Gastric perforation in blunt abdominal trauma. Report of two cases and review of literature.

Gastric perforations as a result of blunt abdominal traumas are rare, with a reported incidence of less than 2%. Usually associated with other solid visceral injuries, isolated gastric ruptures following a blunt abdominal injury are extremely uncommon. The severity of injury, timing of presentation, time elapsed since the last meal, as well as the presence of concomitant injuries are important prognostic factors. Contrast-enhanced CT scan is the gold-standard diagnostic tool in haemodinamically stable patients and allows to detect or raise suspicion of injuries to hollow viscera in about 87% of cases. The authors report two cases of patients suffering from gastric injury following a blunt abdominal trauma. The first one with a double gastric laceration treated with suture repair. The second one with a wide laceration and tissue loss along the greater gastric curvature requiring a wedge resection. Both patients had an uneventful recovery. Authors present a brief review of the literature; a search on PubMed using the key words "blunt abdominal trauma" and "gastric injury" was performed, including all studies published in the last 20 years. Finally, the main data extracted from four reviews were examinated. KEY WORDS: Abdominal trauma, Gastric injury, Hollow viscus perforation.

Laparostomy with topical negative pressure for treating severe peritonitis. Preliminary experience with 16 cases and review of the literature.

INTRODUCTION: The aim of this study was to assess the authors' initial experience with laparostomy and intraperitoneal topical negative pressure (TNP) in patients with severe peritonitis. The authors also reviewed the recent literature on the effectiveness and safety of abdominal TNP. PATIENTS AND METHODS: Sixteen patients (10 male, 6 female, mean age 55 years), suffering from severe peritonitis, underwent emergency laparotomy and laparostomy with TNP. Abdominal sepsis originated from the small intestine (n = 7), large intestine (n = 6), biliary tract (n = 2), and pancreas (n = 1). In 2 patients abdominal wall mesh infection and soft tissue gangrene were observed. RESULTS: The mortality rate was 31.2%. The main complications probably related to TNP were enteric fistulae (25%), bleeding (25%), abdominal abscesses (12.5%), bowel ischemia (6.2%). Delayed primary closure was performed in 8 patients (57.1%) whereas in 6 cases a parietal graft was necessary, and one patient underwent an autologous skin graft. CONCLUSIONS: Laparostomy with intraperitoneal TNP is a safe and effective method for managing patients with severe peritonitis. Morbidity can be reduced through individualized application of the laparostomy dressing and pressure gradient. The abdominal wall should be managed in such a way as to make possible delayed primary closure.

Megacolon for a giant faecaloma with unlucky outcome: case report and review of the literature.

We herein report a case of megacolon with fecaloma in an 83-year-old man who presented with constipation, no intestinal occlusion, and a left hydroureteronephrosis, with A.S.A. 4. The patient asymptomatic, was treated Primariely with laxatives. During the conservative therapy the patient presented an abrupt abdominal distension with a bowel obstruction and abdominal compartment syndrome. After the laparotopy and a Hartmann left colon resection the patient died for cardiovascular and metabolic complications. The aim of this report is to give a brief review of this entity and discuss the treatment options for these cases.

Acute afferent loop obstruction treated by endoscopic decompression. Case report and review of literature.

Afferent loop syndrome (ALS) is a rare complication of Billroth-II gastrojejunostomy. Most cases of ALS are caused by obstruction from adhesions, kinking at the anastomosis, internal hernia, stomal stenosis, malignancy, or inflammation surrounding the anastomosis. A 61-years old man, who had undergone gastric resection 30 years before, was admitted at emergency room with severe abdominal pain in acute onset, nausea and vomiting. Ultrasonography and multi-detector computed tomography suggested acute ALS, due probably to adhesions or internal hernia. The patient was conducted to digestive endoscopy unit and successfully treated with endoscopic decompression of dilated afferent loop. Open surgery is actually considered the gold-standard in treatment of ALS. However, some surgeons report a few cases treated by laparoscopic surgery, interventional radiology techniques, endoscopic decompression. Authors suggest endoscopic decompression of acute ALS due to adhesions or internal hernia as the first treatment, especially in high-surgical-risk patients.

[Spontaneous rectus sheath hematoma: a rare condition with uneasy diagnosis and multidisciplinary treatment. Report of 5 cases and review of literature]. / Ematoma spontaneo del muscolo retto addominale: evenienza rara, diagnosi difficile e trattamento multidisciplinare. Presentazione di 5 casi clinici e revisione della letteratura.

Spontaneous rectus sheath hematoma is a rare condition. It encompasses a wide spectrum of severity (self-limiting to fatal) depending of its size, etiology, and the development of complications. It enters into the differential diagnosis of abdominal pain but it's frequently difficult to diagnose and often radiologic imaging is required. Authors report a series of five patients admitted at emergency room within a 2-year period. Patient were between 63 to 78 years old. One of them was in therapy with warfarin, one was in therapy with acetilsalicililate and clopidogrel and in an another patient a coagulation disorder was detected. Diagnosis was suspected in all cases by clinical exam and ultrasonography, but CT-scan was necessary in three cases. All patients underwent conservative treatment, mainly pain relief and rest. In two cases blood transfusion was performed and in two cases clotting abnormalities were corrected with vitamin K and fresh frozen plasma. Average ospedalization was 10 days (range 5-17). One patient developed late seroma and was treated with ultrasound-guided aspiration. Rectus sheath hematoma is a rare but important entity in the differential diagnosis of abdominal pain. The difficulties in the correct diagnosis frequently lead to delay in treatment or unneeded surgery. CT-scan is the gold-standard investigation. Treatment options are variable and include conservative treatment, intravascular embolization and surgery Frequently an interdisciplinary team approach is needed.

[Squamous-cell carcinoma and pilonidal sinus disease. Case report and review of literature]. / Epitelioma a cellule squamose e malattia del seno pilonidale. Presentazione di un caso clinico e revisione della letteratura.

Squamous-cell carcinoma arising in a pilonidal sinus is a rare occasion. Authors report the case of a 60 years old male, with a 15 years history of recurrent pilonidal sinus disease. The patient underwent incisional biopsy, staging with total body CT, and finally radical surgery. The large wound healed by secondary intention, with a complete formation of the scar in three months. After six months, no complications or signs of recurrence were observed. Authors recommend careful inspection of the pilonidal area in all chronic and longstanding inflammatory lesions to identify promptly malignant transformation.

Adrenal incidentalomas in the laparoscopic era and the role of correct surgical indications: observations from 255 consecutive adrenalectomies in an Italian series.

BACKGROUND: The purpose of our study was to evaluate the impact of laparoscopic adrenalectomy on patients with incidentalomas. We analyzed the results of a multi-centre trial that was performed to evaluate the effectiveness of imaging (computed tomography and magnetic resonance imaging) to obtain a correct preoperative diagnosis. METHODS: We obtained our data from the results of a questionnaire that was distributed by mail or email in May 2005 to several surgical units operating in the Campania Region, Italy. Lap Club, a collaborative laparoscopic surgery study group founded in Naples in 1995, distributed the questionnaire. Thirteen centres participated in the audit. In all, we analyzed 255 adrenalectomies performed on 250 patients. We performed statistical analysis using SPSS software. RESULTS: The distribution of pathologic findings demonstrates that the number of lesions caused by cancer discovered from a preoperative indication of incidentaloma has been even smaller (1/114, 0.8%) than the previous numbers reported in the literature. Moreover, whereas most patients with adrenal cancer had lesions larger than 6 cm (7/8, 87.5%), the majority of patients with adrenal metastases had lesions 6 cm or smaller (10/12, 83.3%). Different indications for adrenalectomy emerged on comparison of endocrine surgery units with general surgery units. This difference appears to be significant (p < 0.001), especially on evaluation of the number of nonfunctioning adenomas and the number of endocrine lesions that were observed and treated. CONCLUSION: Laparoscopy remains the gold standard method for adrenalectomy, but its availability must not obligate physicians to treat with surgery when an incidentaloma is detected through imaging. Adrenal malignancies when metastatic are often 6 cm or smaller. If they are single and they originated from a non-small lung cancer, they must be removed. The endocrine surgery unit remains the best setting to evaluate and treat adrenal gland surgical pathology.

[Percutaneous cholecystostomy and papilloplasty in elderly high-risk patient. Case report]. / Colecistostomia percutanea e concomitante papilloplastica in paziente anziana ad alto rischio chirurgico. Caso clinico.

When acute cholecystitis is suspected in a very high-risk patient, percutaneous cholecystostomy should be considered as a safe and effective temporary management of patients with gallstones. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy. In elderly patients who are inappropriate surgical candidates because of severe concomitant systemic diseases, less invasive treatments may prevent recurrence. Our experience shows the feasibility of percutaneous cholecystostomy to achieve an effective treatment of acute cholecystitis in surgical high-risk patients with a physiologic biliary drainage of gallstones in duodenum to prevent recurrence. Moreover we demonstrated the feasibility of a concomitant percutaneous treatment of biliary disease.

[The extended lymphadenectomy in the treatment of gastric cancer]. / La linfadenectomia estesa nel trattamento del cancro gastrico.

INTRODUCTION: The only potentially curative modality of localized gastric cancer is surgery. However there is area of disagreement among surgeons with respect to the appropriate extent of lymphadenectomy. METHODS: The retrospective study of a personal experience on 155 patients with gastric cancer; the patients were divided in two groups with respect to the extent of lymphadenectomy. RESULTS: The results of this study highlight the more effectiveness of D2 resection compared with D1 resection with respect to 5th year survival. DISCUSSION: The goal of treatment is to reduce the risk of recurrent disease. There is considerable debate as to whether the routine use of an extensive en-bloc resection of second echelon lymph nodes (D-2 resection) is superior to a more limited lymphadenectomy of the perigastric lymph nodes (D-1 resection). Therefore the survival benefit of D2 dissection appears to be limited to N2 disease. CONCLUSION: Since nodal status prediction before or during surgery is inaccurate, all patients with curable disease, including those with N0 or NI disease, should undergone extensive node dissection.

[Interruption of the inferior vena cava in the prevention of pulmonary embolism]. / Interruzione della vena cava inferiore nella prevenzione dell'embolia polmonare.

Pulmonary thromboembolism constitutes the third cause of death after cardiovascular accidents and malignant tumours. Prevention is regarded as the most appropriate and effective therapeutic option. Medical antithrombotic therapy is the most common approach, but when antithrombotic therapy with heparin cannot be performed, vena cava filters are necessary devices in many patients and situations. Over the period from 1995 to 2003, 72 patients were admitted to the Surgical Sciences, Orthopaedics, Trauma and Emergency and Biomorphological and Functional Sciences Departments of the Federico II University of Naples. On the basis of their clinical condition and thrombus characteristics, different filters were applied (definitive, temporary, tempofilter). Thorough clinical and imaging follow-up examinations showed the efficacy of vena cava interruption in the prevention of pulmonary embolism, as well as a low complication rate and convenient risk-benefit ratio. Tempofilter, which allows partial interruption of the vena cava for more than 6 weeks, would appear to be the best filtration device. It is effective in the prevention of pulmonary thromboembolism, is durable and does not entail any significant increase in recurrent venous thrombosis, as is the case with definitive vena cava filters.

[Surgical and endoluminal treatment of carotid stenosis: our experience]. / Trattamento chirurgico ed endoluminale delle stenosi carotidee: nostra esperienza.

Carotid endarterectomy and percutaneous transluminal angioplasty are known to prevent cerebrovascular accidents. From January 1997 to December 2002, 47 patients (35 male, 12 female; median age: 65 years) with carotid stenosis were observed. Neurological accidents were reported in 89.4%, while the other 10.6% were asymptomatic. The operative indications for the asymptomatic patients were high-degree stenosis (> 70%) of the internal carotid artery and ulcerated plaques with a moderate degree of stenosis (50%). Preoperative investigations consisted in colour Doppler ultrasonography, arteriography and cerebral CT scans or NMR. Endarterectomy was performed in 35 patients, while the other 12 underwent percutaneous transluminal angioplasty. The operative mortality in the 35 patients undergoing surgery was 5.7% (2 cases) and perioperative strokes occurred in 3 cases (8.6%). After 36 months, 32/35 patients (91.4%) were stroke-free, and one patient died as a result of a stroke. In the group of patients undergoing angioplasty, re-stenosis occurred in 2 cases (16.7%). Our results suggest that colour Doppler ultrasonography is a reliable examination for investigating the carotid axis and that both carotid endarterectomy and percutaneous transluminal angioplasty are safe procedures capable of preventing future cerebrovascular accidents.

[Gastric non-Hodgkin lymphoma: guidelines for the therapeutic approach]. / Linfoma non Hodgkin a localizzazione gastrica: linee guida nell' approccio terapeutico.

The aims of this study were to contribute to the drawing up of guidelines for the therapeutic approach to primary gastric lymphoma and to identify the most effective sequence of treatment in the different stages of the disease. We conducted a retrospective analysis of the clinical data of 34 patients with primary gastric lymphoma admitted from 1993 to 2001 to the 4th General Surgery Department of the "Federico II" University in Naples. All the patients underwent surgical therapy and neoadjuvant or adjuvant chemotherapy. Patients were subdivided according to stage of disease, histological grade of malignancy and sequence of treatment. The 2- and 5-year overall survival rates were 94% and 68%., respectively. We observed a longer survival (81% at 5 years) in patients with IE-IIE stage disease (according to Mushoff's staging) than those with IIIE-IVE stages (56%). Patients with low and intermediate grade lymphoma (according to the working formulation) had a longer survival (83% and 71%, respectively) than patients with high-grade malignancies (55%). We noted that IE-IIE stage patients who underwent neoadjuvant chemotherapy and surgery survived longer (100%) than those in whom surgery preceded chemotherapy (66%), whereas IIIE-IVE stage patients in whom surgery was the first treatment survived longer (70%) than those in whom surgery followed chemotherapy (37%). On the basis of our experience, in patients with IE-IIE stages of disease chemotherapy should precede surgery while in patients with IIIE-IVE stages the inverse sequence is more effective in achieving longer survival rates.