Elective Treatment of Large-Bowel Obstruction in Asymptomatic Sigmoid Volvulus.

BACKGROUND: Sigmoid volvulus is an uncommon cause of intestinal obstruction representing the 5% of all Western cases, associated with old age and a history of neurological and psychiatric condition. Generally, its diagnosis is established by clinical and radiologic findings. It often represents an emergency and it is commonly associated with pain, vomit and abdominal tenderness. CASE PRESENTATION: We present a case of a 59 years old man, admitted to our emergency department, showing an abdominal X-Ray reporting a distention of large bowel,which was required due to presence of multiple diarrhea episodes during the previous 7 days. He had no significant past medical history and did not report constipation or subocclusive episode. CONCLUSIONS: Volvulus should be considered in the differential diagnosis in adult and healthy patients with bowel obstructions. Surgery is, in all cases, the radical and definitive treatment since there is a higher mortality in case of recurrent volvulus. Despite the massive bowel distention, our choice was the elective open surgery. Primary anastomosis is feasible and safe and did not lead to any complications. In case of unsuccessful colonic decompression, evidence to support or refute the safety and effectiveness of laparoscopic surgical resection for treatment of patients with sigmoid volvulus disease is not yet proven.

Perineal trauma with anal avulsion: case report.

Anorectal avulsion is an exceptional rectal trauma. In this kind of lesions, the anus and the sphincter no longer join the perineum and are pulled upward. We present a case of 34-years-old patient who was admitted because of a pelvic-perineal trauma, presenting a partial anorectal avulsion, exposed femoral fracture with thigh's lacerated-contused wound. Our treatment included primary plastic of the internal anal sphincter with replanting of the rectum on the anal canal and a diverting loop sigmoid colostomy (SCS), so as to prevent sepsis. Closure of the protective SCS was performed four months after the trauma.

Enterocutaneous fistula treatment: case report and review of the literature.

OBJECTIVE: The aim of this work is to evaluate the treatment strategies for a common major surgery complication like the enterocutaneous fistula (ECFs). Since there is not any standard treatment for this common disease and since new therapies, like NPWT and fibrin sealants, have come up a review of all their indications seemed useful. We also present two clinical cases treated in this way. PATIENTS AND METHODS: A research was made in the principle databases such as: "Cochrane", "Pubmed", "Google Scholar" and "Google" using the following Key words "enterocutaneous fistula", "fibrin glue", "VAC", "VAC treatment", "fistula", "conservative treatment", "surgery" and using the MESH Function to search similar key words and expand the research. When two or more article with the same design were encountered (e.g. systematic reviews or case reports etc.) the newest one was chosen as data source. RESULTS: As far as somatostatine and its analogues are concerned, they showed a significant reduction of both time (13.95 vs 20.5 days) and percentage (72% vs 44%) of fistula closure against placebo in 2 meta-analysis. NPWT showed a high success rate between 90% and 100% but longer closure time between 4 weeks and 6 months. Fibrin glues showed heterogeneous results due to the great differencies in fistulas anatomy and treatment technique in the various studies, with 64-100% success rate in closure and a median 11,25 vs 23,25 days against total parenteral nutrition (TPN) alone. CONCLUSIONS: Because of ECFs often come up in patient in bad conditions who are not fitted for surgery and because of their high Mortality and Morbidity, a multimodal approach is necessary. Although TPN is a cornerstone of their treatment, NPWT showed is superiority in reducing fistula output and in some cases leading to fistula closure, nevertheless it often needs long treating time. Fibrin glues often needs complex devices and are nota s good as NPWT in treating the around tissues, but they can be useful when fistulas are only accessible from a little external orifice or they show a complex branched tract; thus they are good when surgery is not possible and the fistula has a mid- or low- output. The lack of prospective randomized studies or meta analysis and systematic review to compare the different methodics makes it impossible to show any evidence of superiority, but the combined application seems reasonable for a tailored treatment.

Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).

Appendicitis and abscess in an adult patient with intestinal nonrotation: Case report.

The aim of the article is showing a particular case of midgut nonrotation. It is a congenital defect of the bowel development, during which fails the rotation of 270° around the vascular pedicle. This anomaly causes a different intestinal arrangement: the small bowel is located in the right side of abdominal cavity while the large bowel is situated in the left side. We present a case of acute appendicitis and abscess treated successfully with urgent surgical intervention in a patient completely asymptomatic for nonrotation. Nonrotation may lead to acute symptoms, vague abdominal pain or may remain asymptomatic throughout all life and be discovered only accidentally. Radiological exams and laparoscopy can help to make a correct diagnosis. A conservative treatment could be preferred in asymptomatic patients and Ladd's surgical procedure should be performed in selected cases.

Early right hepatectomy for severe liver trauma: a case report.

Liver is frequently involved and injured in blunt abdominal trauma. Although over the last three decades the management of blunt hepatic trauma has gradually shifted toward nonoperative approach whit a significant reduction in overall mortality, surgery remains the main option for hemodinamically unstable patients whit severe liver injuries. A 16-yr-old male in good health suffered a blunt abdominal trauma from a sport accident falling while playing football resulting in a grade V liver injury according to the American Association for the Surgery of Trauma Organ Injury Score. He underwent first to liver packing and next to an early right hepatectomy to arrest the clinical condition impairment In high grade liver injuries, liver resection makes possible to effectively control bleeding, remove necrotic tissue and prevent complications as bile leak. Nevertheless when patient's clinical condition continue to deteriorate despite optimal management a quickly and experienced hands performed hepatectomy may solve the situation.

Laparoscopic management of left paraduodenal hernia. Case report and review of literature.

We report a rare case of left paraduodenal hernia in patient with symptoms of abdominal subobstruction treated successful with laparoscopic management in urgent situation that have reduced the length of stay and postoperative pain. Internal hernia is only 1% of the causes of abdominal obstruction and the left paraduodenal hernia about 50% of them; it is a congenital defect that derive from malrotation and abnormal mesenteric adhesion. The modern imaging techniques help for the correct diagnosis despite difficult identification of the pathology for the various clinical presentation. The treatment of choice is the surgical intervention; the laparoscopic approach is rarely described in literature but it can reduce the morbidity, postoperative pain and the length of hospital stay.

Treatment of permagna incisional hernia with skin necrosis and abscess: case report.

Ventral incisional hernia rate is decreasing due to the introduction of new clinical and surgery method. As a result, the complex incisional hernias, are less often described and rarely treated. We describe our experience in emergency case. We present the case of permagna incisional hernia with skin necrosis, subcutaneous abscess and bowel perforation which cause a long-lasting bedding. The successful management includes an emergency surgery applying hernia reduction, bowel resection and abdominal wall reconstruction through a biological mesh and positioning of VAC System. There is not a gold standard treatment that obtained an unanimous consensus, however we recommend the following procedure in that, in our patient, it shows no recurrences, infections and other post-operative complications.

Abdominal emergency in elderly: a case of small bowel obstruction and ischemia caused by bulky IA ovarian cancer.

Bowel obstruction resulting from colorectal and ovarian cancer is a serious and distressing complication of these malignancies. This may be caused by diffuse peritoneal carcinomatosis, bulky masses filling the pelvis and abdomen or postoperative adhesions, and should be carefully worked out by pre-operative imaging. We report the case of a small bowel obstruction and intestinal ischemia caused by a bulky (20x40 cm in diameter) cystic ovarian neoplasm that was found to be a stage IA G2 cystadenocarcinoma, successfully managed by uterus-sparing surgery.

Isolated pancreatic tuberculosis: a diagnostic challenge.

Abdominal tuberculosis is quite commonly found in miliary tuberculosis, especially in countries where TB is endemic, however the abdominal localization of tuberculosis in absence of disseminated disease is a rare condition and the involvement of the pancreas alone is extremely rare. Epidemiology of TB is changing in the latest years, often this illness is found in non-endemic regions and physicians are asked to interpret what happen when an old disease meets new diagnostic technologies. We describe the case of a young male admitted in our hospital for abdominal pain. Echotomography, CT scan and MRI showed a pancreatic mass suspected to be cancer and susceptible to surgical treatment, Endoscopic Ultrasound guided fine needle aspiration (FNA) showed isolated pancreatic tuberculosis.

Abdominal emergency in young women: gynecological or bowel disease? Two case reports.

Abdominal pain is a frequent symptom in Emergency Departments. Often is not so easy make a diagnosis of cause. Particular importance in young women has differential diagnosis with gynecological diseases. Often laboratory exams have not good specificity. US and TC are the imaging techniques most used to make a diagnosis, but both have ours limits. Definitely surgeon's experience is the most important resource for a correct approach to abdominal pain. We present two cases of low abdominal pain in young women due to ovarian teratoma erroneously diagnosed as appendicitis.

VAC (Vacuum Assisted Closure) treatment in Fournier's gangrene: personal experience and literature review.

INTRODUCTION: Fournier's gangrene (FG) is a rapidly developing necrotizing fasciitis that originates in genital and perineal region. The mortality rate is high and requires prompt diagnosis, antibiotic treatment and extensive necrosectomy with derivative colostomy. Vacuum Assisted Closure (VAC) is a wound care system of paramount importance in the treatment of complex wounds, including the perineum. MATERIALS AND METHODS: We evaluated 6 cases of FG (males, mean age: 54.6 yrs) of the last 3 years (February 2008-August 2010). All patients were diabetics. We used intravenous antibiotic treatment and early surgical debridement with colostomy, followed by immediate positioning of a VAC device (NP 125-200 mmHg). The dressing changes were done every 3-4 days. Hyperbaric oxygen therapy (HBOT) was given only to one patient. Microbiological etiology was assessed by multiple cultures to tailor the antimicrobial treatment. RESULTS: The VAC therapy reduces the number of dressings and the hospital length of stay (LOS), in agreement with the literature; in one of the cases a secondary reconstructive surgical intervention was possible. The colostomy was reversed in all patients within 3 months. CONCLUSIONS: Negative pressure is a time saving device, reducing days of hospitalization, patient's discomfort and number of medications. The possibility of a early reconstructive surgery improves significantly quality of life.

Ascaris Lumbricoides infestation and intestinal MZBCL: a surgical and radiological perspective.

Ascaris Lumbricoides is the most common worm found in human beings and it is the largest of the intestinal nematodes parasitizing humanity. The most common complication of Ascariasis is mechanical bowel obstruction caused by a large number of worms. Bowel obstruction can also be caused by various toxins released by the worms. A large worm bolus can also cause volvulus or intussusception. We report a case of Intestinal Obstruction due to an Ileal MZBCL in an Ascaris. Lumbricoides infestation setting.

Traumatic complex wounds, multidisciplinary approach: our experience in a case series.

"Limb-salvage" is a social problem that is rapidly increasing, both in Italy and in the rest of world. Today, as in earlier times, the main causes of open wounds are traumas and such injuries are mainly of II and III stage of Gustilo's classification. Nowadays, the use of modern techniques determined a further dramatic reduction in the infection rates and, above all, in the risk of limb amputation. The most important techniques include: V.A.C. therapy (vacuum assisted closure); PRP gel (platelet-rich plasma gel); hyperbaric oxygen therapy. We treated 4 patients with high energy acute trauma through the combined and innovative use of advanced dressings. The authors report their experience and a brief review of the literature as contribution in regards to treatment of complex wounds of the limbs.

Sigmoidorectal intussusception in adults: a case report.

A 75-year-old women was admitted to our hospital due to anal bleeding from 5 days. At clinical examination abdomen was soft but tenderness in the lower quadrants, where a soft, mobile, round mass measuring 10 cm in diameter was palpable. CT scan demonstrated the presence of sigmoido-rectal intussusception. The patient underwent emergency anterior resection of rectum with stapled termino-terminal colo-rectal anastomosis. Postoperative course was uneventful and the patient was discharged 7 days after the operation. Histopathological examination demonstrated a tubular adenoma with low grade dysplasia, 1,2 cm in diameter, located in the distal sigmoid colon. Intussusception is a rather common pediatric condition that rarely presents in adults. Adults intussusception represents 5% of all cases of intussusception. In children it is usually primary and benign, and pneumatic or hydrostatic reduction of the intussusception is sufficient to treat the condition in 80% of patients. In contrast a demonstrable etiology is found in 70% to 90% of cases in adults, and approximately 40%-50% of them are caused by malignant neoplasms. Surgical intervention is necessary in all cases of intussusception in adults. Due to the low incidence and the rare consideration given to this condition among adults the preoperative diagnosis can be difficult, especially in emergency cases. Abdominal CT provides the most accurate diagnostic rate for intestinal intussusception.

Primary psoas abscess in a patient affected by acquired immunodeficiency syndrome: a rare case according to the reviewed literature.

Abscesses of the psoas muscle can be divided into primary and secondary. In the primary ones, it is not possible to identify any further infected site. The localization to this muscle is due to its rich vascularization and Staphylococcus aureus is the most frequent aetiological agent of the infection. Treatment requires the use of appropriate antibiotics, as well as surgical or percutaneous drainage of the abscess. The percutaneous drainage is much less invasive and a low risk in the patients with acquired immunodeficiency syndrome, and is effective for draining even multiloculated abscess. The authors present a rare case of primary psoas abscess in patient affected by acquired human immunodeficiency syndrome, showing a mass in the inferior lumbar region through the lumbar triangle of Petit and fever. Treatment consisting in percutaneous drainage combined with systemic antibiotic administration was successful.

Gastrointestinal bleeding in emergency setting: two cases of intestinal angiodysplasia and unusual conservative surgical treatment.

The authors report two cases of gastrointestinal bleeding in an emergency setting caused by angiodysplasia of colon and small bowel. They stress the rarity of the lesion and consider the difficulties involved in obtaining a preoperative diagnosis. The optimal management is uncertain and depends on the severity and rate of bleeding. A conservative medical approach is indicated for many patients, while surgery constitutes definitive treatment in case of massive hemorrhage or recurrent bleeding. In the cases reported the diagnosis was performed only via intra-operative enteroscopy. An unusual conservative surgical treatment was performed based on ligation of the vascular elements of the angiodysplasia. This method makes it possible to avoid an intestinal resection and yelds good results.

Mechanical small bowel obstruction due to an inflamed appendix wrapping around the last loop of ileum.

Acute apendicitis rarely presents with a clinical picture of mechanical small-bowel obstruction. The Authors report a case of this inusual clinical occurrence, arised like a complication of a common disease, characterized by a chronically inflamed appendix (mucocele) wrapping around the last loop of ileum that produced volvolus and strangulation. The few similar cases reported in the literature are moreover reviewed.

Intestinal anisakiasis in Italy: case report.

A case of intestinal anisakiasis caused by Anisakis sp. larva type I in a woman from Italy who consumed raw marinated anchovies, is reported. The diagnosis was based on the morphological features characteristic of anisakid larval stages, which were readily recognized in a large granuloma removed after emergency surgical treatment.

Large extrapleural hematoma in an anticoagulated patient after a thoracic blunt trauma.

We report the 7th case of a traumatic extrapleural hematoma that developed in an anticoagulated patient with a thoracic blunt trauma and rib fractures, and required an emergency surgical treatment. Extrapleural hematoma is a rare and life-threatening condition characterized by a collection of blood between the pleura parietalis and the endothoracic fascia. Related symptoms and chest x-ray findings are not characteristic and may present several hours after the injury, leading to delayed diagnosis and treatment. Etiological, surgical and prognostic implications of this finding are briefly discussed.