Fournier Gangrene Management: Is a Stoma Mandatory?

Fournier gangrene is a rare life-threatening surgical emergency mainly due to a polymicrobial infection of the perineal, genital, or perianal region. It is characterized by rapid tissue destruction and systemic signs of toxicity. It is more frequent in males and immunocompromised patients, such as patients with poorly controlled diabetes, alcoholism, or human immunodeficiency virus (HIV) infection. Treatment often involves surgical intervention, broad-spectrum antibiotic therapy, fecal diversion surgery, and negative pressure wound therapy (NPWT). Delays in diagnosis are associated with high mortality due to rapid progression to septic shock.

Adenopathies: A Confusing Presentation of Primary Biliary Cholangitis.

Primary biliary cholangitis (PBC) is an autoimmune disease in which the intrahepatic bile ducts are destroyed. Its symptoms include chronic fatigue, pruritus, steatorrhea, and jaundice, with variable clinical course. We are introducing a case of a 65-year-old woman with anorexia, weight loss, asthenia, and pruritus. The imaging studies revealed dilatation of the intrahepatic and common bile ducts and adenopathies at the level of the hepatoduodenal ligament, histologically compatible with reactive lymphadenitis. After the exclusion of neoplasia, she was referred to Internal Medicine where positivity was obtained for anti-mitochondrial autoantibodies suggestive of PBC. After the initiation of therapy, there was a resolution of the clinical symptoms and the adenopathies were no longer detected in subsequent studies. The authors intend to highlight this case, especially due to the presence of adenopathies and constitutional symptoms where PBC should also be considered, as a differential diagnosis.

Metastatic melanoma: An unusual cause of gastrointestinal bleeding and intussusception-A case report.

INTRODUCTION: Malignant melanoma is responsible for 1-3% of all malignancies being the gastrointestinal tract one of the most common metastatic locations. PRESENTATION OF CASE: We present the case of a 71-year old male with previous history of cutaneous melanoma. Seven years later, while being studied due to suspected small bowel bleeding, he developed small bowel obstruction after being submitted to double balloon enteroscopy. Further investigation revealed small bowel intussusception. He was taken up for emergency laparotomy that confirmed ileal intussusception secondary to an intraluminal mass. We performed segmental enterectomy with primary anastomosis. Histology confirmed intestinal melanoma metastasis. DISCUSSION: Malignant melanoma frequently spreads to the gastrointestinal tract. The presentation is mainly asymptomatic and the diagnosis is often made only after complications develop. Small bowel intussusception and gastrointestinal bleeding are unusual presentations of metastatic melanoma, with few cases reported. Surgical resection not only provides symptom control but also positively affects prognosis. CONCLUSION: Although usually asymptomatic, melanoma metastasis should always be considered in a patient with intestinal symptoms or chronic anemia and personal history of melanoma. Surgical resection is the treatment of choice, leading to an increase in overall survival.

Pseudomyxoma peritonei presenting as irreducible epigastric hernia.

Abdominal wall hernia is a common and usually straightforward pathology presenting in surgery clinics. On occasion, the surgeon is faced with unexpected findings requiring difficult intraoperative decision. We present a case of pseudomyxoma peritonei incidentally found during surgery for epigastric hernia. The patient complained of a long lasting epigastric hernia with recent onset pain and growth. Surgery was limited to laparoscopic incisional biopsy of mucinous peritoneal deposit, confirming the diagnosis and suggesting an appendiceal origin. The patient was subsequently referred to a specialized peritoneal cancer unit for definitive treatment which consisted of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy, which can be compromised by previous organ resection. This case highlights the importance of maintaining a high level of suspicion before unusual clinical courses of common pathology.

Heterotopic mesenteric and abdominal wall ossification - Two case reports in one institution.

INTRODUCTION: Heterotopic ossification occurs when bone develops in tissues which usually don't undergo ossification. Heterotopic mesenteric ossification, also known as intra-abdominal myositis ossificans, is a rare and benign form of ossification, usually related with previous abdominal surgery or trauma. PRESENTATION OF CASES: We report two cases of heterotopic ossification both after multiple abdominal surgeries, with intraoperative findings of mesenteric and abdominal wall ossification. Histopathology revealed metaplastic bone deposition, without evidence of atypia or malignancy. DISCUSSION: This rare entity shares clinical and pathological characteristics of myositis ossificans. It is important to consider the differential diagnosis with sarcomas. In the cases described, the patients were proposed for elective surgery and this pathology was as an incidental finding. CONCLUSION: The simultaneous presence of mesenteric and abdominal wall ossification in both patients makes these cases even rarer.

Locally advanced colon cancer with cutaneous invasion: case report.

BACKGROUND: Locally advanced colon cancer with direct abdominal wall and skin invasion is an extremely rare finding with most data being derived from case reports, historical autopsy-based or single-center retrospective studies. We present a unique case of a colon cancer with direct cutaneous invasion and colocutaneous fistulization. CASE PRESENTATION: Eighty-six year old Caucasian female with multiple comorbidities, referred to Surgical Consultation due to ulcerated skin lesion in the abdomen. She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She denied any digestive or constitutional symptoms. Physical examination showed a large non-reducible umbilical hernia, with an associated painless firm mass within the hernia sac and cutaneous ulcerated growth. Colonoscopy revealed transverse colon cancer (endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon). Computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration and enlarged regional lymph nodes. Rapid local progression led to colocutaneous fistula with total fecal diversion. We performed an extended right hemicolectomy with en bloc excision of the hernia sac and infiltrating cutaneous mass. CONCLUSIONS: In the current era of widespread use of screening colonoscopies, initial diagnosis of locally advanced colon cancer is decreasing. However, this unique case presented an opportunity to recall the advantages of multivisceral resections.

Jejunoileal diverticulosis, a rare cause of ileal perforation - Case report.

INTRODUCTION: Jejunoileal diverticulosis (JID) is a rare condition associated with nonspecific symptoms, consisting of acquired false diverticula. It frequently co-exists with colonic diverticulosis. Diagnosis is usually made incidentally or after complications. These include hemorrhage, obstruction and diverticulitis, with or without perforation. PRESENTATION OF CASE: 81-year-old man presented with a painful abdominal mass in the right lower quadrant (RLQ), diffuse abdominal discomfort and fever. Abdominal examination confirmed a well-defined mass in the RLQ without rebound tenderness. Laboratory analysis revealed elevated inflammatory markers and CT scan showed a cavitated lesion with an air-fluid level in the RLQ, without evidence of intraperitoneal free air or fluid. Admitted for conservative treatment, failure to improve led to laparotomy on the 6th day of hospitalization, with identification of jejunoileal diverticulosis complicated with diverticulitis and walled-off perforation. We performed segmental enterectomy. DISCUSSION: The incidence of JID is estimated at 0.2-7% and it is usually diagnosed in the sixth/seventh decade of life. From a diagnostic perspective, JID is a challenging disorder, without reliable diagnostic tests. Diverticulitis is the most common complication. Perforation generally causes only localized peritonitis, as involved diverticula are often walled off by the surrounding mesentery. In selected cases, medical therapy may suffice. For all other patients prompt laparotomy with segmental intestinal resection is the treatment of choice. CONCLUSION: JID remains under diagnosed. When it presents as an acute complication it may require immediate surgical intervention. In an elderly person, especially with known gastrointestinal diverticulosis, one must have a high index of suspicion for perforation.

Unusual presentation of a Meckel's diverticulum: A case report.

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. Intestinal obstruction is the lead presenting symptom in the adult population due to multiple causes (intussusception, incarceration, adhesions, strictures and torsion). Our patient had a complicated MD with an unique combination of risk factors and findings. PRESENTATION OF CASE: We report an unusual case of an 18-year-old patient presenting with acute small bowel obstruction for several days, who developed focal peritoneal signs on right lower quadrant. On laparotomy, findings included a necrotic giant MD and a small bowel volvulus around a fibrous band that attached MD to the umbilicus. Segmental enterectomy with primary anastomosis was performed. DISCUSSION: Axial torsion and gangrene of MD is the rarest complication. Its pre-operative diagnosis remains elusive as it can be clinically indistinguishable from other intra-abdominal inflammatory conditions. The correct diagnosis of complicated MD before surgery is often difficult because this condition can mimic other acute abdominal pathologies. There are several risk factors that can point to an accurate and early diagnosis, especially when combined with the appropriate imaging techniques, such as computed tomography with oral and intravenous contrast. CONCLUSION: This complication remains underdiagnosed, often with delayed surgical intervention and sub-optimal treatment that leads to significant morbidity and mortality.