Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report.

CASE REPORT: We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration. CLINICAL FINDINGS: The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh. CLINICAL RELEVANCE: The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization. KEY WORDS: Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature.

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.

A delayed conversion may increase the risk of major complications in acute cholecystitis approached laparoscopically. A retrospective comparative cohort study.

AIM: Aim of this study was to evaluate whether timing of laparoscopy lasting longer than two hours before converting to open surgery can worsen the postoperative course during laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). MATERIALS AND METHODS: Medical records of 1,161 patients who underwent urgent laparoscopic cholecystectomy for AC during the period 2001-2017 were retrospectively analyzed. A conversion to open surgery was performed in 70 (6%) patients. Among these, two groups of patients were identified: group 1 (n=51; 73%) included patients who underwent laparotomy within 2 hours from the beginning of the operation, and group 2 (n=19; 27%) included patients who underwent conversion to open surgery after more than 2 hours of laparoscopy. Patients were analyzed for demographic data and comorbidities. Major outcome measures were mortality, morbidity and length of stay. A p value < 0.05 was considered significant. RESULTS: Reasons for conversion to open surgery included severe inflammation (46%), visceral adhesions (27%), inability to manage common bile duct stones (17%), intolerance to pneumoperitoneum (7%) and the presence of a cholecystoduodenal fistula (1%). By comparing these groups, no significant differences were noted regarding overall morbidity (29% vs 42%, p=0.31), mortality (2% vs 5%, p=0.46) and mean postoperative length of stay (8.7 vs 8.2 days, p=0.75). Major postoperative complications (grade III-V according to Clavien and Dindo classification) were significantly more frequent in group 2 (p=0.03). CONCLUSIONS: When approaching AC laparoscopically, the decision to convert to open surgery within two hours may prevent the occurrence of major postoperative complications. Early conversion does not seem to affect the mortality and length of hospital stay. KEY WORDS: Acute Cholecystitis, Conversion, Laparoscopy.

Laparoscopic resection of multiple aneurysms of the gastroepiploic arterial arcade.

BACKGROUND: Gastroepiploic arterial aneurysms (GEAA) represent a very rare disorder [1, 2]. The risk of GEAA rupture is high, and it is associated with a high mortality rate [3]. GEAAs are usually identified following rupture or are incidentally diagnosed. In emergency, an open surgical approach to treat GEAAs has been most frequently reported [4]. Alternatively, if the patient is hemodynamically stable, an angiography and embolization can be attempted. Herein we report the case of a patient presenting with two fissurated GEAAs that were successfully excised laparoscopically after failure of the endovascular approach. MATERIALS AND METHODS: A 83-year-old lady was admitted for acute epigastric pain. Upon admission, her general status was stable. The abdomen was soft and slightly painful at deep palpation in epigastrium, with no sign of peritonism. In her past medical history, she had a transient ischemic attack and atrial fibrillation episodes for which a pacemaker had been placed. Her blood examinations showed a slight anemia (hemoglobin 10.5 g/dl). An abdominal ultrasonography identified two solid, circular, nodules next to the gastric anterior wall that, in a following angio-TC, were diagnosed as two aneurysms of the gastro-epiploic arterial arcade (GEA), one measuring 17 mm × 13 mm, the other 39 mm × 33 mm. Both showed X-ray signs of impending rupture and intraluminal "thrombization". The patient underwent selective angiography, during which, after an attempt of common hepatic artery catheterism, a dissection and, consequently, an occlusion of the hepatic artery and the celiac trunk unfortunately occurred. Therefore, after a catetherism of the superior mesenteric artery, only a partial and incomplete embolization procedure was possible. As a matter, at the end of the angiographic procedure, reperfusion of the GEA coming from the splenic and hepatic artery was recognized. After 24 h, repeated abdominal CT scan with contrast showed the persistence of the aneurysms with no dimensional changes and the presence of a small active extravasation of contrast from the lateral aneurysm. RESULTS: Laparoscopic surgical exploration was then warranted. Two voluminous GEA arcade aneurysms, very close to greater curvature of the stomach, were identified. After a cautious visceral dissection, the right and left gastroepiploic arteries were clipped and sectioned. Due to the presence of strength adhesions between the aneurysms and the greater curvature of the stomach, we decided to perform double aneurismectomy "en bloc" with the excision of the adjacent greater gastric curve by using an articulated laparoscopic stapler (Endo GIA™ 60 mm Articulating Medium/Thick Reload with Tri-Staple™ Technology, MEDTRONIC, Minneapolis, US). No intraoperative complications were reported. The patient was discharged in fifth post-operative day. CONCLUSIONS: In case of failure of a non-surgical management of ruptured GEA aneurysms, the laparoscopic resection is a safe and effective procedure.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment.

BACKGROUND: The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome. MATERIALS AND METHODS: Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer. RESULTS: Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified. CONCLUSION: Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.

Early cholecystectomy for non-severe acute gallstone pancreatitis: easier said than done.

BACKGROUND: Laparoscopic cholecystectomy (LC) carried out within 3 days after an attack of non-severe acute gallstone pancreatitis (NSAGP) is recommended to reduce hospital stay and overall costs. Aim of the study was to evaluate factors that may delay a timely surgical management of NSAGP and the consequences of this deviation. METHODS: We reviewed the charts of patients admitted for NSAGP and managed by LC during the last 14 years. A total number of 316 patients entered the study, 98 of whom underwent early LC. A comparison of pre-operative and outcome data from the group of patients undergone early LC and those who received a delayed LC (>3 days since the admission) was made. RESULTS: Only 31% of patients presenting with NSAGP were managed by early LC. Respect to these, patients who received a delayed LC were significantly older and had a greater occurrence of clinical signs suggesting common bile duct stones (CBDS). Stabilization of co-morbidities and need to investigate preoperatively the common duct were the main factors associated to the surgical delay. By comparing patients undergone early LC and those who received delayed LC, differences regarding conversion to open surgery (2% vs. 1.3%), need to explore the common bile duct (18.3% vs. 25.6%), CBDS clearance rates (94.4% vs. 94.6%), morbidity (8.1% vs. 8.7%), and postoperative hospital stay (3.9 vs. 3.2 days) were however statistically not significant. CONCLUSIONS: Several reasons could delay the 3-day recommendation for surgery in NSAGP. These include the need to achieve before surgery the control of age-related co morbidities, and the workup to investigate for common duct stones. A fast track program aiming to early surgery would be advisable for patients presenting with NSAGP. Compared to delayed LC, early LC appears to shorten overall hospitalization but it does not seem to have any clinical impact on the course.

Pancreatoduodenectomy for groove pancreatitis Report of two cases.

Groove pancreatitis is a rare condition with patients having clinical characteristics similar to those of chronic pancreatitis. Differentiating on clinical and radiological basis between groove pancreatitis and paraduodenal head cancer can be extremely challenging. Due to diagnostic uncertainty and to poor response to medical treatment surgery may offer these patients the best chance of cure. As the main localization of the inflammatory process is at the groove between the duodenum and the head of the pancreas, pancreato-duodenectomy is proposed as the most reliable surgical procedure. We report about two patients presenting with clinical and radiological features suggesting a groove pancreatitis in which control of symptoms was achieved by pancreatoduodenectomy. KEY WORDS: Groove pancreatitis, Paraduodenal pancreatic cancer.

An unusual case of repeated splenectomy: traumatic rupture of an accessory spleen in a previously splenectomized patient.

The traumatic rupture of an accessory spleen is a very rare condition and only few cases have been reported in the literature. We describe the case of a 51-year-old man undergone splenectomy for trauma several years before, who developed hemoperitoneum due to a laceration of a voluminous accessory spleen, following an accidental two-meter fall. As a conservative management of the injury was not possible, an accessory splenectomy was then required. Thus, a briefly review of the literature about this uncommon topic was perfomed. KEY WORDS: Accessory spleen, Laparotomy, Trauma.

Acute abdomen caused by greater omentum torsion: A case report and review of the literature.

Torsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review.

Incidental appendectomy? Microscopy tells another story: A retrospective cohort study in patients presenting acute right lower quadrant abdominal pain.

BACKGROUND: Optimal management of macroscopically normal appendix encountered during laparoscopy for acute abdominal pain is still unclear. METHODS: 164 acute abdominal pain cases in which laparoscopy showed a normal appendix were reviewed. No other intra-peritoneal acute disease was present in 50 patients (Group 1) whereas a miscellanea of intra-peritoneal conditions was identified in the other 114 (Group 2). All the patients underwent appendectomy with specimen examination. RESULTS: Following incidental appendectomy significant microscopical changes were seen in 125 specimens (76%). Among these, inflammation was found in 122 and neuroendocrine tumors in 3. Appendices harbored pathological changes in n = 45 patients (90%) of Group 1 and in n = 34 patients (70%) of Group 2 patients (p < 0.05). Morbidity for incidental appendectomy was 2%. CONCLUSION: This study supports an appendectomy in patients who are undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection.

Splenic abscess after splenic blunt injury angioembolization.

INTRODUCTION: Splenic Angioembolization (SAE), during Nonoperative Management (NOM) of Blunt Splenic Injury (BSI), is an effective therapy for hemodynamically stable patients with grade III, IV, and V OIS splenic injuries. We report a case of a patient with a blunt abdominal trauma due to an accidental fall, who presented splenic abscess a week after SAE and a review of the literature. CASE REPORT: A 38-year-old male arrived at Emergency after an accidental fall with contusion of the left upper quadrant of the abdomen. Abdominal CT scan revealed the fracture of the lower splenic pole with intraparenchymal pseudoaneurysms (OIS spleen injury scale IV). Considering the hemodynamic stability, NOM was undertaken and SAE was performed. After a week, the patient developed a splenic abscess confirmed by Abdominal CT; therefore, splenectomy was performed. There was no evidence of bacterial growing in the perisplenic hematoma cultures but the histological examination showed multiple abscess and hemorrhagic areas in the spleen. DISCUSSION: Splenic abscess after SAE during NOM of BSI is a rare major complication. The most frequently cultured organisms include Clostridium perfringens, Alpha-Hemoliticus Streptococcus, gram-positive Staphylococcus, gram-negative Salmonella, Candida, and Aspergillus. This case represents our first reported splenic abscess after SAE. CONCLUSION: SAE is a very useful tool for BSI managing; splenic abscess can occur in a short time, even if it is a rare major complication, so it may be useful to monitor patients undergoing SAE, focusing not only on the hemodynamic parameters but also on the inflammatory and infectious aspects.

The role of laparoscopy in adult bowel obstruction caused by intussusception.

AIM: The intestinal intussusception in the adult represent 1% of all occlusions. Organic causes are detectable in 90% of cases. Aim of this study is to discuss the diagnostic and therapeutic iter of adult intestinal intussusception with particular emphasis on role of laparoscopy. MATERIALS AND METHODS: We retrospectively considered 10 cases of intussusception between January 2000 and January 2013, demographic and clinical issue, location of invagination, the type of surgical treatment, the post-operative morbidity and mortality and histological nature of occlusion cause. RESULTS: Ten (F: M 1.5:1) patients were admitted in emergency with bowel obstruction, the median age was 50 years (r.18-91). All required surgical treatment. Three patients (30%) underwent a totally laparoscopic procedure, four patients (40%) laparoscopic exploration followed by laparotomy, three patients (30%) open surgery directly. The invagination was ileo-ileal (50%), ileo-colonic (40%) and colo-colonic (10%). Nine out of ten underwent to surgical resection. The malignancy was the most frequent cause. DISCUSSION: In case of colonic intussusception should not be performed any reduction because the frequent association with neoplastic disease. The laparoscopy can be safe and effective to allow, in entero-enteric and entero-colic intussusception, the definitive treatment of the occlusion. In the case of colo-colonic intussusception laparoscopy is a valuable diagnostic aid and can facilitate the later processing. CONCLUSION: The intestinal invaginations diagnosis can often be difficult. Laparoscopy is safe and effective in the diagnosis and treatment of adult intussusception.