Francesco Cardì

Presentation and management of splenic injury after colonoscopy: a systematic review.

This study reviewed all single experience of splenic injuries after colonoscopy in the last 40 years to define the possible risk factors and the management of this complication. A MEDLINE and a PubMed search was undertaken to identify articles in English, French, Spanish, and Italian from 1974 to 2012 using the key words: “splenic injury,” “splenic rupture,” and “colonoscopy.” Data were analyzed using descriptive statistic. A total of 103 cases have been described in 75 reports. The majority of the patients were women (71.56%) and 6.85% underwent previous pelvic surgery. The mean age was 63 years (range, 29 to 90 y). About 61 of the 103 studies (59.2%) reported the presence or the absence of previous abdominal surgery and within these, only 31 of 61 patients (50.82%) underwent previous abdominal surgery. In this review, over half of the patients with splenic injury underwent colonoscopy for routine surveillance (62.75%), and only one third of the splenic injures were associated with biopsy or polypectomy. The majority of patients (78.57%) developed symptoms within the first 24 hours after colonoscopy and in a minority of cases (21.43%), there was a delayed presentation 24 hours after colonoscopy. Computed tomography was used as the primary modality to make the diagnosis in 69 of 98 cases (70.41%) and as a confirmatory test in many additional cases. Twenty-six of 102 patients (25.49%) were treated by conservative methods, whereas the majority of patients (69.61%) underwent splenectomy as a definitive treatment. Because of possible medicolegal implications, the endoscopists should consider mentioning splenic injury on the consent form of colonoscopy after bowel perforation and bleeding, particularly in higher risk patients.

Diffuse colonic lipomatosis with giant hypertrophy of the epiploic appendices and diverticulosis of the colon

PURPOSE: A case of diffuse colonic lipomatosis, dolichosigmoid, hypertrophy of the epiploic appendices and diverticulosis of the colon producing constipation, recurrent subocclusive episodes with diarrhea and vomiting, and weight loss is reported. METHODS: Careful preoperative assessment of clinical, radiologie, and endoscopie findings suggested the diagnosis. Results: A total colectomy, followed by a lateroterminal ileoproctostomy, gave complete relief from symptoms. Conclusions: Of the 12 cases of colonic lipomatosis previously reported, only 2 have isolated involvement of the entire organ, but they do not present lipomatosis of the epiploic appendices.

Pharmacokinetics of a new subcutaneous diclofenac formulation administered to three body sites: quadriceps, gluteus, and abdomen.

OBJECTIVE To assess the relative bioavailability of a new subcutaneous (SC) diclofenac hydroxypropyl b-cyclodextrin (HPbCD) formulation administered to three body sites: quadriceps, gluteus, and abdomen. MATERIALS AND METHODS This was a pilot, single-dose, randomized, three-way crossover relative bioavailability study. A total of 12 healthy subjects received a single SC injection of diclofenac HPbCD 50 mg/1 mL in the quadriceps, gluteus, or abdomen. RESULTS The AUC was comparable after SC diclofenac HPbCD in the quadriceps, gluteus, and abdomen. The Cmax was comparable after SC administration in the quadriceps or abdomen, and ~ 17% higher in the gluteus. The absorption was rapid (30 minutes) after administration of the treatment at any site. The treatment was well tolerated. CONCLUSIONS The relative bioavailability of SC diclofenac HPbCD was comparable when administered to the quadriceps, gluteus, and abdomen. The new diclofenac formulation can therefore be administered subcutaneously to any of these sites without clinically significant differences. A further adequately powered study would be necessary to reveal any differences among injection sites in terms of peak plasma concentration.

The role of 68-Ga-DOTATOC CT-PET in surgical tactic for gastric neuroendocrine tumors treatment: Our experience: A case report

Gastric neuroendocrine tumors (g-NETs), which originate from gastric enterochromaffin-like (ECL) mucosal cells and account for 2.4% of all carcinoids, are increasingly recognized due to expanding indications of upper gastrointestinal endoscopy. Often silent and benign, g-NETs may however, be aggressive and sometimes they mimic the course of gastric adenocarcinoma. Current nosography distinguishes those occurring in chronic conditions with hypergastrinemia, as the type 1 associated with chronic atrophic gastritis, and the type 2 associated with Zollinger-Ellison syndrome in MEN1. Conversely, type 3 and 4 (according to some authors) are unrelated to hypergastrinemia and are frequently malignant, with a propension to develop distant metastases. While there is a general agreement concerning the treatment of malignant gastric neuroendocrine tumors, for types 1 and 2, current possibilities include surveillance, endoscopic polypectomy, surgical excision, associated or not with surgical antrectomy, or total gastrectomy. This report, based on our clinical experience, discusses how the size, number, depth, histological grading, staging with CT, MRI, and the use of recently developed somatostatin receptor tracers (68Ga-DOTATATE, 68Ga-DOTA-TOC) could allow the correct identification of a benign or malignant propensity of an individual tumor, thus avoiding underestimation or overtreatment of these uncommon neoplasms.

Staple line as a cause of unusual early internal hernia after appendectomy

The use of mechanical stapling devices in laparoscopic appendectomies has become a common practice. Occasionally, the retained staples have been described to cause adhesions that might result in bowel obstruction. Early bowel obstruction after routine abdominal surgery should be closely investigated and might warrant early re-exploration. We present a rare case of small bowel obstruction caused by a staple line adhesive band one week after appendectomy. A 46-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. A linear endoscopic stapling device was utilized during the procedure. The patient was discharged without complication. One week later, the patient presented to the emergency room for abdominal pain and she was discharged after adequate pain control. Several hours later she returned with similar symptoms, and she was diagnosed with distal small bowel obstruction by computed tomography scan. During the diagnostic laparoscopy there was an internal hernia through a defect created by the appendiceal staple line and the adjacent small bowel mesentery. After reduction of the hernia, the small bowel venous drainage improved, and no intestinal resection was necessary. The offending staple was removed and the staple line covered with omentum. The patient had complete resolution of symptoms and she was discharged the following day. No perioperative complications occurred. Mechanical staplers are routinely used in laparoscopic appendectomy. The staple line should be inspected at the end of the procedure to confirm the absence of free, unformed staples that can generate adhesions and postoperative complications.

Villous Adenocarcinoma of the Duodenum Invading the Ampulla of Vater: Case Report and Review of Literature

We report a case of villous adenocarcinoma of duodenum arising from the ampulla of Vater with a review of the literature. Although preoperative endoscopic biopsies were performed, no malignancy was identified. Because of the pathological uncertainty we decided to perform a pylorus-preserving pancreatoduodenectomy. Microscopic examination demonstrated glandular dysplasia with aspects of villous adenoma and well differentiated adenocarcinoma. We conclude that both in malignant cases and in cases with uncertain diagnosis a pylorus-preserving pancreatoduodenectomy is the best surgical treatment because it results in better 5 year survival.