The alterations of the sigmoid-rectal junction in diverticular disease of the colon revealed by MR-defecography.

PURPOSE: The sigmoidorectal junction (SRJ) has been defined as an anatomical sphincter with particular physiological behavior that regulates sigmoid and rectum evacuation. Its function in clinical conditions, such as diverticular disease has been advocated. The aim of our study is to identify the SRJ and to compare the morphometric and dynamic features of the SRJ between patients with diverticular disease and healthy subjects using MR-defecography. METHODS: Sixteen individuals, eight with uncomplicated diverticular disease and eight healthy subjects, were studied using MR-defecography to identify the SRJ and to compare the morphometric and dynamic features observed. RESULTS: In each subject studied, MR-defecography was able to identify the SRJ. This resulted in the identification of a discrete anatomical entity with a mean length of 31.23 mm, located in front of the first sacral vertebra (S1) and at a mean distance of 15.55 cm from the anal verge, with a mean wall thickness of 4.45 mm, significantly different from the sigmoid and rectal parietal thickness. The SRJ wall was significantly thicker in patients with diverticular disease than the controls (P = 0.005), showing a unique shape and behavior in dynamic sequences. CONCLUSION: Our findings support the hypothesis that SRJ plays a critical role in patients with symptomatic diverticular disease; further investigation may clarify whether specific SRJ analysis, such as MR-defecography, would predict inflammatory complications of this diffuse and heterogenic disease.

Traumatic subclavian arterial rupture: a case report and review of literature.

Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90's, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years' literature.

Laparoscopic colorectal surgery in urgent and emergent settings.

Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. The use of LC in the emergency setting is relatively unstudied. Authors describe their experience with a series of 34 emergent and urgent LC cases for a variety of benign and neoplastic colorectal diseases, admitted from 2007 to 2009 at Emergency Department of a tertiary level hospital, comparing laparoscopic group with matched control open group. Twenty-one LC was performed for benign complicated disease, 12 for malignant disease and 1 for iatrogenic perforation during colonoscopy. Two cases were converted to open procedure (5.8%), the average operative time was 188 minutes (SD 61.84). The average postoperative length of hospital stay was 6.57 days (SD 1.75), with no postoperative mortality and no major morbidity. Results of laparoscopic group compared with 61 patients treated with open colorectal procedure confirm the advantages of laparoscopic approach similar to those established in elective colorectal surgery. With increasing experience, LC would be a feasible and an effective option in nonelective situations lowering complication rate and length of hospital stay.

Gerota's fascia flap: a technique for autogenous packing in major liver injuries.

Hepatic trauma occurs in ∼ 5% of patients admitted to emergency rooms and nonoperative management has become the standard of care in hemodynamically stable patients with blunt trauma, for most of the injured solid organs. However, the staged surgery represents the first line of treatment in hemodynamically instable patients. The abdominal packing is considered the first step of this surgical policy. The authors describe a new surgical technique consisting of Gerota's fascia dissection that provide an autogenous pedunculated flap to obtain a definitive hemostasis of the injured liver with a permanent packing system.

[Emergency laparoscopic cholecystectomy in the treatment of acute cholecystitis: when and how?]. / Colecistectomia laparoscopica d'urgenza nel trattamento della colecistite acuta: "quando" e "come".

Optimal surgical timing and operative technique in the treatment of acute cholecystitis are of major importance and are still debatable issues. We report the results of our study on the timing of surgery in a consecutive series of 163 patients treated in the emergency setting for acute cholecystitis over the period from 1998 to 2008. Early surgery and the partially downwards laparoscopic cholecystectomy technique provide a safe and effective way of treating these patients and preventing major complications. The mean time period between onset of symptoms and surgery was 69.2 hrs, with a median value of 53 hrs. The mean operative time was 63.9 min, with a conversion rate of 0.6% and a specific complication rate of 1.22%. The mean postoperative hospital stay was 3.2 days. The timing of surgery (measured in hours) and operative time (measured in minutes) were recorded and analysed to verify whether or not there was a statistically significant relationship between these two variables and establish the best timing for surgery. Our results show a linear relationship between operative time and the timing of surgery. Moreover, at the cut-off point of 57 hrs, the later subgroup (over 57 hrs) had a two-fold increase in operative time compared to the earlier subgroup. At more than 60 hrs approximately from the onset of symptoms, the pathological changes in the surgical target begin, with increasing rapidity, to present a troublesome challenge to the surgeon, making laparoscopic cholecystectomy for acute cholecystitis more difficult and less safe than when performed earlier.

Laparoscopic transperitoneal decortication of a giant peripelvic renal cyst.

Laparoscopic decortication is currently considered the standard treatment of peripelvic renal cysts, in spite of the technical challenge due to the close contiguity with renal hilar structures. However, to date, few small series or single cases of laparoscopic decortication for symptomatic peripelvic cyst have been reported. In this paper, we report the first case of a giant peripelvic cyst (25 x 18 x 9 cm) treated by transperitoneal laparoscopic decortication in a young adult female. Pain relief and hypertension control were obtained early after surgery, and the patient is symptom free at a 30-month follow-up.

Acute emphysematous cholecystitis as a cause of pneumoperitoneum.

The authors report a rare case of acute emphysematous cholecystitis with pneumoperitoneum. Emphysematous cholecystitis is an uncommon variant of acute cholecystitis. Association with pneumoperitoneum is very rare and the finding of a macroscopic perforation of the gallbladder is possible only in a few cases. A review of the literature revealed 15 other cases of this combination. Diagnostic options and treatment modalities in these patients are discussed here.

[Therapeutic and diagnostic protocol for mild acute biliary pancreatitis: our experience and review of the literature]. / Protocollo diagnostico terapeutico della pancreatite acuta biliare lieve: nostra esperienza e revisione critica della letteratura.

Through a critical review of the literature, the authors analyze and re-assess the current diagnostic and therapeutic algorithms used in the treatment of mild acute biliary pancreatitis, reporting their experience with 27 cases observed in the Policlinico Umberto I Emergency Department (Rome) over the period from March 2003 to May 2005. All patients were treated with the same diagnostic and therapeutic protocol: once the diagnosis of acute biliary pancreatitis had been made and the severity evaluated, patients presenting clinical or ultrasonographic signs of main biliary duct stones underwent ERCP within 72 hours of onset of symptoms. All patients then underwent a standard-technique laparoscopic cholecystectomy during the same hospital stay, and whenever ERCP had not been performed preoperatively, an intraoperative cholangiography was performed at the time of surgery. No intra- or postoperative complications were observed, with a mean hospital stay of 10.6 days (range: 5-25 days).

The best timing of surgery in laparoscopic cholecystectomy for acute cholecystitis: when and how is to be performed.

BACKGROUND/AIMS: In the treatment of acute cholecystitis the optimal timing of operation, regardless of whether performed laparoscopically or conventionally, is of major importance and not yet well defined feature among the different authors. We report our study on the timing of surgery in a consecutive series of 133 patients. METHODOLOGY: The surgical technique consists in a partially downwards cholecystectomy from the infundibulum to the cystic duct. The dissection never involves the Calot Triangle's structures; this provides a safe and effective way to prevent major complications procedure related. Length of time interval from the onset of symptoms to surgery (ST measured in hours) and operating time (OT measured in minutes) have been recorded and analyzed to find out how these two variables are each other linked and what is the best timing for surgery. We also split the series taking a progressively increasing of ST as a cut off point and analyzed the two derived subgroups to outline which was the time of surgery (period of ST) that provided the best result in term of worsening of laparoscopic procedure difficulty. RESULTS: 51.3 hrs of average time between the onset of symptoms and surgery has been reported, with minimum of 24 hrs and maximum of 90 hrs, and median value of 48 hrs. The curve fit analysis on the scatterplot of the variable ST (independent) and OT (dependent) shows that these two variables are directly each other linked. The best division of the series was at the cut off of 57 hrs; each subgroup reached a statistical correlation coefficient: the late subgroup (the one over the cut off time of 57 hrs) had a twofold operating time increasing respect to the early group. CONCLUSIONS: Our results outline that there is a linear relationship between the technical difficulties, expressed in term of operating time, and time intervals from the onset of symptoms to surgery. At the cut off time of 57 hrs of interval from the onset of symptoms to surgery, the linear regression coefficient that links the dependent variable OT to the independent variable ST changes increasing up to 1,92. Over 60 hrs from the onset of symptoms the pathological changes of the surgical target becomes more and more quickly a troublesome challenge to the surgeon, letting the laparoscopic cholecystectomy for AC more difficult and less safe than that performed early.

Perforated jejuneal diverticulosis. Case report and review of literature.

Acquired (non-Meckel's) jejunoileal diverticulosis is an uncommon disease, generally characterised by vague and unspecific symptoms. This rare condition is mainly expressed as acute complications: gastrointestinal haemorrhage, mechanic obstruction of the small intestine or perforated diverticulum, requiring urgent surgical intervention. The authors report a case of this unusual clinical occurrence characterized by a picture of abdominal pain due to perforation of jejuneal diverticulum. The final etiological diagnosis was possible only during surgery.

Iatrogenic intramural hematoma of the duodenum caused by endoscopic therapy of bleeding peptic ulcer. A case report.

The authors report a case of intestinal obstruction resulting from a duodenal intramural hematoma after therapeutic upper digestive endoscopy with injection therapy. Intramural duodenal hematomas are rare clinical entities, mostly caused by blunt traumas. They may also, more rarely, be due to complications of peptic duodenal ulcers, or be the iatrogenic result of an endoscopic biopsy or placement of a percutaneous endoscopic gastrostomy catheter. It has recently become obvious that surgery is not necessary in most patients with duodenal hematomas. The treatment of choice for cases of intramural duodenal hematomas is of a conservative kind. Today we can employ minimally invasive diagnostic and therapeutic techniques for the percutaneous or laparoscopic evacuation of the hematoma, which seem to guarantee optimal results, compared to the high morbidity rate associated with laparatomy evacuation.

Comparison among preoperative single-slice CT and multi-slice CT in simple, closed loop and strangulating bowel obstruction.

BACKGROUND/AIMS: The aim of this study is to compare preoperative single-slice CT (SSCT) and multislice-CT (MSCT) accuracy in the evaluation of patients with bowel obstruction and intestinal necrosis. METHODOLOGY: 64 patients were enrolled. We analyzed the SSCT scans of 30 patients and the MSCT scans of 34 patients with clinical and abdominal plain film evidence of bowel obstruction. Presence, site, kind, and cause of the obstruction were evaluated; specific signs of strangulating or closed loop obstruction and wall necrosis were also identified. Three radiologists interpreted the CT scans independently; a consensus review was obtained, indicating the need of emergency or delayed surgery. The results were assayed on the basis of surgical findings. RESULTS: SSCT and MSCT findings of bowel obstruction presented good correlation with the surgical report. Sensitivity, specificity, PPV and NPV were 86.1%; 89.3%; 91.1%; and 83.3% respectively. The k coefficient of interobserver agreement was significant (0.729; p<0.01). A major difference was observed between findings in SSCT and MSCT in detecting intestinal ischemia (p <0.05); a noteworthy statistical difference between these techniques was observed especially in the sensitivity and specificity of the edema, twisting and/or thickening of mesenteric vessels (p<0.05). CONCLUSIONS: The first objective of abdominal CT in patients with bowel obstruction is to evaluate the need for emergency surgery because delayed operations potentially result in high mortality. A CT presenting high correlation to surgical findings allows a correct surgical timing and planning thanks to the correct identification of site, kind, and causes of bowel obstruction. MSCT presents better results compared to SSCT in assessing intestinal necrosis.

Laparoscopic cholecystectomy in acute cholecystitis: a proposal of safe and effective technique.

Laparoscopic cholecystectomy is slowly taking its place also in an emergency setting, regardless of its initial unfortunate course when iatrogenic lesions during surgery, complications and conversion rate make the laparoscopic approach in acute cholecystitis a hazard. With the development of laparoscopic technique, the laparoscopic cholecystectomy for acute cholecystitis becomes a reality, but its role in emergency is not yet defined. From December 1998 to December 2005, 133 consecutive laparoscopic cholecystectomies for acute cholecystitis were performed in our institution by the same surgeon. The mean age of patients was 48 years old, 21 were over seventy. In the series patients in ASA III and IV were included. All procedures were performed with the same technique, developed in the examined period, which represents a standardized downwards laparoscopic cholecystectomy, easy to reproduce and safe to perform. We report our surgical technique and our results. We did not report mortality, and there was very low morbidity. Only one patient was converted, giving an extremely low conversion rate of 0.7%. The average operating time was 52 min (range 17-70 min). Analyzing the operating time and the time between the onset of symptoms to surgery, we found that these two variables seem to be alike with a linear relationship; we found that the best timing for surgery is within 60 hr from the onset of symptoms. The latter analysis is reported. Laparoscopic cholecystectomy, when performed with an adequate technique and as early as possible represents a safe procedure to treat acute cholecystitis in an emergency setting. The technique described, considering the results, lack of iatrogenic lesions and acceptable operating time, represents a standardized surgical strategy to approach acute cholecystitis (AC) in a safe, effective and reproducible manner.

[Conservative approach to IV grade renal trauma]. / Approccio conservativo al trauma renale di IV grado.

A case of grade IV renal trauma is reported and the literature reviewed. A 29-year-old man was admitted in an emergency setting for a grade IV renal and splenic trauma as a result of a motorcycle accident. Since the patient was haemodynamically stable and the retroperitoneal haematoma was neither expanding nor pulsating, a conservative approach was adopted and the renal trauma was managed with interventional radiology. The case shows that major renal traumas can be usefully managed by non-operative treatment, necessarily consisting in a mutidisciplinary approach.

[Classification and management of gynecologic acute abdomen at a secondary level hospital emergency department]. / Inquadramento e gestione dell'addome acuto di origine ginecologica in un Dipartimento di Emergenza ed Accettazione di II livello. Analisi di 103 casi.

This study retrospectively evaluates the preoperative work-up and the classification and operative treatment of acute abdomen caused by gynaecological disorders in emergency admissions to our department. All female patients admitted in the emergency setting and operated on for gynaecological acute abdomen in our emergency department over the period from 1997 to 2002 were included in the study. A total of 103 patients were identified (54 undergoing emergency operations, 9 operated on within 72 hours, and 40 managed conservatively with medical therapy. The 54 emergency operations performed were 24 ovarian resections, 17 salpingectomies, 5 oophorectomies, 4 exploratory laparotomies, 2 uterine polypectomies and 2 hysterectomies. The non-specific presentation of the disease and an inadequate preoperative work-up in these patients often led to a generic diagnosis at admission. This approach tends to increase the number of operations performed on an emergency basis, whereas a wait-and-see type of management should be adopted. A proper use of surgery is mandatory especially in those patients in whom preservation of reproductive capability has a major impact on outcome.

[Multidisciplinary approach to the patient with multiple trauma: a case report]. / Approccio multispecialistico al paziente politraumatizzato: un caso clinico.

A multidisciplinary approach to severe polytraumatized patient is very important for a rapid, uncomplicated recovery. Specialized centres with special beds, monitoring equipment, and a multidisciplinary team are required. The authors report a case of a 26-year-old man admitted to their department in an emergency setting for a crush injury (occupational trauma) of the lumbar, gluteal and perineal areas, complicated with septic shock and gas gangrene of the injured areas. A multidisciplinary approach to the patient, consisting in surgical and plastic surgical therapy, hyperbaric oxygen therapy and the use of a special antidecubitus fluidized bed allowed complete recovery within 7 months without any motor or sphincter disorders.