Daniel Sermoneta

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by ‘open’ or ‘close’ abdomen management. We recently introduced the use of intra‐abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

BackgroundDistant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.Case presentationWe report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.ConclusionTo the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Peptic Ulcer in Gastric Heterotopia of the Gallbladder Without Evidence of Helicobacter pylori Infection

Gastric heterotopia has been described throughout the gastrointestinal tract, from the oral cavity to the rectum, including the liver and the gallbladder [1–6]. We report a case of peptic ulcer in heterotopic gastric mucosa of the gallbladder in a 56-year-old man submitted to laparoscopic cholecistectomy for chronic calculous cholecystitis. From the first case of gastric heterotopia of the gallbladder, reported in 1934 [7], we reviewed 49 cases, including our report. In nine cases gallstones were also found and in four cases a peptic ulcer was identified [8]. The case reported describes the first association between peptic ulcer in gastric heterotopia of the gallbladder and gallstones. The presence of HP was investigated in order to evaluate its possible role in the ethiology of the ulceration.

Acquired Poststenotic Jejunal Diverticulosis

The incidence of jejunal diverticulosis is reported to be 1% to 2% [1] but autopsy studies suggest that their true incidence is higher and that most likely they are underdiagnosed [2]. Usually jejunal diverticulosis is asymptomatic [2–4] or oligosymptomatic and the finding is often occasional during laparotomy for other indications [5]. But the condition carries the inherent risk of serious complications such as intestinal perforation, hemorrhage [3], fat and protein malabsorption, and macrocytic anemia [6–8]. Chronic symptoms include vague abdominal pain in the periumbilical region, nausea, vomiting, flatulence, and diarrhea [2]. The pathogenesis of acquired diverticula is still debated and both jejuno-ileal dyskinesia and weakness of the bowel

Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device

Retroperitoneal colonic perforation is a very rare condition, usually due to the presence of a nondiagnosed diverticular disease. Most frequently it manifests with the presence of abscesses of the abdominal wall that invariably causes severe systemic complications. Toilette and drainage is the therapy of choice together with the confection of a derivative colostomy. However, often abscess healing takes a long time. The introduction of vacuum-assisted device medication has proven to be helpful in keeping patient discomfort at minimal levels and helping the healing process. Commercial vacuum-assisted device medication is however costly and often not available for immediate use. We recently encountered a case of a retroperitoneal sigmoid diverticular perforation that led to a devastating necrosis of the abdominal wall, flank, and buttock extending to the articulation of the hip in an obese and diabetic patient, which was successfully treated by a homemade vacuumassisted device (HVAD). This strategy was adopted because of the unavailability of the commercial device. A 61-year-old female was admitted to our department with a 15-day history of left lateral abdominal pain diffused to the homolateral lower extremity. Past history was significant for obesity (body mass index 40) and type II diabetes. Physical examination revealed the following: body temperature 39.2°C, blood pressure 100/60 mm Hg, pulse rate 110 beats per minute, and respiratory rate 40 breaths/minute. There was severe cognitive deterioration. Patient was intubated and transferred to the intensive care unit with diagnosis of septic shock and multiple organ failure. Presence of a large fluctuating abscess extending from the left hip to the gluteal region was evident. Blood and laboratory test results were as follows: white blood cell count 14 600/mm, hemoglobin 11.4 g/dL, platelet count 563 000/mm, blood urea nitrogen 106 mg/dL (normal 10-23 mg/dL), creatinine 3.4 mg/dL (normal 0.71.2 mg/dL), bilirubin 5.6 mg/dL (normal 0.3-1.2 mg/dL), and GOT 165 IU/L (normal 7-45 IU/L). A computed tomography scan (Figure 1) showed a muscle fascial thickening of the left abdominal wall with multiple gas bubbles between the muscle fibers. An abscess measuring 8 cm in diameter extended up to the left iliac crest and a thickening and an enhancement of the perinefric and paranefric left fascie were present. Wide spectrum antibiotic therapy was administered (teicoplanin, meropenem, metronidazole) and a timely surgical intervention for complete drainage was performed. A huge abscess involving the left abdominal wall was drained and a retroperitoneal sigmoid diverticular perforation was detected. A wide muscolofascial necrosis extended from the iliac wing up to the homolateral hip joint (Figure 2). During this operation, a derivative colostomy on the transverse colon was performed. At intervention the use of vacuum-assisted device was considered useful because of the enormous extension of the tissue necrosis, the presence of concomitant comorbidities such as diabetes, obesity, and septic shock. A HVAD was then assembled in the following manner. Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device