Tube pancreatico-duodenostomy for management of a severe penetrating pancreaticoduodenal injury.

CONTEXT: Optimal management of penetrating pancreaticoduodenal injuries and better outcomes are associated with simple, fast damage control surgery and shorter operative time. The performance of pyloric exclusion and tube duodenostomy has markedly decreased. However, there is still a trend toward their performance in cases of delay duodenal repair or severe pancreaticoduodenal injury. CASE REPORT: The present report describes a case of a hemodynamically stable patient with a single penetrating gunshot trauma causing an AAST-OIS grade III pancreatic head injury and grade IV injury of the second portion of the duodenum. The patient was treated in our Level IV rural trauma center and submitted to primary closure of the posterolateral duodenal wall (the laceration of the contralateral inner medial duodenal wall could not be repaired), external duodenal and pancreatic drainage, and duodenal decompression by tube pancreatico-duodenostomy (insertion of a 18 Fr Foley catheter through the laceration of the pancreatic head toward the duodenal lumen), tube cholangiostomy, and pyloric exclusion accompanied with a feeding jejunostomy. CONCLUSIONS: Tube pancreatico-duodenostomy, which is described for the first time in the literature, turned out to be effective and can be considered as an option in pancreaticoduodenal trauma when the inner medial duodenal wall cannot be repaired.

Air in gallbladder: Emphysematous cholecystitis or else?

Gas in gallstones represents a rare but well described radiological finding. Other causes of gas in gallbladder include biliary-enteric fistula, sphincterotomy, gas forming organisms cholangitis. However, gas in gallbladder raises suspicion of emphysematous cholecystitis which necessitates prompt diagnosis and management due to its rapid clinical course and high mortality rate.

Non-worrisome scenario of acute abdomen.

Differential diagnosis between benign and life-threatening pneumatosis intestinalis poses a great dianostic dilemma.

A case of right inguinal necrotizing skin and soft-tissue infection.

Mesh infection is the most common complication after elective hernia repair with an increasing incidence with time.

Intractable low back pain during acute exacerbation of systemic lupus erythematosus.

Diagnosis of acute low back emergencies during a systemic lupus erythematosus flare necessitates high clinical suspicion and early CT.

Large papillary thyroid cancer bed recurrence causing overlying skin ulceration and bleeding.

Salvage surgery is an acceptable option for palliative treatment of thyroid bed recurrence in metastatic papillary thyroid carcinoma when other non-invasive options fail to control local skin complications.

Undifferentiated shock in a cirrhotic patient: Ascites matters.

In cirrhotic patients with undifferentiated shock, early CT with emphasis in ascitic fluid density should be performed to exclude rare causes of shock such as secondary peritonitis or hemoperitoneum.

An unusual case of obstructive uropathy.

Although inguinal bladder hernia associated with obstructive uropathy is an extremely rare entity, it should be suspected in elderly patients with bladder outlet obstruction presented with inguinal hernia and lower urinary tract symptoms.

Procedure of choice in a patient initially operated for a suspected epithelial appendiceal neoplasm.

In patients operated for a suspected appendiceal neoplasm, radical appendectomy is the procedure of choice because it provides definitive treatment in most of appendiceal neoplasms, except from mucinous or colonic-type adenocarcinoma and NET>2 cm.

Difficult diagnosis of an air-containing, abscess-like, and mass-like pancreatic head lesion.

Duodenal diverticulosis can be a difficult CT diagnosis and should be considered in the differential diagnosis when a periduodenal mass-like structure that may contain air, air-fluid level, or oral contrast material is depicted.

A case of massive primary tumor growth in the immediate postoperative period.

Major surgical trauma along with discontinuation of antiangiogenic treatment can exacerbate primary tumor growth even in the immediate postoperative period.

Mystery of the lost gallstone-Part 2.

If gallbladder perforation occurs during cholecystectomy, every spilled gallstone should be retrieved to minimize possible late gallstone-related complications.

Aorto-cutaneous fistula from an infected ascending aorta graft resulting in massive hemorrhage after a Valsalva maneuver for a heavy weight lift.

In the setting of an infected prosthetic ascending thoracic aorta, prompt and definitive surgical treatment is mandatory to avoid catastrophic bleeding complications.

Mystery of the lost gallstone-Part 1.

If gallbladder perforation occurs during laparoscopic cholecystectomy, every spilled gallstone should be retrieved to minimize possible late gallstone-related septic complications.

A misdiagnosed cause of early postoperative bowel obstruction.

In the setting of altered anatomy, diagnosis of superior mesenteric artery syndrome requires high clinical and imaging suspicion as the defined imaging criteria cannot be applied.

Preoperative endoscopic tattooing for colonic polyp localization: From blue to black.

When surgical polypectomy and not segmental resection is planned, preoperative endoscopic tattooing with high-volume undiluted methylene blue should be avoided as it can result in colon perforation.

Meckel's Diverticulum in Adults: Surgical Concerns.

Since Meckel's diverticulum (MD) is rarely diagnosed in adults, there is no consensus on what type of procedure to be performed for symptomatic MD and whether to resect or not an accidentally discovered MD. Treatment of symptomatic MD is definitive surgery, including diverticulectomy, wedge, and segmental resection. The type of procedure depends on: (a) the integrity of diverticulum base and adjacent ileum; (b) the presence and location of ectopic tissue within MD. The presence of ectopic tissue cannot be accurately predicted intraoperatively by palpation and macroscopic appearance. When present, its location can be predicted based on height-to-diameter ratio. Long diverticula (height-to-diameter ratio >2) have ectopic tissue located at the body and tip, whereas short diverticula have wide distribution of ectopic tissue including the base. When indication of surgery is simple diverticulitis, diverticulectomy should be performed for long and wedge resection for short MD. When indication of surgery is complicated diverticulitis with perforated base, complicated intestinal obstruction and tumor, wedge, or segmental resection should be performed. When the indication of surgery is bleeding, wedge and segmental resection are the preferred methods for resection. Regarding management of incidentally discovered MD, routine resection is not indicated. The decision making should be based on risk factors for developing future complications, such as: (1) patient age younger than 50 years; (2) male sex; (3) diverticulum length >2 cm; and (4) ectopic or abnormal features within a diverticulum. In this case, diverticulectomy should be performed for long and wedge resection for short MD.

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.