Idiopathic spontaneous haemoperitoneum due to a ruptured middle colic artery aneurysm.

INTRODUCTION: Idiopathic spontaneous intra-abdominal haemorrhage is a rare, but challenging condition, associated with high mortality if not managed appropriately. The preoperative diagnosis is difficult, despite the recent advances in imaging. We present the clinical manifestations of this condition, as well as the available diagnostic and therapeutic modalities. PRESENTATION OF CASE: We report a case of a spontaneously ruptured dissecting aneurysm of the middle colic artery, which was managed with an emergency laparotomy and aneurysmatectomy. Interestingly, no evidence of vasculitis, infection or collagen disease was discovered during the histopathology examination of the specimen. DISCUSSION: The treatment of idiopathic spontaneous intra-abdominal haemorrhage revolves around patient resuscitation and management of the source of bleeding. In case of a ruptured aneurysm of the middle colic artery, the surgical management includes emergency laparotomy, arterial ligation and resection of the aneurysm. Transarterial embolisation has been suggested as a safe and less invasive alternative approach. CONCLUSION: A ruptured middle colic artery aneurysm should be included in the differential diagnosis of any unexplained intra-abdominal haemorrhage. Aneurysmatectomy is the treatment of choice, with radiologic interventional techniques gaining ground in the management of this entity.

Preventing intraperitoneal adhesions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats.

OBJECTIVES: The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats. METHODS: Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons. RESULTS: The adhesion scores (mean +/- standard deviation) for groups 1, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively). CONCLUSIONS: These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats.

Ectopic parathyroid adenoma located inside the hypoglossal nerve.

BACKGROUND: Intraneural parathyroid adenomas are extremely rare, with only 9 cases of intravagal adenomas reported. We report the first case of an ectopic parathyroid adenoma located within the hypoglossal nerve. METHODS AND RESULTS: A 62-year-old woman presented with a palpable nodule in the right submandibular area, reduced bone mass, and elevated calcium and parathormone levels. Preoperative investigation with neck ultrasound and MRI did not provide a definitive diagnosis, whereas sestamibi scan showed slightly increased radiotracer accumulation in the same area. Intraoperatively, the right hypoglossal nerve was found to course through the lesion and, despite the attempt to salvage it, most of its fibers were transected. Histopathology confirmed the presence of a parathyroid adenoma inside the trunk of a nerve. Postoperatively, calcium and parathormone levels decreased but right hypoglossal nerve paresis was noted. CONCLUSION: This unique case emphasizes the variability of parathyroid anatomy and the difficulties faced by the surgeon when treating this disease process.

Management of ingested foreign bodies. How justifiable is a waiting policy?

Foreign body ingestion is a commonly seen accident in emergencies, usually in children (80%), elderly, mentally impaired, or alcoholic individuals, whereas it may occur intentionally in prisoners or psychiatric patients. According to the literature, 90% of ingested foreign bodies pass through the gastrointestinal tract without complications, 10% to 20% necessitate endoscopic removal, whereas only 1% of them will finally need surgical intervention. In clinical practice, we often face the dilemma of choosing the appropriate treatment modality. We present 13 cases treated in our department, emphasizing in a "waiting and close observation" policy. Among these cases, only 1 patient needed to be operated because of obstruction of ileocecal valve by a large coin. Indications for treatment where applicable are also being discussed.

Laparoscopic cholecystectomy for severe acute cholecystitis in a patient with situs inversus totalis and posterior cystic artery.

Situs inversus totalis is an inherited condition characterized by a mirror-image transposition of thoracic and abdominal organs. It often coexists with other anatomical variations. Transposition of the organs imposes special demands on the diagnostic and surgical skills of the surgeon. We report a case of a 34-year-old female patient presented with left upper quadrant pain, signs of acute abdomen, and unknown situs inversus totalis. Severe acute cholecystitis was diagnosed, and an uneventful laparoscopic cholecystectomy was performed. A posterior cystic artery was identified and ligated. Laparoscopic cholecystectomy is feasible in patients with severe acute calculus cholecystitis and situs inversus totalis; however, the surgeon should be alert of possible anatomic variations.

Long, parallel cystic duct in laparoscopic cholecystectomy for acute cholecystitis: the role of magnetic resonance cholangiopancreatography.

Congenital malformation of the gallbladder and cystic duct that cause operative difficulty are rare developmental abnormalities of embryogenesis. We report the case of a 47-year-old male patient who presented with right upper quadrant pain, tenderness, mild jaundice, moderately elevated liver function tests, and ultrasound evidence of acute calculus cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) excluded choledocholithiasis, but revealed the cystic duct anomaly. A difficult laparoscopic cholecystectomy was performed successfully. This is an unusual case of laparoscopic cholecystectomy for severe acute calculus cholecystitis in a patient with very low conjunction to the common bile duct (CBD) of a long, parallel cystic duct.