Tutino R

Surgical Emergencies in Crohn’s Disease

Crohn’s disease, as a chronic inflammatory disease of unknown etiology that can affect any part of the alimentary canal from the mouth to the anus, has a highly variable course and a very unpredictable evolution.

Surgery and Crohn’s Disease

It is known that the treatment of Crohn’s disease (CD) absolutely needs a multidisciplinary approach with an important relationship between gastroenterologist and surgeon.

Update in Laparoscopic Approach to Acute Mesenteric Ischemia

AMI is an uncommon but serious disease often associated with a bad prognosis, associated with occlusion of Superior Mesenteric Artery (SMA) for embolism or thrombosis (67.2 %), mesenteric venous thrombosis (15.7 %), and non-occlusive mesenteric ischemia (15.4 %). Clinical markers are often aspecific and symptoms low suggestive. The gold standard for the diagnosis is multidetector CT Angiography (CTA) with sensibility of 93.3 % and specificity of 95.9 %. Abdominal exploration could be useful to confirm cases of AMI without signs of SMA occlusion at CTA. Few reports have been found on the diagnostic role of Exploratory Laparoscopy. To increase the sensibility of laparoscopy in the diagnosis of AMI in the last ten years, some studies had shown the possibility of using fluorescein to underline the bowel areas of interest by ischemia. The best of laparoscopy in AMI diagnosis remains the second look and bedside use (directly in ICU when possible) overall in patients with Aortic dissection type B (preferable chronic type). In a limited number of cases, it is possible to evaluate bowel perfusion laparoscopically and at the same time perform a laparoscopical bowel resection of residual ischemic segments. However, laparoscopic primary access overall in AoD is an important tool for leading therapeutic decision and timing. Finally, laparoscopy may be a feasible alternative to CTA in patients with kidney failure that contraindicates injection of iodate CT contrast medium.

Traumatic Isolated Intramural Duodenal Hematoma Causing Intestinal Obstruction.

A 21-year-old man was admitted 36 hours after a blunt abdominal trauma occurred during a sporting competition. He complained of colic epigastric abdominal pain, nausea, and vomiting. He was hemodynamically stable; blood counts and metabolic panel were normal. Abdominal CT showed an intestinal obstruction caused by an 8 x 6 x 11 cm hematoma on the right lateral duodenal wall without signs of active bleeding (Figure 1). He underwent gastric decompression and started total parenteral nutrition and intravenous pump inhibitors. Esophagogastroduodenoscopy (EGD) performed 48 hours after the diagnosis showed an extrinsic compression by a bluish obstruction in the first part of the duodenum resembling an extraparietal hematoma (Figure 2). After 5 days, repeat EGD revealed a massive parietal hematoma in the posterior wall of the duodenal bulb. Two weeks later, an endoscopic ultrasound to evaluate the possibility of endoscopic drainage showed a delimitation of the lesion below the third layer of the duodenal wall, surrounded by the remaining layers (Figure 3). Endoscopic drainage was not performed, and the patient was managed conservatively. Three weeks later, EGD showed complete reabsorption of the hematoma; a soft oral diet was started (Figure 4). On follow-up, the patient was asymptomatic.