Intestinal obstruction by giant Meckel's diverticulum. Case report

Most cases of Meckel’s diverticulum (MD) are asymptomatic and discovered by chance. Management of MD is controversial. The authors describe an exceptional case of intestinal obstruction caused by a giant MD in a patient who had previously undergone appendectomy. A review of the contradictory literature on this subject leads to the conclusion that careful consideration of clinical and morphological data (patient's age, ASA score, the surgical procedure to be performed, morphology and position of the MD, any fibrotic bands) is required before deciding whether or not to resect an asymptomatic MD.

Laparoscopic surgery in acute small bowel obstruction. Our experience

Small bowel obstruction (SBO) is a very common condition, in the vast majority of cases caused by post-operative adhesions. It often requires surgical treatment. Traditionally, this consisted of a laparotomy, but nowadays a laparoscopic approach is also possible. This study discusses 24 cases of SBO and compares them with literature data. Successful complete laparoscopic treatment was feasible in 9 patients, while conversion to laparoscopically-assisted surgery or laparotomy was required for the others.

Small bowel obstruction caused by mesh migration. Case report

Introduction. Endoscopic hernia repair methods have become increasingly popular over the past 15 years. Nonetheless, there is no consensus regarding an optimal fixation method. Transabdominal sutures and titanium tacks or staples are the most traditional ones. Case report. We present a case of mechanic small bowel obstruction due to mesh migration occurring one year and a half after incisional hernia repair with polytetrafluoroethylene mesh fixed by spiral tacks. Discussion. Titanium spiral tacks are dangerous because of their sharp components, which can damage organs such as the small intestine, by causing microperforations. The type of prosthesis used has also contributed to the intraluminal migration, since polytetrafluoroethylene mesh is very flexible and poorly integrates in the abdominal wall. Conclusion. A prosthesis of a different material combined with a different fixation system such as absorbable tacks, biological glue, or mechanical tacks without sharp components, would have obviated mesh migration. .

Primary neuroendocrine lung tumor presenting with acute ileal obstruction. Case report

The authors describe a clinical case of a patient with neuroendocrine carcinoma of the lung diagnosed after the onset of an intestinal obstruction from an ileal metastasis. A review of literature reveals that the incidence of symptomatic gastro-intestinal metastases from lung cancer has been estimated to be about 2-3% and is exceedingly rare that the intestinal symptoms may be the initial presentation of cancer of the lung. The authors emphasize the difficulty of preoperative diagnosis of gastro-intestinal metastases which is made, almost always, too late because of the lack of specific symptoms. In our case, on account of the computed tomography, we leaned towards the diagnosis of lymphoma because of the double mediastinal and abdominal localization. Furthermore, this diagnosis was supported by the fact that the pulmonary lesion did not have clear radiological features of a lung cancer. The prognosis is poor because once intestinal metastases occur, other metastatic sites, which would make surgery only a palliative measure, are already present. The review of the literature shows that the average survival rate of these patients is 136 days. In our case the patient survived 277 days.

Retrocaval mass in patient with von Recklinghausen disease. Case report

Type I Neurofibromatosis (NF1) is an autosomal-dominant inheritable disorder, with an incidence of 1:3,000, and a prevalence of 1:4,000 to 5,000. Pathogenesis is based on mutations of the NF1 gene, a tumor suppressor gene encoding a cytoplasmic protein named neurofibromin that controls cellular proliferation. Patients affected by NF1 typically present with cutaneous neurofibromas, cafè au lait spots and eye involvement, but they can also be affected by various visceral tumors, such as neurofibromas (nodular or plexiform type), gastrointestinal stromal tumors or endocrine tumors, such as pheochromocytomas. Visceral neurofibromas are often asymptomatic but when growing in size they may present with pain, palpable abdominal mass, symptoms secondary to bowel obstruction or main vessels compression, and even gastrointestinal bleeding when mucosa or submucosa are involved. In these cases surgery becomes mandatory in order to remove all neoplastic tissue. The Authors describe a case of a young man affected by NF1 with associated retrocaval abdominal mass with compression and displacement of the inferior vena cava, thus requiring a complex surgical procedure.

Cecal volvulus during pregnancy. Case report

Introduction. Acute intestinal obstruction in pregnancy is a rare, but life-threatening complication associated with high fetal and maternal mortality. Case report. A 20-year old gravida presented with a 24 hour history of several episodes of vomiting, complete constipation and severe crampy abdominal pain. The patient was admitted with the diagnosis of acute abdomen associated with septic shock. On examination echography showed distended intestinal loops and presence of free peritoneal fluid. Abdominal X-ray with shielding of the fetus revealed colonic air-fluid levels. The obstetrician consult diagnosed dead fetus in utero and was decided to operate immediately. On laparotomy was found complete cecal volvulus with gangrene of cecum, part of ascending colon and terminal ileum. A right hemicolectomy was performed with side to side ileotransverse anastomosis. Afterwards a lower segment cesarean section was made and a stillborn fetus was delivered. The patient made an uneventful recovery and was discharged on 9th postoperative day. Conclusion. Cecal volvulus during pregnancy is a rare, but serious surgical problem. Correct diagnosis may be difficult until exploratory laparotomy is performed. Undue delay in diagnosis and surgical treatment can increase the maternal and fetal mortality.

Anastomotic strictures in colorectal surgery: treatment with endoscopic balloon dilation

The incidence of anastomotic stricture following colorectal surgery has increased in recent years. This complication is observed in 2-5% of all operated patients and is probably due to the greater number of low anastomoses performed with surgical staplers. We observed 31 patients with postoperative stricture, arising from one to nine months post-surgery. All patients had been treated for colorectal cancer and underwent endoscopy either during routine follow-up or for symptoms of stenosis. In 16 patients (group A) the stricture diameter was less than 4 mm and the patients had symptoms attributable to partial bowel obstruction. In the remaining 15 patients (group B), who had difficult bowel movements, the stricture diameter ranged from 4 to 8 mm. All patients were treated with endoscopic dilation using achalasia balloons. The results were considered good when the post-dilation anastomosis diameter achieved was at least 13 mm, fair when it was 9-12 mm and poor when it was less than 9 mm. The short term results (3 weeks) were good in 27 patients (87.2%), fair in 3 patients (9.6%), and poor in 1 patient (3.2%). After several unsuccessful dilations, the latter was treated by surgery. Follow-up at 3-4 months of the remaining 30 patients revealed good results in 20 (66.6%), fair in 6 (20%), and poor in 4 (13.3%). In 1 of these 4 patients, cancer recurrence was observed and a new surgical resection was performed. In 2 patients a self–expandable metal stent was inserted for 4-6 weeks, with satisfactory results. In 1 patient a biodegradable polydioxanone stent was inserted with good results after 6 months. Follow-up at 3-4 months showed good results in 25 patients. After 38 months, cancer recurrence in the area of the anastomosis was observed in 1 patient, who was treated surgically. Endoscopic dilatation should be considered the first therapeutic approach in case of anastomotic strictures, as it is immediately effective, repeatable, and does not preclude surgery if this should become necessary. .

Simultaneous volvulus of the transverse and sigmoid colon. Case report

Introduction. Volvulus of transverse colon is rare when compared to cecal and sigmoid volvulus. Cases involving simultaneous volvulus of the transverse colon and another colonic segment are extremely rare. Case report. We report a rare case of simultaneous sigmoid and transverse colon volvulus in a 82-year-old Caucasian female Conclusion. Volvulus is a well recognized cause of large bowel obstruction. The development of transverse and sigmoid volvulus in the same patient is extremely rare. Though rare this possibility must always be considered in the differential diagnosis, when dealing with recurrent intermittent abdominal pain or acute intestinal obstruction.

Laparoscopic approach in abdominal emergencies: a 5-year experience at a single center

Background. Laparoscopy is ever more common in both elective and emergency surgery. In fact, in abdominal emergencies it enables the resolution of preoperative diagnostic doubts as well as treatment of the underlying disease. We present a retrospective study of the results of a 5-year experience at a single center. Patients and methods. Between September 2006 and August 2011, 961 patients were treated via laparoscopy, including 486 emergency cases (15 gastroduodenal perforation; 165 acute cholecystitis; 255 acute appendicitis; 15 pelvic inflammatory disease and non-specific abdominal pain [NSAP]; 36 small bowel obstruction). All procedures were conducted by a team trained in laparoscopic surgery. Results. The conversion rate was 22/486 patients (4.53%). A definitive laparoscopic diagnosis was possible in over 96% of cases, and definitive treatment via laparoscopy was possible in most of these. Conclusions Our own experience confirms the literature evidence that laparoscopy is a valid option in the surgical treatment of abdominal emergencies. In any case, it must be performed by a dedicated and highly experienced team. Correct patient selection is also important, to enable the most suitable approach for each given situation.

Colonic lipomas. Three surgical techniques for three different clinical cases

Colonic lipomas larger than 2 cm in diameter are likely to be symptomatic. In some cases a complication is the first clinical sign. Massive lower intestinal bleeding or obstruction, acute bleeding, prolapse or perforation or, rarely, acute intussusception with intestinal obstruction require urgent surgery. Diagnosis is often made following colonoscopy, which can also have a therapeutic role. Imaging procedures such as CT has a secondary role. Patients with small asymptomatic colonic lipomas need regular follow up. For larger (diameter > 2 cm) and/or symptomatic lipomas, resection should be considered, although the choice between endoscopic or surgical resection remains controversial. We believe that even lipomas > 2 cm can safely be removed by endoscopic resection. If surgery is indicated, we consider laparoscopy to be the ideal approach in all patients for whom minimally invasive surgery is not contraindicated.

How new imaging techniques can aid in defining the cardiovascular profile of the high-risk patient

Cardiovascular prevention has been developed in the last eight years producing an ever increasing amount of data requiring frequent updating. Studies using angiography to determine change in coronary obstruction have indicated progression, stabilization, or regression of coronary lesions associated with changes in plasma lipids and lipoproteins. Moreover, the guidelines on arterial hypertension published in 2007 listed the risk factors affecting prognosis but even by 2009 an update modified not only the list of risks, but even the philosophy behind the thought process which introduced as essential element in the prognosis of hypertension the ascertained existence of a damaged organ. Thus, the documentation of atherosclerotic vascular disease (plaques) and the quantification of its extension in the arterial tree became a determinant in the definition of cardiovascular risk. Magnetic Resonance (MRI) and coronary computed tomography (coro CT) applied to the heart and large vessels are the most promising methods.

Recurrent gallstone ileus: case report and literature review

The gallstone ileus is a rare complication of cholelithiasis and it represents the 1-4% of small intestinal mechanical obstruction. Gallstone is generally wedged in the terminal ileum, even if unusual locations have been described. The literature reports a very high morbidity and mortality, often because misdiagnosis or delayed diagnosis. There is no unique opinion in literature about the choice between one-stage and two-stage surgery. We report a clinical case that summarizes the diagnostic and therapeutic difficulties of gallstone ileus.

Whipple’s disease infection surgical treatment: presentation of a rare case and literature review

The Whipple’ Disease (W.D.) is a very rare disease with an incidence of 1 per 1.000.000 inhabitants; it is a systemic infection that may mimic a wide spectrum of clinical disorders, which may have a fatal outcome and affects mainly male 40-50 years old. The infective agent is an actinomycete, Tropheryma Whipplei (T.W.) that was isolated 100 years after first description by Wipple, and identified in macrophages of mucosa of the small intestine by biopsy which is characterized by periodic acid-Schiff-positive, products of the inner membrane of his polysaccharide bacterial cell wall. The multisystemic clinical manifestations evolve rapidly towards an organic decay characterized by weight loss, malabsorption, diarrhea, polyathralgia, opthalmoplegia, neuro-psychiatric disorders and sometimes associated to endocarditis. Early antibiotic treatment with trimethoprim and sulfometathaxazole reduces the fatal evolution of the disease. The authors present a rare experience about a female subject in which the clinical gastrointestinal signs were preceded by neuro-psychiatric disorders, and evolved into obstruction and intestinal perforation which required an emergency surgery with temporary ileostomy, recanalized only after adequate medical treatment with a full dose of antibiotic and resolution of clinical disease for the high risks of fistulae for the edema and lymphadenopathy of mucosa. The diagnosis was histologically examined by intestinal biopsy performed during surgery, which showed PAS-positive histiocytes, while PRC polymerase RNA was negative, which confirms the high sensibility of PAS positive and low specificity of RNA polymerase for T.W.

An Unusual Case of Cerebral Oedema

Hereditary angioedema (HAE) is a rare genetic disorder transmitted as an autosomal dominant trait, characterized by reduced plasma concentration or by the presence of non-functional C1 esterase inhibitor. Oedema caused by HAE mostly affects the skin and bowel and can induce swelling of genitalia. Oedema can be life threatening if it causes swelling of the larynx with obstruction of the airways. We describe the case of a 52-year-old man who presented a neurological emergency (coma), where the remarkable localization of the clinical manifestation and the unusual symptomatology hindered the correct diagnosis.

Suspecting Renal Artery Thrombosis

Renal artery thrombosis is a threatening clinical diagnosis, in which renal infarction may occur. Often misdiagnosed, for mimicking other common diseases, it should be considered in persistent flank pain to improve care and reduce morbidity. We review a case of a healthy, 57 year-old woman with renal artery thrombosis mimicking pyelonephritis and renal calculus obstruction, highlighting features of this clinical condition. An accurate diagnosis is essential for optimal management and prompts treatment, which still remains to be defined.