Mauro Podda

Acute Diverticulitis in the Young: The Same Disease in a Different Patient

Background. Natural history and risk factors for diverticulitis in young patients are still debatable. This study aimed to assess whether difference exists in patients aged 50 and younger when compared to older patients and to identify risk factors for acute diverticulitis in the young. Patients and Methods. From January 2006 to December 2011, 80 patients were admitted to our department for acute diverticulitis. We carried out a cross-sectional study in 23 patients (28.7%) aged 50 and younger and 57 older patients (71.3%). Results. Acute diverticulitis in the young was not more aggressive than in the older patient. Diverticulitis at patients admission was similar with respect to Hincheys stage and prior history of diverticulitis. No significant difference was found for both medical and surgical treatment. The rate of recurrent diverticulitis in nonoperated patients was similar. Male gender, body mass index ≥25, and assumption of alcohol were independent risk factors for the occurrence of an acute diverticulitis in the young. Conclusions. The same disease seems to be affecting young patients such as overweight or obese male individual. Current policies to prevent diverticular disease and its related complications must include obesity control together with high-fiber diet and regular exercise.

Intracorporeal anastomoses in emergency laparoscopic colorectal surgery from a series of 59 cases: where and how to do it - a technical note and video

Laparoscopy offers the benefits of minimally invasive surgery and faster recovery. Acute surgical patients may potentially benefit from the great advantages of emergency laparoscopy, which is more clinically relevant in acute than elective patients. Fashioning a laparoscopic intracorporeal anastomosis (ICA) after emergent colorectal resection, whenever technically feasible and not contraindicated by the patients general and haemodynamic condition, is a most challenging technical skill.

An uncommon presentation of metastatic melanoma: a case report.

AbstractMetastases to the spleen are rare and are generally part of a multi-visceral metastatic disease. The most common sources of splenic metastases include breast, lung and colorectal malignancies as well as melanoma and ovarian carcinoma. Solitary splenic metastasis is very uncommon.We present a case of a 44-year-old man who presented at our department for gallstones symptoms. He had a past medical history of neck cutaneous melanoma (T3bN0M0—Stage IIb). He had not attended follow-up schedule for personal reasons. However, abdominal ultrasound revealed the presence of a solitary solid lesion in the spleen. Preoperative workup was completed with CT scan that confirmed the presence of a large splenic lesion with subcapsular fluid collection, also compatible with a post-traumatic lesion.Preoperative findings could not exclude malignancy and patient was therefore submitted to surgery. At laparoscopy, a condition of peritoneal melanosis was present. Splenectomy was carried out. Histological report confirmed the peritoneal melanosis and the diagnosis of metastatic spleen lesion from melanoma. Patient was observed, but died of metastatic disease 14 months after surgery.Splenic metastases are uncommon. Isolated metastases from melanoma are rare and could be found several months after primary diagnosis of melanoma. Surgery remains the most effective treatment, especially for metachronous disease, offering the best chance of long-term survival. Prognosis remains poor, as metachronous disease is indicative of aggressive widespread of the disease.

Gastric Cancer in the Young: Is It a Different Clinical Entity? A Retrospective Cohort Study

Background. The rate of gastric cancer in young patients has increased over the past few decades. The aim of this study was to search for independent risk factors related to patients of younger age. Methods. From January 1996 to December 2012, a series of 179 consecutive patients were admitted to our surgical department because of a gastric cancer. We carried out a retrospective cohort study in 20 patients younger than 50 and in 112 patients aged 50 and older treated by curative gastrectomy. The comparison involved the evaluation of patient and tumor characteristics. Results. Younger patients had significantly less comorbidities and a more favorable American Society of Anesthesiology score; they had significantly less preoperative weight loss and a significantly longer duration of symptoms; Helicobacter pylori infection and diffuse histological type were significantly associated with younger age. There was no statistically significant difference regarding overall and cancer-related 5-year survival; advanced cancer stage and diffuse histological type were the independent negative prognostic factors influencing cancer-related survival. Conclusions. We do not have sufficient evidence to consider gastric cancer in younger patients as a different clinical entity. Further studies are needed to understand carcinogenesis in younger patients and to improve gastric cancer classification.

Beware of the difference between randomized controlled trials and daily clinical practice (in reply to “Surgery or antibiotics for acute appendicitis? Take care about study’s design and methodology!”, by Ceresoli M, et al.)

To the Editors-in-chief of Updates in Surgery Prof. F. Basile Prof. F. Calise Dear Editor, We are indeed grateful to Dr. Ceresoli for the interest in our study exploring the outcomes of laparoscopic appendectomy vs antibiotic therapy for acute appendicitis, published on “Updates in Surgery” in September 2017 [1, 2]. The study results should be interpreted in view of the important limitations we have already discussed and acknowledged in the manuscript. The study gives an insight into the daily clinical management of acute appendicitis both for diagnostic and treatment strategies. 63% of patients were diagnosed with acute appendicitis via radiologic investigations, whereas the remaining 37% underwent either surgical or antibiotic treatment following clinical evaluation alone. This trend in the pre-interventional work-up has been also confirmed on a large scale by the results of the recently published POSAW Study [3]. The distinction between uncomplicated and complicated appendicitis remains difficult, and even multiple-detector CT scan struggles to differentiate between uncomplicated and complicated appendicitis. About 2% of patients initially diagnosed with uncomplicated appendicitis at CT scan did have instead a complicated or perforated appendicitis at surgical exploration, and this percentage increases to 18% when preoperative imaging is not obtained. The study by Verma et al. showed that presence of extraluminal air bubbles, increased wall thickness > 3 mm, and intraluminal fecalith should increase suspicion for perforation. Conversely, when these findings are absent, the sensitivity of CT scan to detect perforation is very low [4]. Moreover, only around 13% of patients actually undergo preoperative imaging in Europe. Thus, the routinely use of preoperative imaging as reported in clinical trials protocols published to date could affect the external validity of the studies, ultimately limiting the transferability of the results into the everyday clinical practice. In our study, patients with clinical diagnosis of diffuse peritonitis confirmed by the findings of four-quadrants free fluid and extraluminal air at CT scan were excluded from the study population. On the other hand, 14 patients (8.7%) in the antibiotic-first therapy group with radiological signs of complicated disease (phlegmon or abscess) but with clinical findings of localized peritonitis, were included and initially scheduled for surgery for the next available emergency list. This group consisted of patients who, although being suitable for surgery, fully and rapidly recovered with non-operative management at an early stage. Three of them (21%) were re-admitted for recurrence at the follow-up, but the multivariate analysis showed that the classification of the disease was not directly related to failure or success of the antibiotic therapy. Similarly, in a recent study about non-operative management of complicated appendicitis, the conservative strategy with antibiotics only was associated with a failure rate of 25.7% [5]. Thus, although in the presence of complicated acute appendicitis appendectomy or percutaneous drainage are the most appropriate choices, radiological findings of phlegmon and abscess should not be considered the only * Mauro Podda mauropodda@ymail.com

Robotic-assisted approach to Median Arcuate Ligament Syndrome with left gastric artery originating directly from the aorta. Report of a case and review of the current mini-invasive treatment modalities

Median Arcuate Ligament Syndrome (MALS) is a rare clinical condition.

The Close Relationship between Large Bowel and Heart: When a Colonic Perforation Mimics an Acute Myocardial Infarction

Colonoscopic perforation is a serious and potentially life-threatening complication of colonoscopy. Its incidence varies in frequency from 0.016% to 0.21% for diagnostic procedures, but may be seen in up to 5% of therapeutic colonoscopies. In case of extraperitoneal perforation, atypical signs and symptoms may develop. The aim of this report is to raise the awareness on the likelihood of rare clinical features of colonoscopic perforation. A 72-year-old male patient with a past medical history of myocardial infarction presented to the emergency department four hours after a screening colonoscopy with polypectomy, complaining of neck pain, retrosternal oppressive chest pain, dyspnea, and rhinolalia. Right chest wall and cervical subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and bilateral subdiaphragmatic free air were reported on the chest and abdominal X-rays. The patient was treated conservatively, with absolute bowel rest, total parental nutrition, and broad-spectrum intravenous antibiotics. Awareness of the potentially unusual clinical manifestations of retroperitoneal perforation following colonoscopy is crucial for the correct diagnosis and prompt management of colonoscopic perforation. Conservative treatment may be appropriate in patients with a properly prepared bowel, hemodynamic stability, and no evidence of peritonitis. Surgical treatment should be considered when abdominal or chest pain worsens, and when a systemic inflammatory response arises during the conservative treatment period.

Pancreas-sparing, ampulla-preserving duodenectomy for major duodenal (D1-D2) perforations: Pancreas-sparing, ampulla-preserving duodenectomy

Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas‐sparing, ampulla‐preserving duodenectomy for these patients.

Syncope with Surprise: An Unexpected Finding of Huge Gastric Diverticulum.

A gastric diverticulum is a pouch protruding from the gastric wall. The vague long clinical history ranging between dyspepsia, postprandial fullness, and upper gastrointestinal bleeding makes this condition a diagnostic challenge. We present a case of large gastric diverticulum that has been diagnosed during clinical investigations for suspected cardiovascular issues in a patient admitted at the medical ward for syncope. A 51-year-old man presented to the medical department due to a syncopal episode occurring while he was resting on the beach after having his lunch, with concomitant vague epimesogastric gravative pain without any other symptom. A diagnosis of neuromediated syncopal episode was made by the cardiologist. Due to the referred epimesogastric pain, an abdominal ultrasound scan was carried out, showing perisplenic fluid. A CT scan of the abdomen was performed to exclude splenic lesions. The CT scan revealed a large diverticulum protruding from the gastric fundus. The upper gastrointestinal endoscopy visualized a large diverticular neck situated in the posterior wall of the gastric fundus, partially filled by undigested food. The patient underwent surgery, with an uneventful postoperative course. Histologic examination showed a full-thickness stomach specimen, indicative of a congenital diverticulum. At the 2nd month of follow-up, the patient was asymptomatic.