Delayed diagnosis of blunt carotid trauma in a seat belt syndrome with associated abdominal wall injury A case report.

The aim of this case report is to be aware of occult carotid lesions in thoracic- abdominal trauma because, carotid artery injury consequent to blunt trauma is rare, affecting less than 1% of patients as reported in literature. A 45-years-old female, involved in a traffic accident, arrived to Emergency Room hemodynamically stable, with a Glasgow Coma Scale of 15, complaining abdominal pain, without any neurological signs. She underwent Computed Tomography (CT) scan that showed a complete disruption of left abdominal wall muscles, associated with massive bowel loops herniation. No free air nor other visceral injuries were found. The radiological brain evaluation was negative for neurological injuries. Considering the nature of the trauma, an explorative laparotomy was performed. During the fifth postoperative day, the patient presented neurological side signs with right facial-brachial-crural hemiparesis and expressive aphasia. Head and neck CT scan revealed a lesion of the left common carotid artery with distal embolization of the internal carotid. A left-carotid-axis revascularization procedure and a surgical endarterectomy were immediately performed. Patient was discharged after 20 days without neurological consequences. Physicians should be aware of neck vascular injuries when evaluating patients with multiple trauma, even in neurological asymptomatic patients without seatbelt abrasions of the neck skin. KEY WORDS: Abdominal Hernia, Carotid artery, Seat belt, Surgery.

An approach to complicated diverticular disease. A retrospective study in an Acute Care Surgery service recently established.

AIM: Acute diverticulitis is a frequent disease in the Western Countries. The increase number of patients admitted in the Surgery Departments led the necessity of new Scores and Classifications in order to clarify, in absence of clear guidelines, the best treatments to offer in the different situations. METHODS: A retrospective study of ninety-nine patients treated in our Department from June 2010 and March 2015. RESULTS: In our study 41 patients were treated conservatively, the remaining 58 were operated, 56 laparotomic and 2 laparoscopic. 5 patients submitted US guided drainage of abscess which failed in 2 cases. 25 submitted Hartmann's Procedure (HP), 29 Primary Resection and Anastomosis (PRA), 3 Contemporary Closure of Perforated Diverticula (CC) and just 2 Laparoscopic Peritoneal Lavage and Drainage (LPL). We related different Hinchey groups and up-groups with the treatments approached, identifying patients risk factors, ASA score and complications. DISCUSSION: The treatment of perforated diverticulitis is debated. CT scan is becoming an useful instrument to make a correct diagnosis. Hinchey I and II patients are preferentially treated conservatively except in cases of complicated presentations. Hinchey III and IV are necessarily treated with surgical approach. We analyze the different types of intervention currently approached. CONCLUSION: We believe in PRA in Hinchey III and IV selected patients, HP is the gold standard in higher ASA scores patients but the low number of stoma reversal remains an open problem. Many studies are ongoing concerning LPL and now there are insufficient data to think of a widespread use of this technique. Key words: CT scan, Diverticular Disease, Hartmann's Procedure, Intr-abdominal abscess, Laparoscopic Peritoneal Lavage and Drainage (LPL), Peritonitis, Primary Resection and Anastomosis (PRAHinchey Classification, US and CT guided drainage.

Benign multicystic mesothelioma of peritoneum complicating acute appendicitis in a man: a case report.

BACKGROUND: Benign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon. CASE PRESENTATION: We describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation. CONCLUSIONS: We showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply.

Gastrointestinal stromal tumours. Our experience ten years later.

AIM: To analyze GISTs behaviour observing their clinical evolution and outline the best approach to this neoplasia. MATERIAL OF STUDY: In a period between December 1999 and October 2009 came to our observation, at the Institute of General Surgery, 37 patients with GIST. We conducted a retrospective study evaluating the anatomo-pathological aspects, the clinical situation and the tumour characteristics of the 37 patients with GIST. RESULTS: The 37 patients included 21 women (57%) and 16 men (43%), the mean age was 67 years. GISTs originated from the stomach (27), jejunum (5), ileum (3), anus (1) and transverse mesocolon (1), the symptom most frequently found was acute anaemia and in 5 cases the diagnosis was occasional; 36 patients underwent surgical treatment. Based on tumor size, mitotic count, presence of areas of necrosis and/or haemorrhage, GISTs were classified according to the categories of potential high-grade malignancy (13 pts), intermediate grade (8 pts), low grade (16 pts). DISCUSSION: According to international literature, surgery remains the cornerstone of treatment for patients with primary resectable GIST without evidence of metastasis and should also be utilized when surgery has minimal risk of morbidity for the patient. The goal of surgery is complete surgical resection with negative margins (R0). The follow-up for some patients is still ongoing; only 10 patients underwent to adjuvant therapy with Imatinib. CONCLUSIONS: In the last decade, GISTs have become an emblematic example of the possibility of pharmacologically interfering with the molecular mechanisms of carcinogenesis.