Endoscopic versus surgical treatment for a rare form of gallstone ileus: Bouveret's syndrome. Two case reports and review of the literature.

BACKGROUND: Bouveret's syndrome is a gastric outlet obstruction due to a gallstone impacted in the duodenal lumen or in the stomach via a bilioenteric fistula. It's the rarest form of gallstone ileus, with few cases reported in medical literature. Typically, this condition affects elderly people and causes high morbidity and mortality rates. METHODS: We present a review of the published cases of Bouveret's syndrome between 2006, year of publication of the largest case series, and 2015 with particular regard to the operative management and treatment options. Two demanding cases of Bouveret's syndrome reported in our Hospital are also described. RESULTS: Bouveret's syndrome is a rare clinical condition and data reported in medical literature only derive from single case reports and case series. Therefore no clear management indications have been ruled out and treatment options are still matter of debate. CONCLUSION: Bouveret's syndrome is a rare clinical entity with a challenging operative management. Surgical or endoscopic treatments should be tailored on patient medical conditions and clinical presentation. KEY WORDS: Bouveret's Syndrome, Cholelithiasis, Gallstone Ileus, Gastric Outlet Obstruction, Intestinal Obstruction.

Splenosis of the abdomen and pelvis complicated by torsion of a splenic implant clinically mimicking an acute bowel ischemia.

We present a case of splenosis of the abdomen and pelvis complicated by torsion of a splenic implant in a young female patient clinically mimicking an acute bowel ischemia. Splenosis is a benign condition defined as heterotopic auto-transplantation of splenic tissue throughout different body areas. It may occur after rupture of the spleen, either traumatic or secondary to surgical procedures. Although the presence of heterotopic splenic tissue is often asymptomatic and an incidental finding, it may present with sudden abdominal pain and bleeding. CT and MRI play a critical role in the detection of splenosis-related complications, such as torsion of the vascular pedicle and infarction. Splenosis torsion is extremely rare and it is still a diagnostic dilemma; the complication of abdominal splenosis should be considered in the differential diagnosis in patients with previous splenectomy.

Pyogenic vertebral osteomyelitis complicating abdominal penetrating injury: case report and review of the literature.

Pyogenic vertebral osteomyelitis is a rare condition usually associated with endocarditis or spinal surgery. However, it may also occur following abdominal penetrating trauma with associated gastrointestinal perforation. Diagnosis might be challenging and appropriate treatment is essential to ensure a positive outcome. In trans-abdominal trauma, 48 hours of broad-spectrum antibiotics is generally recommended for prophylaxis of secondary infections. A case report of vertebral osteomyelitis complicating trans-colonic injury to the retroperitoneum is presented and clinical management is discussed in the light of literature review.

Acute bowel ischemia: analysis of diagnostic error by overlooked findings at MDCT angiography.

To retrospectively evaluate the frequency and type of findings that were missed in the original reports of multi-detector CT angiography (MDCTA) in patients with suspected acute bowel ischemia. From January 2007 to March 2011, a series of 35 patients who underwent MDCTA of the abdomen and pelvis and had surgery were included. The reports of the initial CT were retrospectively compared with the discharge diagnosis and surgical reports. Discrepant or missing findings were re-evaluated and divided into relevant or not relevant regarding the diagnosis. In 23 of the 35 patients (66 %), all findings were correctly diagnosed in the initial MDCTA report. In the remaining 12 of the 35 patients (34 %), lesions that were not reported were present at surgery. In 10 of the 12 (83 %) patients, the overlooked findings were relevant and subtle: gas in the portal vein (n = 3), gas in the bowel wall (n = 3), gas in the portal vein and bowel wall (n = 2), thrombotic occlusion of the superior mesenteric artery (n = 1), and thrombotic occlusion of the inferior mesenteric artery (n = 1). In 2 of the 12 (17 %) patients in whom the MDCTA-overlooked findings were classified as non-relevant, bowel ischemia was found at surgery. With retrospective image interpretation, 83 % of the patients with occlusive mesenteric ischemia at surgery were correctly identified, whereas the remaining 17 % with non-occlusive mesenteric ischemia at surgery showed non-relevant findings at MDCTA. About 33 % of relevant findings of bowel ischemia were overlooked by the initial MDCTA interpretation, most were subtle findings. However, secondary reading revealed most of these findings and can serve to improve diagnostic performance.

Healing of Blunt Liver Injury After Non-Operative Management: Role of Ultrasonography Follow-Up.

BACKGROUND: Non-operative management of patients with blunt liver trauma has become the standard of care. Usually after initial computed tomography (CT) evaluation and a short-term intra-hospital instrumental and clinical monitoring, no other imaging assessment is routinely requested. A restriction of physical activities for a few (unfixed number of) months is the most common recommendation. A few studies investigated the re-establishment of normal hepatic parenchymal architecture, but there is no evidence of the correct length of time for a certain resumption to normal life. To understand the progression of traumatic liver damage and the time course of healing, and to indicate the correct spontaneous recovery time, a long-term sonographic followup was done. METHODS: Forty-four patients with blunt non-operatively managed hepatic injury were selected by a retrospective review of a prospectively collected database. At admission, in accordance with the American Association for the Surgery of Trauma (AAST), all lesions were evaluated by CT and graded by the Organ Injury Scale (OIS). The progression of liver repair was followed by ultrasonographic (US) controls on days 3, 5, 10, 15, 30, and 60, and monthly up to a complete clinical recovery and sonographic disappearance of lesions. RESULTS: One OIS grade I, 20 grade II, 13 grade III, eight grade IV, and two grade V hepatic injuries were included in the study. Forty patients were monitored until liver normalization by 218 US examinations. The median time for liver repair in OIS grades II, III, IV, and V was 30, 63, 62, and 118 days, respectively, and 75% of the patients recovered in 60, 80, and 98 days in the II, III, and IV classes, respectively. CONCLUSION: In our experience, a long time variability for spontaneous liver repair after blunt trauma and non-operative treatment was found, but a parenchymal US normalization was evidenced in a median time shorter than that usually reported in the literature.

[Analysis of quality in a first level trauma center in Milan, Italy]. / Analisi di qualità di un trauma center di I livello nella città di Milano.

BACKGROUND: In Italy there isn't a State Trauma System. Many attempts have been done to increase the quality of trauma care in prehospital and hospital phases, but only by local resources. In Mila (Italy)o Emergency Medical System is organized by Regional rules and five Hospitals warrant high level of care for trauma patients. There isn't an official registry for trauma. Creating a Trauma Registry is the prerogative to analyse the quality of assistance and to propose new solutions. OBJECTIVES: To analyse major trauma patients admitted to Ospedale Maggiore Policlinico IRCCS; to evaluate diagnostic and therapeutic protocols in order to identify preventable deaths. PATIENTS: We have observed trauma patients admitted to Ospedale Maggiore from January to December 2004. We collected demographic data, informations about the traumatic event and prehospital rescue, emergency room examination, diagnostic exams, surgical operations and results of treatment. We selected patients admitted among 6917 trauma patients observed in this period. We have calculated RTS, ISS and TRISS. Patients were followed during their staying at the hospital to record length of staying, lenght of ICU and mortality rate. We collected the autopsy of the all death patients. RESULTS: We selected 299 patients, 207 males and 92 females. Mean age was 42.4 +/- 19.5 for males (range 15 - 99) and 57.7 +/- 22.5 for female (range 7 - 101). Motorvehicle and road incident were the main cause of trauma (55.5%). A penetrating injury was observed only in 5% of cases. Mean RTS was 7.5 +/- 1. ISS and TRISS were (mean +/- SD) 13 +/- 9 and 94.9% +/- 11.5, respectively. Patients with ISS = 16 were 109 (36.4%). Forty five patients (15%) required a surgical treatment during the first 48 hours. Total length of staying was 8.9 +/- 11.2 (mean +/- SD) days (median of 5.5 days) and the length of ICU was (mean +/- SD) 11.7 +/- 10.3 days (median 9 days). 12 patients died (mortality rate 4.08%), 11 at Policlinico (2 in the emergency room, 3 in the operative room, 5 in ICU. One patient died in surgical ward), 1 at Ospedale Niguarda. Autopsy was available for 8 patients. In 2 cases the cause of death was established by clinical examination and in 1 case police are still investigating for poisons or other letal drugs. The main cause of death was the cerebral injury. Only for 1 patient it was impossibile to determine the cause of death so he was considered a potentially preventable death. His clinical RTS in the emergency room was 12 (7,4808 in the statistical analysis) and no severe lesions were observed during primary and secondary survey. CONCLUSIONS: Our data are typical of an urban area of a western country. Penetrating injury are very rare, 5% of incidence. Diagnostic and therapeutic protocols are similar to countries where a Trauma Center is active. The 4% of overall mortality rate is similar to Trauma Centers in USA. This result is better than other hospitals in Milan. The high number of ATLS providers in the trauma team could be one of causes of good results. Quality audit can't consider only RTS, ISS and TRISS. Scores are very practical and useful but they aren't enough. We must analyse every single case of death and Trauma Registry is the first tool to evaluate trauma care in a modern EMS.

[Role of the severity score and of the multiple organ dysfunctions in the treatment of severe acute pancreatitis and its infective complications]. / Ruolo dei punteggi di gravità e dell'insufficienza multipla d'organo nel trattamento della pancreatite acuta severa e della sua complicanza infettiva.

INTRODUCTION: There is considerable controversy about timing of surgery in acute pancreatitis. Scoring system is widely used in Intensive Care Units (ICU) but above all in order to assess the severity of disease. AIM OF THE STUDY: In this prospective clinical study, modification of clinical evolution and scores (APACHE II, SAPS II and SOFA) are analyzed. Scores were computed, daily or every other day. Two particular phases were observed: the day of ICU admission and the day of surgical treatment. MATERIAL AND METHODS: Twenty-one patients are studied; they were all surgically treated only after identification of positive pancreatic coltures. Open-packing was performed 2-6 weeks after the beginning of acute pancreatitis. In six patients who died, a progressive deterioration was noticed between admission and identification of infected necrosis. All scores were higher in patients who died, in particular a significant difference was found between SOFA score at admission and at treatment (mean +/- SD: 5.0 +/- 3.2 vs 8.5 +/- 3.0, p < 0.05). CONCLUSIONS: In conclusion when clinical conditions are critical a high SOFA score could contribute to indicate surgical treatment even without identification of sepsis.

Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care.

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department. The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma.

Neurofibromatosis-1 and Ampullary Gangliocytic Paraganglioma Causing Biliary and Pancreatic Obstruction.

Gangliocytic paragangliomas (GPs) are exceedingly rare tumors that arise in close proximity of the papillaof Vater. Nevertheless, jaundice is an uncommon presenting symptom, reported in only 3 of 125 casesdescribed in the literature to date, with gastrointestinal bleeding being more common.Association between GPs and neurofibromatosis 1 (NF-1), described in two patients, may be more thancasual, being the frequency in normal population 1:3000.We report an additional case of this association, presenting for the first time with simultaneous obstructionof the common biliary duct, and of the main pancreatic duct. Previous cases of GPs with jaundice and/orNF-1 are reviewed, and updating of the histogenesis presented.