Pneumomediastinum: Experience with 87 Patients.

OBJECTIVE: The aim of the present series was first to present our experience in the management of 37 patients with spontaneous pneumomediastinum (SPM), and further to indicate the necessity of identifying true SPM cases as they are currently inadequately defined. METHODS: This is a single-center, retrospective study, conducted in a university hospital. Consecutive adult patients with pneumomediastinum (PM) between January 2009 and March 2020 were involved in the series. The data about age, gender, symptoms, signs, treatment, length of hospital stay (LOS), and in-hospital mortality were evaluated. RESULTS: In total, 87 cases with pneumomediastinum (37 with spontaneous and 50 with secondary PM) were analyzed. Patients in both groups were of similar ages (P=0.4). Sufferers with secondary PM were more likely to have: an associated pneumothorax (19% vs 58%, P<0.05), a chest tube placed (18.9% vs 58%, P<0.05), an associated pleural effusion (0% vs 18%, P<0.05). They presented with a longer LOS (3.9 vs 5.3 days, P<0.05), and were more likely to die (0% vs 10%, P<0.05). Additionally they showed a higher prevalence of radiologic subcutaneous emphysema (49% vs 74%, P<0.05). CONCLUSION: Spontaneous pneumomediastinum is an onset of clinical importance with a low mortality rate, short LOS and good longterm prognosis. It often presents with chest pain, dyspnea and/or subcutaneous emphysema. However, secondary causes of mediastinal air must be ruled out, due to their potential devastating outcome if not diagnosed promptly. A consensus aimed at an update of the classification guidelines is more than indispensable.

Computed tomography-guided percutaneous cholecystostomy: a single institution's 6-year experience.

Background: Acute cholecystitis (AC) is an emergency commonly managed by a surgical department. The interventional part of the standard treatment algorithm includes laparoscopic or open cholecystectomy. Percutaneous cholecystostomy (PC) under imaging guidance is recommended as the first-line approach in the subset of high-risk patients for perioperative complications, as a bridging therapy to elective surgery or as a definitive solution. The aim of the present study was to evaluate the mortality and morbidity of PC performed under computed tomographic (CT) guidance in patients at high surgical risk. Methods: Medical and imaging records from all consecutive patients who underwent a CTPC between 2015 and 2020 were reviewed. Adult patients with a definite indication for CTPC were recruited and mortality 7 and 30 days post-procedure was recorded. Variables potentially affecting those outcomes were retrieved and included in our analysis. Results: Eighty-six consecutive patients at high risk for surgical management were identified and included in the present study. Most patients (58.1%) were diagnosed with AC, while 14 (16.3%) had concurrent AC and cholangitis, 13 (15.2%) gallbladder empyema, and 9 (10.4%) hydrops. The 7- and 30-day mortality rates were 16.3% (14/86) and 22.1% (19/86), respectively, and were significantly associated with patients' hospitalization in the intensive care unit (P<0.05). Other parameters investigated, such as age, sex, diagnosis, catheter diameter, and duration of hospital stay were not significantly associated with our primary outcome. Conclusion: PC is a safe alternative to surgery in patients with high perioperative risk, thus providing acceptable mortality rates.

Surgical Repair of Iatrogenic Duodenal Injuries with a Roux-en-Y Duodenojejunostomy: A Physiology-oriented Approach.

Introduction: Iatrogenic duodenal injuries represent a condition associated with high morbidity and even mortality. Management is still controversial with a lack of consensus among experts regarding the optimal treatment. The purpose of the present study was to test and assess the results of a certain reconstruction technique. Material and Methods: Four patients (2 males and 2 females) of a mean age of 83 years with iatrogenic duodenal injuries underwent surgical repair of the duodenal perforation, with a two-layer duodenojejunostomy and a Roux-en-Y jejunal loop. Results: Three out of four patients (75%) had a rapid and uncomplicated recovery (13 days mean postoperative length of hospital stay), while the fourth patient died in the ICU due to ARDS three weeks later, without however evidence of anastomotic leak. Conclusion: A variety of surgical repair techniques have been proposed to date; however, with controversial results. A repair using an isolated jejunal Roux-en-Y loop seems to fulfill all the optimal prerequisites for a successful anastomotic outcome and proved efficient in its certain form for the given patient sample.

Metastatic rectal cancer in the ampulla of Vater: A unique case.

BACKGROUND: A metastatic lesion located in the ampulla of Vater is considered extremely rare, with only 32 cases reported globally. CASE: A 65-year-old patient was primarily diagnosed with a rectal adenocarcinoma. Twenty-four months later as part of the oncological follow-up, the patient was diagnosed with a single secondary tumor in the ampulla of Vater. After undergoing a pancreaticoduodenectomy (Whipple procedure), the patient experienced an uneventful recovery and received adjuvant chemotherapy. Sixteen months later the patient remained disease-free. CONCLUSION: To the best of our knowledge, the present case represents the first reported metastatic tumor in the ampulla of Vater, originating from a rectal adenocarcinoma. This case underlines the critical role of immunohistochemistry in arriving at a correct diagnosis in order to guide clinical decision-making.

Reaching the Challenging Diagnosis of Complicated Liver Hydatid Disease: A Single Institution's Experience from an Endemic Area.

Background and Objectives: Hydatid disease (HD) remains a significant public health issue causing morbidity and mortality in many Mediterranean countries. Material and Methods: The present cohort study included 50 consecutive patients with liver hydatid disease who underwent surgery in a tertiary University Hospital. A total of 18 patients (36%) had a case of complicated HD, including simple communication of the cyst with the biliary tree (6 cases), rupture of the cyst into the biliary tree (6 cases), presence of a bronco-biliary fistula (2 cases), rupture of the cyst in the peritoneal cavity (2 cases), and rupture of the cyst and formation of a hepatic abscess (2 cases). Endoscopic retrograde cholangiopancreatography (ERCP) was pre-operatively performed on six patients. Results: The main clinical symptom presented was right upper quadrant pain in 16 patients (88%), which was associated with high fever (>39 °C) in 14 patients (78%). C-reactive protein (CRP) was the primary indicator of a complicated HD (p = 0.003); however, it was only elevated in 67% of cases. CRP was a more sensitive indicator of a rupture in the biliary tree cyst (p = 0.02). Computer tomography (CT) detected more cases (44%) of a complicated HD than ultrasonography (US) (25%); however, the difference was not statistically significant. Conclusions: For prevention and control of HD, a high suspicion of the disease leading to early referral to specialized centers, mainly in endemic areas, is required. Prior to surgical or percutaneous intervention, a combination of imaging and laboratory findings are essential in diagnosing a complicated case and avoiding unnecessary interventions.

Asymptomatic unilateral aplasia of the left parotid gland: an unusual entity and case report.

Congenital agenesis of major salivary glands is considered a very infrequent condition and typically appears to be a coincidental finding. It can be present as sporadic case or may be combined with aplasia or hypoplasia of other salivary glands or the lacrimal glands, or as a part of syndromes. Only 23 cases documented in the literature to date, while the youngest patient was 50 days old. Plenty of radiographic useful techniques and treatment is closely related to the clinical manifestations; therefore. We present a case of 52 year old female who was referred to our radiology department for recurrent numbness of the left upper limb, experienced over the previous three months. Complete absence of the left parotid gland was incidentally demonstrated at the brain MRI scan. Based on the patient's past medical history, physical examination and demonstrated radiographic techniques it was an asymptomatic, no-syndromic and no-familious unilateral aplasia of the parotid gland. In the present report, we aimed to underline that this rare condition may be asymptomatic and co-exist with other medical conditions and syndromes.

Low-Grade Appendiceal Mucinous Neoplasm (LAMN) Primarily Diagnosed as an Ovarian Mucinous Tumor.

BACKGROUND: Low-grade appendiceal mucinous neoplasms (LAMN) are detected in 0.7 to 1.7% of all appendicectomies. The diagnosis can be challenging, particularly in female patients where the differential diagnosis of primary appendiceal and ovarian mucinous neoplasms is unclear. Case Presentation. A 71-year-old female was referred to our tertiary hospital with the working diagnosis of a right ovarian cystic tumor. The lesion was identified through a transvaginal ultrasound performed for vague lower abdominal pain symptoms. CT scan confirmed these findings. Intraoperatively, an appendiceal mucocele was identified and a right hemicolectomy was performed. The histopathology examination revealed a LAMN. Six months later, the patient remains disease-free. A close biannual oncological follow-up has been suggested. CONCLUSION: This case underlines the difficulty in determining the origin of mucinous neoplasms of the right pelvic area. Mucocele of the appendix should be considered in the differential diagnosis of a mass in the right iliac fossa.

A rolling stone: vomiting of a gallstone without the presence of a biliary-enteric fistula.

Gallstones may pass into the gastrointestinal tract spontaneously through the ampulla of Vater or through a biliary-enteric fistula. This report describes an extremely rare case of a patient vomiting a gallstone without the presence of a fistula between the gallbladder and the gastrointestinal tract. Furthermore, no imaging findings of gallstones disease appeared. The patient has been treated conservatively and all symptoms subsided. The patient remains asymptomatic 3 months after treatment and an elective laparoscopic cholecystectomy was arranged. Including this reported case, only three cases have been described in the literature worldwide. However, our case is the only one characterized by retrograde flow of the gallstones into the stomach without symptoms of bowel obstruction or other underlying pathologies.

Chronic Progressive Dyspnea in a 71-Year-Old Man: A Diagnostic Ithaca After 8 Years of Consultation.

CASE PRESENTATION: A 71-year-old ex-bus driver (ex-smoker, 20 pack-years) was admitted for the first time to the respiratory department because of chronic dry cough and progressive exertional dyspnea with insidious onset 8 years ago. The patient also reported weight loss of about 20 kg in 3 years and proximal muscle weakness. A decade ago, he was diagnosed with gastric adenocarcinoma and subjected to partial gastrectomy and splenectomy, followed by an unspecified chemotherapy regimen. Additionally, the patient has coronary disease and underwent coronary bypass graft surgery 7 years ago. In the course of his disease, many diagnostic procedures have been performed including Mantoux tests, five CT scans, a CT-guided biopsy, two bronchoscopies, and an 18F-fluorodeoxyglucose PET scan with inconclusive results. The patient was referred to the hospital to have his long-lasting condition diagnosed and treated.

Dimitrios Mavrokordatos Disproving the Hemostatic Myth of Aqua Binelli.

"Aqua Binelli" or "Aqua Balsamica Arterialis" was a hemostatic compound invented by the Italian Fedele Binelli in 1797. Its hemostatic properties were viewed as the solution to treating hemorrhage in cases of wounds and surgical operations. Those who opposed the compound were persuaded of its total lack of effectiveness, supporting the view that hemostasis could be achieved by exerting pressure on, stitching, and ligating a vessel. The publications of Karl Ferdinand von Gräfe, Professor at the University of Berlin and fervent advocate of Aqua Binelli, helped spread the use of the compound in Europe. In 1832, however, one of his students, a young Greek named Dimitrios Mavrokordatos, who became the first Professor of Anatomy and Physiology in the newly established University of Athens in 1837, published in Würzburg his dissertation titled Observations on the Potency of Aqua Binelli (Weitere Nachrichten über das Binellische Wasser), where a completely different picture emerged relating to those applications of the compound that von Gräfe considered successful. The case of Mavrokordatos' dissertation was a typical 19th-century scientific controversy between a young student and his teacher who enjoyed the support of his associates. Eventually, the myth of the hemostatic activity of Aqua Binelli was debunked.

Pseudoaneurysm of gastroduodenal artery and pulmonary embolism: rare co-incidence of two complications of pancreatitis.

Preventing and curing complications of acute and chronic pancreatitis, which may be local or systemic, remains a challenge. Pseudocysts and walled-off pancreatic necrosis are two local complications that most frequently require surgical intervention. Two rare complications of pancreatitis are pseudoaneurysms and pulmonary embolism. Angiographic embolization can be the treatment of choice for pseudoaneurysms, while for pulmonary embolism apart from anticoagulation treatment, the optional inferior vena cava filter placement could be useful. As far as we know, in literature, these complications of pancreatitis have never been reported simultaneously yet.