE PRESENTATION: A 67-year-old Caucasian male with presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting, diarrhea and fever. Physical examination revealed LLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a LSAA with intraluminal appendicoliths, fat infiltration and pericecal fluid collection in a patient with SVI. The patient underwent laparoscopic appendectomy: a gangrenous and perforated appendicitis was sectioned and removed with drainage of pericecal abscess. The postoperative course of the patient was uneventful. CLINICAL DISCUSSION: LSAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of LSAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming SVIT or MM. Laparoscopic appendectomy represents the correct treatment of LSAA. CONCLUSION: LSAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Preoperative diagnosis of LSAA needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of LSAA.

Idiopathic giant pancreatic pseudocyst presenting in emergency with abdominal compartment syndrome and intestinal occlusion: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: This is the first case of idiopathic giant pancreatic pseudocyst (IGPP) causing intestinal occlusion, intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) reported in the literature. Diagnosis of IGPP in emergency is a challenge because of its rarity and the absence of a history of pancreatitis or pancreatic trauma and specific clinical presentation. Abdominal contrast-enhanced computed tomography (CECT) represents the gold standard in diagnosing of pancreatic cyst (PP). Different types of treatment of PP are reported in the literature. CASE PRESENTATION: A 52-year-old Caucasian female was admitted to the Emergency Department with a three-day history of abdominal pain, inability to pass gas or stool, nausea and vomiting, oliguria and a seven-day history of abdominal swelling and swollen legs. Physical examination revealed abdominal distention, abdominal pain, swelling in the legs. CECT showed a voluminous cystic pancreatic mass suspected of neoplasm. Laboratory tests reported high serum levels of BUN, creatinine and C-reactive protein and neutrophilic leukocytosis. After preoperative diagnosis of ACS, the patient was taken to the operating room for pancreatic resection. The postoperative course was uneventful. Diagnosis of IGPP was made by histopathological examination. CLINICAL DISCUSSION: IGPP is difficult to diagnose in emergency. Although different types of drainage of IGPP are described in the literature, pancreatic resection represents the treatment of choice when a cystic pancreatic neoplasm cannot be excluded. CONCLUSION: IGPP is a rare disease that may cause intestinal occlusion, IAH and ACS. Pancreatic resection if necessary is safe and therapeutic with acceptable morbidity and mortality.

Non-traumatic rupture of voluminous non-typhoid Salmonella splenic abscess presenting with peritonitis: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Splenic abscess (SA) is an uncommon, life-threatening disease with about 600 reported cases in the literature. It is caused by various infective pathogens and generally occurs in immunocompromised patients. SA is a rare complication of non-typhoid Salmonella (NTS) infection. Diagnosis of ruptured SA is a challenge because the absence of specific symptoms and signs. Abdominal computed tomography (CT) scan represents the gold standard in diagnosing of SA. Splenectomy is the treatment of choice of ruptured SA with peritonitis. CASE PRESENTATION: A 26-year-old Caucasian female was admitted to the Emergency Department with a three-day history of abdominal pain and fever. Physical examination revealed severe and generalized abdominal pain on superficial and deep palpation with obvious muscle guarding and rebound tenderness. Abdominal CT scan showed ruptured SA. Laboratory tests reported anemia (hemoglobin 10.4 g/dl). The patient was taken emergently to the operating room for splenectomy. The postoperative course was uneventful, the patient was discharged on the 7th post-operative day. Diagnosis of NTS SA was made by pus cultures. CLINICAL DISCUSSION: SA is a rare complication of NTS infection associated with high morbidity and mortality rates. Although different types of treatment of SA are reported in the literature, splenectomy represents the treatment of choice of ruptured SA. CONCLUSION: NTS SA is difficult to diagnose because of its rarity and non-specific clinical presentation, often fatal if left untreated. Although there is no gold standard for treating SA, splenectomy with peritoneal lavage is mandatory in case of ruptured SA with peritonitis.

Laparoscopic mini-gastric bypass: short-term single-institute experience.

The elevated variety of procedures proposed for surgical treatment of obesity in the last few years suggests the necessity to find an ideal operation. Laparoscopic mini-gastric bypass (LMGB) was developed to obtain better results with lesser morbidity and mortality. LMGB was introduced by Rutledge, in 1997, and it consists of a long lesser-curvature tube with a terminolateral gastroenterostomy 180 cm distal to the Treitz ligament. From July 1995 to May 2011 we have performed 552 bariatric operations, among them we have operated 197 laparoscopic mini-gastric bypass (Fig. 1). There were 147 female (75%) and 50 male (25%) with the mean age of 37.9 years (range 20-55) and the mean BMI of 52.9 kg/m(2). All procedures were completed laparoscopically, without conversion and the mean operative time was 120 min (range from 90 to 170 min). The average postoperative stay was 5.0 days. We report one case of mortality for pulmonary septic complications. Major complications were two cases of pulmonary embolism (treated in ICU), six cases of melena on seventh postoperative day and three cases of anastomotic ulcers resolved with high doses of PPI. We registered a significant reduction of BMI and percentage of excess weight after surgery with a significant improvement in obesity-related comorbidities including blood pressure, hyperglycemia, blood lipid, uric acid, and liver function. An ideal weight loss operation should be effective, easy to perform and safe. Laparoscopic Roux-en-Y Gastric Bypass is actually the "gold-standard" technique but LMGB seems to be an attractive alternative: shorter operative time, with less morbidity and mortality, easier to teach and to perform. Another advantage could be the presence of a single anastomosis alone reducing the possibility of leaks.

Carcinoma of the appendix and its natural history in relation to surgical management. A case report.

There are several classifications of appendicular epithelial cancer with a wide variety of nomenclature. Epithelial tumours of the appendix have been classified into four distinct types: carcinoids, mucinous adenocarcinoma (often called mucinous cystadenocarcinoma or malignant mucocele), colonic-type adenocarcinoma, and adenocarcinoids with a dual cell origin. We report a case of a woman who presented to our emergency unit with a history of acute appendicitis and who had undergone an appendectomy. The histopathological analysis showed the presence of a well differentiated mucinous adenocarcinoma, infiltrating the full thickness of the appendix wall.