Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study.

METHODS: Recent randomized control trials (RCTs) have confirmed that antibiotics in acute uncomplicated diverticulitis (AUD) neither accelerate recovery nor prevent complications or recurrences. A retrospective cohort study was conducted, including all consecutive AUD patients hospitalized 2015- 2018 at Helsingborg Hospital (HH) and Skåne University Hospital (SUS), Sweden. HH had implemented a non-antibiotic treatment protocol in 2014 while SUS had not. Main outcomes were proportion of patients treated with antibiotics, complications, recurrences, and adherence to routinely colon evaluation. RESULTS: A total of 583 AUD patients were enrolled, 388 at SUS and 195 at HH. The diagnosis was CT-verified in 320 (83%) vs. 186 (95%) patients respectively (p < 0.001). Forty-three (11%) and 94 (48%) of patients respectively did not receive antibiotics during hospitalization (p < 0.001). CRP was higher in the antibiotic group compared to the non-antibiotic group, both at admission and peak (90 mg/L vs 65 mg/L; p = 0.016) and (138 mg/L and 97 mg/L; p < 0.001). There were no significant differences in recurrences (22.0% vs. 22.6%; p = 0.87) and complications (2.5% vs. 2.9%; p = 0.77) between the antibiotic/non-antibiotic groups. CONCLUSION: The structured treatment protocol led to reduced antibiotic use and a higher standard of care in terms of CT-verification. Clinicians' compliance to the treatment protocol and best clinical practice was poor and warrants further studies.

Laparoscopic Management of Boerhaave's syndrome: a case report with an intraoperative video.

BACKGROUND: Boerhaave's syndrome involves a sudden elevation in the intraluminal pressure of the esophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Its treatment is challenging, and early surgical intervention is the most crucial prognostic element. CASE PRESENTATION: We present a case of a 32 year-old male who presented after severe emesis with an acute onset of epigastric pain. He was diagnosed with Boerhaave's syndrome. Displaying signs of shock mandated immediate surgical exploration with laparoscopic primary repair. CONCLUSION: The golden period of the first 24 hrs of the event still applies to cases of esophageal perforation. The scarcity of these cases makes a comparison between the various treatment methods difficult. Our data support the use of laparoscopic intervention with primary repair as the mainstay of treatment for the management of esophageal perforation.

Axillary schwannoma, preoperative diagnosis on a tru-cut biopsy: Case report and literature review.

INTRODUCTION: Schwannoma is a benign encapsulated tumor of the peripheral nervous system which is mainly located in the head and neck. However, axillary Schwannoma is rare. In this article, the author presents an interesting case of a right axillary Schwannoma, where the diagnosis was preoperatively made on a Tru-cut biopsy. CASE PRESENTATION: We report a case of an enlarged right axillary swelling in a sixty-year-old male. Proper radiologic workup was performed. Furthermore, a Tru-cut biopsy was taken which revealed evidence of schwannoma. Having such symptomatic lesion, operative excision was done with the use of a nerve stimulator, which aided in preserving nerve function. CONCLUSION: With such non-specific presentation, axillary Schwannoma may be easily missed and mismanaged. A Tru-cut biopsy may provide great help in expert hands, aiding operative planning; likewise in the case we are presenting. Furthermore, utilizing an intraoperative nerve stimulator will facilitate nerve preservation.

Case report: preoperatively diagnosed perforated Meckel's diverticulum containing gastric and pancreatic-type mucosa.

BACKGROUND: Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract, and it represents a persistent remnant of the omphalomesenteric duct. Although it mostly remains silent, its infrequent occurrence is mirrored by the paucity of large series of data on it in the literature. Hemorrhage, obstruction and inflammation are most common complications of Meckel's diverticulum. Perforation of Meckel's diverticulum is considered very rare. CASE PRESENTATION: We present the case of a 17-year -old male, who presented to the emergency department with 1-day history of lower abdominal pain. CT of the abdomen suggested a perforated Meckel's diverticulum, which was confirmed later at the exploratory laparotomy. Perforation was due to progressive inflammation and presence of gastric and pancreatic tissue found on histopathology. CONCLUSION: Perforation of Meckel's diverticulum is rarely suspected. Complications of Meckel's diverticulum can be difficult to diagnose, and early recognition with timely operative intervention must occur in order to provide the best outcome for these patients. This is an interesting and unusual case of Meckel's diverticulum perforation that highlights the importance of considering Meckel's diverticulum as a differential diagnosis in every patient presenting with acute abdomen.

Transient small bowel intussusception in an adult: case report with intraoperative video and literature review.

BACKGROUND: The term intussusception refers to invagination of a segment of the gastrointestinal tract into the lumen of an adjacent segment. This is a rare entity and it is more prevalent in children and less common in adults. The diagnosis of intussusception in adults is difficult as a result of the nonspecific signs and symptoms. As there are many common causes of acute abdomen, intussusception should be considered when more frequent etiologies have been ruled out. The laparoscopic approach offers both a diagnostic option and a therapeutic one for intussusception in adults. CASE PRESENTATION: We report a forty-one year old male patient, who presented to our Emergency Department complaining of peri-umbilical pain associated with nausea and vomiting for 1 day. Diagnosed with transient small bowel intussusception without any obvious underlying pathology. This report is the first to present an intra-operative video showing the small bowel intussuscepting and reducing spontaneously. Furthermore, the authors present a review about this rare condition, including previously reported similar cases in literature. CONCLUSION: Transient intussusception is extremely rare and is a challenging condition. Imaging techniques, especially CT scan, are helpful in the diagnosis of intussusception. However, laparoscopy offers the advantage of distinguishing transient intussusception from persistent intussusception.

A case report: Cecal volvulus caused by Meckel's diverticulum.

INTRODUCTION: Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to Meckel's diverticulum include hemorrhage, intestinal obstruction and inflammation. Acute large bowel obstruction is a rare complication of Meckel's diverticulum and in the presented case it is caused by volvulus. PRESENTATION OF CASE: We report a 39 year old female who presented with the diagnosis of a large bowel obstruction occurring as a result of cecal volvulus caused by adhesions of a perforated diverticulum. DISCUSSION: The reported case presents one of the rare complications of MD, which is volvulus. The case described above presented with signs and symptoms suggestive of acute intestinal obstruction and radiological findings suggestive of cecal volvulus. The patient was taken to the operation room for exploration and we discovered the presence of a perforated MD. The main treatment of such case is to perform diverticulectomy in all symptomatic patients. CONCLUSION: MD is mostly identified intraoperatively. Knowledge of the pathophysiologies by which MD can cause complications such as volvulus is important in order to plan management.

Post traumatic acquired multiple mesenteric defects.

INTRODUCTION: Internal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.(1) Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2-0.9%.(2) PRESENTATION OF CASE: In this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found. DISCUSSION: In the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.(11) Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries. In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. (16) CONCLUSION: The diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.