Traumatic perforated diverticulum of the fourth duodenal portion: First case report and literature review.

INTRODUCTION: Duodenal rupture following blunt abdominal trauma is rare, and traumatic rupture of duodenal diverticula is exceptional. However, duodenum is the second most frequent location of intestinal diverticula following colon. Duodenal diverticula are common but only in few cases they are symptomatic due to the onset of complications such as inflammation, hemorrhage, or perforation. Perforation, although rare, especially post-trauma, is the most serious life threatening complication. CASE PRESENTATION: We report the case of a patient who, 24 hours after a blunt trauma secondary to a car accident, complained symptoms related to the perforation of a diverticulum of the fourth portion of the duodenum. A computed tomography was performed and extraluminal fluid-air collection was identified. During emergent laparotomy, a fourth portion perforated duodenal diverticulum was diagnosed, and resected. The recovery was uneventful. DISCUSSION: Diagnosis of perforated duodenal diverticulum represents a challenge in diagnosis and few guidelines exist about the management of this rare occurrence, especially in a traumatic setting. The present case is the first report of traumatic perforated diverticulum of the fourth duodenal portion. CONCLUSION: Surgery still remain the most common approach in the treatment of this pathology, including diverticulectomy and primary repair.

Safety Profile of the New Harmonic Focus: Different Emissivity and Temperature Behavior Between the Active and the Inactive Blade.

Ultrasonic devices disperse less energy in the tissues. The new Harmonic Focus+ (HF+) seems to be more efficient but thermal damages have been reported. This study examined the temperature and the emissivity profile of the active and passive blades of the HF+, on a pig tissue model at different power settings. The FLIR System B series thermal imaging camera has been used on various biological pig tissues to evaluate the emissivity of the ultrasonic device. The active blade heats up faster than the passive one and the increase in power increases the speed of the temperature raising only on the active blade. Increasing the power setting reduces the dissection time and the temperature of both blades. Active blade temperatures of <60°C are obtained with cutting times close to 5 seconds; with these cutting times, the inactive blade does not exceed 30°C. The HF+ emissivity profiles demonstrate that the behavior of the inactive blade is significantly different from the active one. To prevent thermal damages, keep the active blade toward the operator, do not exceed 5 seconds of activation, use the maximum power, and avoid the use of the instrument as a dissector immediately after its activation.

Spontaneous perforation of Meckel's diverticulum: case report and review of literature.

AIMS: Meckel's diverticulum is a congenital anomaly found in approximately 2% of the general population. The complications caused by Meckel's diverticulum include intussusception, volvulus in adolescents and acute bleeding in adults 3. This is an interesting and unusual case of spontaneous perforation of Meckel's diverticulum, in a Caucasian woman. METHODS: A 46-year-old Caucasian woman was admitted because of severe abdominal pain and diarrhoea. A CT (Fig. 1) scan of the abdomen and pelvis was obtained, which demonstrated free air and a moderate amount of free fluid in the pelvis tracking up the gutters. The patient was consented and taken to theatre for diagnostic laparoscopy. A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum (Fig. 2). Wedge resection of the perforated Meckel's diverticulum was performed with endoGIA stapler fired at the base of diverticulum. Histopathology showed heterotopic gastric mucosa within the diverticulum and evidence of acute inflammation with perforation. The patient was followed up for two years and is symptom-free. DISCUSSION: The total lifetime rate of complications is widely accepted at 4%, with a male-to female ratio ranging from 1.8:1 to 3:1 4,5. Hemorrhage is the most common presentation in children and is reported in over 50% of cases 10. In adults, hemorrhage occurs often but only in 11.8% is present 5. 90% of bleeding diverticula contain heterotropic mucosa, most often gastric mucosa 13. In one study, 11% of children with complicated Meckel's diverticulum (MD) were initially diagnosed with appendicitis.8 CONCLUSIONS: The diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis. Laparoscopy has a definite role in patients with symptomatic Meckel's diverticulum, especially when the diagnosis is in doubt and it has proved definitive in facilitating diagnosis.

Giant submucosal lipoma cause colo-colonic intussusception. A case report and review of literature.

BACKGROUND: Lipoma of the large intestine is rare, with a reported incidence ranging between 0.2% and 4.4%. We present a case of a giant colonic lipoma causing descending-colonic intussusception. AIMS: A 54-year-old woman visited our emergency room with sudden onset of intermittent abdominal cramps. She was nauseous and had rectal blood loss for three days. Physical examination showed a tender palpable mass in the left lower abdominal quadrant. Rectal examination showed little blood on the glove. A CT scan demonstrated a clear intussusception of the descending-colonic (Fig. 1). Since the clinical presentation was that of an imminent ileus a laparotomy was performed. The intussusception was found in the descending coloni (Fig. 2), en-bloc resection with left hemicolectomy and was performed with end-to-end anastomosis. DISCUSSION: Lipomas of the gastrointestinal tract are rare conditions first described by Baurer in 1757. Lipomas in the intestinal tract are still relatively rare, however, being present in only 0.2% of a large autopsy series of 60 000 cases reported in 1955. In 90% of cases, lipoma of the colon are localized at submucous level. Submucosal lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain. Accurate preoperative diagnosis is difficult and lipoma is often mistaken for adenomatous polyp or carcinoma. CONCLUSION: Differential diagnosis includes malignancy, diverticulosis, adenomatous polyps and previous anastomosis. CT is the examination of choice. Surgical approach remains the treatment of choice for large colon lipoma.

Parenchymal compression and new devices for hepatic resections: re-visitation of an old technique.

BACKGROUND/AIMS: This reports on the modification of a technique of parenchymal compression ideated to reduce blood loss during liver transection, favorably affecting patient's outcome by reducing the need of Pringle maneuver and operative time through the active role of the second surgeon. METHODOLOGY: After echographic examination a water-cooled, high-density, monopolar dissecting sealer is introduced into the hepatic parenchyma allowing pre-coagulation of liver tissue. After coagulation of the traced line, a small Kelly forceps is used to fracture the liver parenchyma. As the transection proceeds, the hemostatic efficacy of the dissecting sealer reduces. At this step, where the Pringle maneuver is usually requested to stop bleeding, bimanual compression determines the occlusion of all the afferent vessels, bleeding is effectively stopped with a limited amount of residual backflow arising from the opposite plane. RESULTS: During a three-year period this approach was used in 9 patients affected by HCC. The Pringle maneuver was not necessary in any patient. The median blood loss was 200mL. The median transection time was 120 min, with a median operative time of 180 min. No mortality occurred. CONCLUSION: Compression during the transection represents a valid support not only for the dissecting sealer, but also in all cases in which similar devices are used, and by avoiding the need of further devices there is an unquestionable reduction of costs.

Two clinical cases of insulinoma misdiagnosed as psychiatric conditions.

We describe the clinical cases of two male subjects, respectively 73 and 41 years old, affected with insulinoma, misdiagnosed for many years as psychiatric subjects and scarcely responsive to therapy with benzodiazepins, antidepressants and antiepileptics. Although Whipple's triad was satisfied in both subjects since the onset of symptoms, they had to wait a long time for the correct diagnosis and appropriate treatment. Once the surgical therapy was carried out, our subjects recovered totally and ended the psycho-drugs.

Hepatic resections using a water-cooled, high-density, monopolar device: a new technology for safer surgery.

Several techniques and devices have recently been developed in an effort to allow safer liver resections and avoid intraoperative blood loss. The aim of this study was to analyze our initial experience with hepatic resections using a new water-cooled, high-density, monopolar device--the Tissuelink Monopolar Floating Ball (Tissuelink Medical, Inc., Dover, NH)--in order to avoid bleeding during hepatic surgery. We analyzed patients who underwent hepatic surgery between January and June 2003. Sex, age, type of disease, and type of surgical procedure, in association with the duration of the surgical procedure, blood loss, use of vascular clamping of the liver, length of hospital stay, morbidity, and mortality were analyzed. Seven minor liver resections, two major liver resections, and one total cystopericystectomy were performed with the use of this new device. Average blood loss was 150 ml (range 50 to 300 ml). No vascular clamping was used with the exception of one patient. No deaths were recorded. Morbidity included ascites in one case and pleural effusion in another. In conclusion, the Tissuelink Monopolar Floating Ball permitted excellent coagulation of the cut liver surface, thus avoiding bleeding and vascular clamping. As a result, postoperative morbidity and mortality were low.